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When we discuss
hospital-acquired infections (HAIs) we usually first consider
catheter-associated urinary tract infections (CAUTIs), catheter-associated
bloodstream infections (CLABSIs), and ventilator-associated pneumonias (VAPs).
But nonventilator hospital-acquired pneumonia (NV-HAP) is another frequent HAI that is potentially
preventable.
Nonventilator hospital-acquired pneumonia (NV-HAP) is often
a complication in patients with stroke or other conditions with impaired
swallowing or impaired consciousness. But it is also a frequent post-operative
complication.
In our June 2022 What's New in the Patient
Safety World column Guideline Update: Preventing
Hospital-Acquired Pneumonia we discussed the 2022 update of Strategies
to prevent ventilator-associated pneumonia, ventilator-associated events, and nonventilator hospital-acquired pneumonia in acute-care
hospitals (Klompas 2022). That update was collaborative work of the
Society for Healthcare Epidemiology (SHEA), the Infectious Diseases Society of
America (IDSA), the American Hospital Association, the Association for
Professionals in Infection Control and Epidemiology, and The Joint Commission,
with input from multiple other organizations and societies.
That
update included a new section on prevention of nonventilator
hospital-acquired pneumonia (NV-HAP). That section notes there is actually a scant evidence base for strategies to prevent
NV-HAP. This section emphasizes oral care, recognizing and managing dysphagia,
early mobilization, and implementing multimodal approaches to prevent 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.
Our
July 2013 What's New in the Patient Safety World column I Cough highlighted a multicomponent intervention
bundle that was demonstrated to reduce post-operative pulmonary complications (Cassidy
2013). The I COUGH program was associated with
a reduction in the incidence of post-op pneumonia from 2.6% to 1.6% and
unplanned intubations from 2.0% to 1.2%. The acronym I COUGH stands for the
components of the intervention bundle use:
I Incentive spirometry
C Coughing and deep breathing
O Oral care (brushing teeth and using
mouthwash twice daily)
U Understanding (patient and family
education)
G Getting out of bed frequently (at least
3 times daily)
H Head-of-bed elevation
The
authors also note that postoperative pain control was a key element of the
bundle. The educational piece involved not only patients and families but also
physicians and nurses. They developed a standardized order set to incorporate
all the key interventions. Unit-specific audit of nursing practice changes
probably also played an important role.
Sustainability
is an issue any time new improvement initiatives are put in place. When intervention
bundles are implemented, it is important to assess compliance with both the
overall bundle and each element of the bundle. One academic medical center
recently introduced a 10-item checklist to help improve compliance with
elements of I COUGH (Lamm 2022). The intervention included both provider-driven
initiatives (patient oral care, ambulation,
frequency of patient being in chair, having incentive spirometer within reach, having information
booklet within reach, and the
patients ability to perform incentive spirometry
correctly) as well as patient
awareness initiatives (importance of oral care, cough
and deep breathing, ambulation, and incentive spirometer
use).
The
checklist actually consisted of a list of 5
intervention items and templates for how those 5 interventions should be recorded
in progress notes:
Postoperative
Pneumonia Prevention Checklist
Postoperative
Pneumonia Prevention Progress Note:
The
medical center had a policy modeled on I COUGH since 2016 but implemented the
above checklist in 2020. The research team interviewed 135 postoperative
general surgery patients over the study time period, 96 prior to implementation of the checklist, and 39 following
implementation.
All the
provider compliance measures improved
post-implementation: patient receiving/performing oral care twice daily
+5.2%, ambulating a minimum of
20 feet at least three times daily +10.2%, being
out of bed and in a chair at least twice daily +2.3%, having the incentive spirometer within reach +14.3%, having the
ICOUGH explanation booklet in
the patients room +12.2%, and patients
ability to perform correct usage of incentive spirometry
when prompted by interviewer
+9.5%.
Likewise,
all patient awareness measures improved after
checklist implementation: importance of oral care +1.4%, deep coughing +13.5%,
ambulation +20.5%, and incentive spirometer
use +7%.
Overall
impact on occurrence of post-op pneumonia improved, though it did not reach
statistical significance. Using data from the NSQIP database, the rate of post-op
pneumonia was 1.97% (31 cases among the
1,577 patients) after the intervention, compared to 2.70% (46 cases among 1,706
patients) in the year before implementation (p=0.104).
The
updated guidelines (Klompas 2022) did not specifically deal with post-op
patients, but looked at broader studies of oral care in prevention of nonventilator hospital-acquired pneumonia (NV-HAP). They
note that before-and-after series suggest a possible benefit but that two
large, cluster randomized trials conducted in nursing homes did not show a
benefit, though their generalizability to acute-care hospitals is unknown. Also,
most randomized trials in acute-care hospitals have focused on ICU patients,
most of whom were on mechanical ventilation, making it difficult to discern their
effect on NV-HAP. Nevertheless, given little risk of harm, they recommend toothbrushing
daily given its benefits for oral health and the possible positive impact on
objective outcomes.
