Ventilator-associated pneumonia (VAP) is a commonly tracked healthcare-associated infection, and frequently the target of interventions to protect patients. On the other hand, non-ventilator healthcare-associated pneumonia (NV-HAP) falls into a gray area, where it often remains unreported in surveillance systems.
After a patient that seemed on her way to recovery developed NV-HAP and died, Barbara Quinn, RN, ACNS-BC, a clinical nurse specialist at Sutter Health in Shingle Springs, CA, began looking into the problem. Quinn recently presented her findings in Portland at the annual APIC conference, reporting that a major risk factor for NV-HAP is disrupted bacteria in the patient’s mouth that are aspirated into the lungs to seed pneumonia. The lack of oral care during hospital stays emerged as a major risk factor.
“We started looking into this and trying to figure out if we had an issue,” she said. “We did a retrospective chart review for one year. That included 24,000 patients in that year and over 94,000 patient days.”
Not surprisingly, the majority of the NV-HAP cases happened outside of the ICU.
“They were not our ICU patients on ventilators — they were medical-surgical patients, oncology, orthopedic, and neurology,” Quinn said. “In those patients, when we looked at the preventive care that we knew actually helps prevent pneumonia — especially oral care, because we felt like that was the most modifiable risk factor for all of these patients — only 27% of the patients had oral care. When we looked at the chart for the frequency of oral care, it was like once every other day. It was mortifying from a nurse’s perspective.”
With that as a “dismal” baseline, Quinn and colleagues reviewed the literature to analyze the cost, length of stay, and mortality.
“Those three things — because to do anything about it, we needed funding,” she said. “We needed some kind of return on investment strategy. When we looked at our year’s worth of data, we found $4.5 million dollars were spent, 23 patients died with pneumonia, and over 1,000 patient days [resulted] that could have been prevented.”
They then performed an oral-care gap analysis by reviewing the literature and deciding what to include. “What is the best practice, and what are our gaps in those areas?” she said. “That would help direct us to areas where we needed to take action.”
These(cost, length of stay, and mortality) were the three most common gaps identified in the analysis, and likely a good starting point for IPs wanting to look into the problem at their facility.
“A common gap that we find is that the only oral care protocol or policy is for patients in the ICU on a ventilator,” she said. “That was something that we had to change. We had to write a policy to cover all of the patients.”
Similarly, ICU patients on vents were receiving best practice oral chlorhexidine washes. Another best practice was brushing patients’ teeth or having them brush. Those were added for non-vent patients.
“We’ve been working with the American Dental Association [ADA] at the national level to come up with a protocol that meets the particular needs of a hospitalized patient, and follows the ADA guidelines,” she said, showing the recommendations on a slide. “The first thing you’re going to notice where it says frequency — four times a day. An audible gasp is usually what we get. But think about how quickly the bacteria replicates — five times every 24 hours. That means every six hours, you have to start all over again. How quickly the bacterial pathogens found in the environment get into those mouths.”
The task may seem daunting, but Quinn reminded that about 75-80% of patients in the hospital can brush their own teeth. They will need initial instructions and tips, along with a reminder of why it’s important, but the results can be dramatic. Suction toothbrushes are available to use for dementia or stroke patients that may be prone to aspirate during the cleaning.
After 2.5 years, NV-HAP was reduced by 70% from baseline.
“In that two-and-a-half years, we avoided 164 cases of hospital-acquired pneumonia,” she said. “That means we saved 31 lives. We saved $6 million and about 1,500 extra patient days.”