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Patient Safety Tip of the Week
May 30, 2023
Non-Ventilator-Hospital-Acquired
Pneumonia Finally Gets Attention
Our June 2022 What's New in the Patient Safety World column “Guideline
Update Preventing Hospital-Acquired Pneumonia” noted an update (Klompas 2022) from
several organizations on prevention of ventilator-acquired pneumonia (VAP). But
that update was unique in that, for the first time, it also addressed non-ventilator-hospital-acquired
pneumonia (NV-HAP). Results of a survey published in 2018 (Magill 2018) showed that pneumonia was the most common
health care-associated infection. The Magill study noted that its results
showed success in reducing CAUTI’s (catheter-associated urinary tract
infections) and SSI’s (surgical site infections) but little change in hospital-acquired
pneumonia. Hospital-acquired pneumonia is associated with high morbidity,
mortality, and health care use.
In 2020 a group of
U.S. healthcare leaders issued a call to action to address NV-HAP (Munro 2021), noting it
is one of the most common and morbid healthcare-associated infections, but it
is not tracked, reported, or actively prevented by most hospitals. Most hospitals only have surveillance and
prevention programs for VAP but not for NV-HAP.
Researchers (Jones 2023) analyzed EHR data drawn from 284 acute care hospitals
in the Veterans Affairs (VA) health care system and HCA Healthcare networks to
assess the incidence and outcomes of NV-HAP. They found the overall incidence of
NV-HAP was 0.54 per 100 admissions and 0.96 per 1000 patient-days.
Patients with NV-HAP
were older (median age 69 vs 66 years among all hospitalized patients) and most
had multiple comorbidities (median 6), most commonly congestive heart failure (29.5%),
neurologic disease (25.2%), chronic lung disease (19.6%), and cancer (16.7%).
Most cases (74.9%) occurred outside intensive care units. The inpatient
mortality rate was 22.4% among admissions meeting the NV-HAP surveillance
definition vs 1.9% among all other admissions.
Median
length-of-stay for patients with NV-HAP was 17 days vs 4 days for the general
hospital population. Patients with NV-HAP were also less likely to be
discharged to home and more likely to be discharged to hospice care.
The authors note
that the incidence and crude individual mortality of NV-HAP in this study were
within the range reported in previous studies using point prevalence, manual,
or semi-automated approaches.
The authors
conclude that the high incidence and mortality rate associated with NV-HAP
suggests it is an important hospital complication that warrants the development
and testing of prevention programs. They note there is very little consensus on
how best to prevent NV-HAP.
The 2022 guideline update (Klompas 2022) also
acknowledges that little robust data exist on interventions to prevent NV-HAP.
Most studies are nonrandomized, and many do not report the impact on objective
outcomes such as length of stay, mortality, or antibiotic utilization.
That new section in that guideline on NV-HAP emphasizes
oral care, recognizing and managing dysphagia, early mobilization, and
implementing multimodal approaches to prevent viral infections (since 20-40% of
NV-HAP are due to viral infections). It also notes there is insufficient
evidence regarding any recommendations about bed positioning or stress-ulcer
prophylaxis and it states that systemic antibiotic prophylaxis is not generally
recommended. As neurologists, we’ve long recognized the importance of dysphagia
as a leading cause of hospital-acquired pneumonia so we routinely screen patients for impaired swallowing prior to allowing them anything by mouth.
The guideline discusses uncertainties about the best methods for oral care but
concludes that daily
toothbrushing makes sense.
Similarly, early mobilization has been part of many “bundles” that were
associated with reduced pneumonia rates. While the specific contribution of early mobilization to those reduced rates is unknown, it makes
sense to include early mobilization in your NV-HAP programs. It also notes the
many interventions in the COVID-19 era to prevent viral infection transmission (screening, surveillance, masking, etc.).
One of the biggest
problems in surveillance for NV-HAP has been lack of a consensus definition. Jones
et al. also note that discharge diagnosis codes do not provide reliable
estimates of NV-HAP incidence and outcomes because they too are neither
sensitive nor specific. The definition used in the Jones study requires a
decrease in oxygen saturation or increase in supplemental oxygen sustained for
2 or more days after 2 or more days of stable or improving oxygenation, plus an
abnormal temperature (≤36 °C or ≥38 °C) or white blood cell count
(<4000 or ≥12 000 cells/mm3), plus completion of chest imaging
(x-ray or computed tomography), plus administration of 3 or more days of new
antimicrobials starting on the first or secondary day of oxygen deterioration.
The study does show that, using this definition, electronic medical record data
can provide reasonable identification of NV-HAP that can be used to follow
trends over time.
The time has come to recognize NV-HAP as a
leading hospital-acquired condition and develop and implement programs to
prevent it.
Some of our prior
columns on HAI’s (hospital-acquired infections):
December 28, 2010 “HAI’s: Looking In All The Wrong Places”
October 2013 “HAI’s:
Costs, WHO Hand Hygiene, etc.”
February 2015 “17% Fewer HAC’s: Progress or Propaganda?”
April 2016 “HAI’s:
Gaming the System?”
September 2016 “More
on Preventing HAI’s”
November 2018 “Privacy
Curtains Shared Rooms and HAI’s”
December 2018 “HAI
Rates Drop”
January 2019 “Oral
Decontamination Strategy Fails”
February 2019 “Infection
Prevention for Anesthesiologists”
March 2019 “Does
Surgical Gowning Technique Matter?”
May 2019 “Focus
on Prophylactic Antibiotic Duration”
July 2019 “HAI’s
and Nurse Staffing”
February 2020 “NICU:
Decolonize the Parents”
June 16, 2020 “Tracking Technologies”
August 2020 “Surgical
Site Infections and Laparoscopy”
December 2020 “Do
You Have These Infection Control Vulnerabilities?”
May 2021 “CLABSI’s
Up in the COVID-19 Era”
August 2021 “Updated
Guidelines on C. diff”
October 2021 “HAI’s
Increase During COVID-19 Pandemic”
June 2022 “Guideline
Update: Preventing Hospital-Acquired Pneumonia”
June 21, 2022 “Preventing Post-op Pneumonia”
June 28, 2022 “Pneumonia in Nervous System
Injuries”
August 2022 “Resistant
Infections Up During COVID-19 Pandemic”
November 15, 2020 “Which Antiseptic?”
December 2022 “Game
Changer to Prevent SSI’s in Abdominal Surgery?”
References:
Klompas M, Branson R, Cawcutt K, et al.. Strategies to prevent
ventilator-associated pneumonia, ventilator-associated events, and nonventilator hospital-acquired pneumonia in acute-care
hospitals: 2022 Update. Infect Control Hosp Epidemiol 2022; 20: 1-27
Magill SS, O’Leary E, Janelle SJ, et al; Emerging Infections Program
Hospital Prevalence Survey Team. Changes in prevalence of health
care-associated infections in US hospitals. N Engl J Med 2018; 379(18):
1732-1744
https://www.nejm.org/doi/10.1056/NEJMoa1801550
Munro SC,
Baker D, Giuliano KK, et al. Nonventilator hospital-acquired pneumonia: a call to
action. Infect
Control Hosp Epidemiol 2021; 42(8): 991-996
Jones BE, Sarvet AL, Ying J, et
al. Incidence and outcomes of non–ventilator-associated hospital-acquired
pneumonia in 284 US hospitals using electronic surveillance criteria. JAMA Netw Open 2023; 6(5) :e2314185
https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2805014
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