They
also note that data for early mobilization to prevent NV-HAP among hospitalized
patients are sparse. They do cite that a quasi-experimental study of intensified
postoperative physical therapy for elderly patients undergoing hip fracture
surgery was associated with less pneumonia and shorter length of stay compared
to historical controls.
They also
note the difficulties in assessing results of implementation of bundles to
reduce NV-HAP, noting the heterogeneity of the bundles and lack of
understanding the impact of individual elements in those bundles.
Elevating
the head of the bed is part of the I COUGH protocol. The updated guidelines
note that there is insufficient data to determine the impact of this on NV-HAP.
They note that elevating the head of the bed is recommended to prevent VAP and
VAE despite sparse evidence because some studies suggest benefit, it is simple,
economical, and associated with minimal risk of harm in ventilated patients.
Even fewer data, however, are available to inform whether and to what extent
this applies to NV-HAP.
And
the one intervention having the strongest evidence base, diagnosis
and management of dysphagia, probably has limited applicability in the typical post-op
patient population.
The
updated guidelines do provide recommendations for how to implement strategies
to reduce ventilator-associated pneumonia, ventilator-associated events, and nonventilator hospital-acquired pneumonia. They emphasize
that prevention of VAP, VAE, and NV-HAP requires implementing best practices to
reduce the risk of infection and nurturing a culture that supports
implementation, and that accountability is an essential principle for
preventing healthcare-associated infections. The document provides
recommendations regarding use of multidisciplinary teams, engagement of local champions,
utilization of peer networks, educational sessions, educational materials, standardization
of care processes, and measurement of performance. They also stress the
importance of creating redundancy, including reminders about best practice and
can take the form of posters, bulletins, pens, stamps, pocket cards, 1-page
signs, daily goal lists in patient rooms, checklists, and preprinted order
sets, text messages, and screensavers on clinical computers.
The
updated guidelines also note the importance of engaging family members to
assist with preventive care as appropriate and/or to discuss prevention
practices with the care
team
daily. They note that this provides an external prompt for the performance of
best practices and can help increase patient acceptance of practices such as
oral care, mobilization, and delirium prevention.
The Lamm study includes details of how they used multiple
modalities to educate staff on the checklist initiative and incorporated
feedback from reviewers. Importantly, they stressed the rationale for the
checklist that the initial good adoption of I COUGH principles had declined
over time.
One
important element not discussed in either the updated guidelines or the Lamm study is the role of pain management. This, of course,
is a double-edged sword. Adequate pain control improves both coughing/incentive
spirometry and early ambulation. But that needs to be balanced against the
risks of overmedication of the post-op patient, which can lead to respiratory
depression, falls, etc. The original I COUGH study (Cassidy
2013) notes that, while not included in the I
COUGH acronym, an important aspect of the program is postoperative pain
control.
The Lamm study provides yet another example of the utility of
checklists and reminds us that sustainability of quality improvement requires
ongoing measurement.
Some of our prior columns on HAIs
(hospital-acquired infections):
December 28, 2010 HAIs:
Looking In All The Wrong Places
October
2013 HAIs: Costs, WHO Hand Hygiene, etc.
February 2015 17%
Fewer HACs: Progress or Propaganda?
April 2016 HAIs: Gaming the System?
September 2016 More on Preventing HAIs
November 2018 Privacy Curtains Shared Rooms and HAIs
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 HAIs 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 CLABSIs Up in the COVID-19 Era
August
2021 Updated Guidelines on C. diff
October
2021 HAIs Increase During COVID-19 Pandemic
June
2022 Guideline Update: Preventing
Hospital-Acquired Pneumonia
Some
of our prior columns on checklists:
·
May 2019
WHO Surgical Safety Checklist Cut Mortality
37% in Scotland
·
July 16, 2019 Avoiding
PICCs in CKD
·
June 2020 Are
Two Checklists Better Than One?
·
March 2021 Medical
Crisis Checklists in the ED
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
Cassidy
MR, Rosenkranz P, McCabe K, Rosen JE, McAneny D. I
COUGH: Reducing Postoperative Pulmonary Complications With
a Multidisciplinary Patient Care Program. JAMA Surg 2013; 148(8): 740-745
https://jamanetwork.com/journals/jamasurgery/fullarticle/1693122
Lamm R, MD, Creisher BA, Curran
JG, et al. Postoperative Pneumonia Prevention Checklist Improves Provider
Compliance and Patient Awareness of Previously Established Reduction Protocol. Patient
Safety 2022; 4(2): 62-69
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