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Patient Safety Tip of the Week

June 21, 2022

Preventing Post-op Pneumonia



When we discuss hospital-acquired infections (HAI’s) we usually first consider catheter-associated urinary tract infections (CAUTI’s), catheter-associated bloodstream infections (CLABSI’s), and ventilator-associated pneumonias (VAP’s). 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.


The authors also felt that the composition of the workgroup that developed and implemented the program was extremely important. That multidisciplinary workgroup consisted of surgeons, nurses, internal medicine representatives, respiratory therapists, physical therapists, infection control, and quality improvement personnel. They also felt that nurse managers were especially crucial to the success of the program. The catchy acronym ICOUGH also helped staff and patients and families remember the key intervention components.


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 patient’s 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 patient’s room +12.2%, and patient’s 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 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”



Some of our prior columns on checklists:

·       May 2019 “WHO Surgical Safety Checklist Cut Mortality 37% in Scotland”

·       July 16, 2019 “Avoiding PICC’s in CKD”

·       June 2020 “Are Two Checklists Better Than One?”

·       March 2021 “Medical Crisis Checklists in the ED”






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



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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