What if there were a routine addition to patient care that could save some 10,000 lives annually? An increasing body of research says there is.
A new study at 21 hospitals nationally shows that routine oral care of hospitalized patients and other basic measures were strongly associated with decreases in non-ventilator hospital-acquired pneumonia (NV-HAP).
Eradicating bacteria in the mouth reduces the likelihood that patients’ aspiration of oral fluids into their lungs will not seed a pneumonia infection in the lungs. Though long overshadowed by ventilator-associated pneumonia (VAP) in the ICU, NV-HAP has a comparable morality rate and can strike a broader, younger group of patients in all areas of the hospital.
These NV-HAP patients are 8-fold more likely to require intensive care “and/or die during hospitalization,” the researchers reported. Even if discharged, NV-HAP patients were readmitted at a rate of 19%.
“If a U.S. national effort was made to address NV-HAP, we predict that with appropriate intervention to prevent [this infection] by even 50%, we could save approximately 9,886 lives, 487,622 extra hospital days, and $2.43 billion annually,” the authors concluded.1 “When the morality rate from a preventable hospital harm is as high as 14%-31%, it is time for a call to action.”
The interventions to prevent NV-AP include oral/dental care, elevation of the head of the bed, patient mobility, and deep breathing and coughing exercises. In particular, routine oral care such as brushing teeth and eradicating bacteria in patients’ mouths should be a standard of care, the authors argued.
Unfortunately, that is not the case in many hospitals, as NV-HAP remains a “hidden harm” that could be addressed by these basic interventions.
“Oral care is not the only risk factor, obviously, but it is the only one that every single patient has when they are in the hospital,” says co-author Barbara Quinn, RN, ACNS-BC, a clinical nurse specialist at Sutter Health in Shingle Springs, CA. “It is also the one we can control the most. We can’t eliminate all micro-aspiration, but we know how to kill germs in the mouth and how to get biofilm off of teeth. So that is something we actually have control over, which is not always the case in healthcare.”
Prior to publication of the study, Quinn presented data last year at the annual APIC conference in Portland showing oral care four times a day could dramatically reduce pneumonia. About three-quarters of patients can brush their own teeth, so that is not quite as labor-intensive as it sounds. Best practice oral decontamination for vented patients includes oral chlorhexidine washes. (For more information, see the story in the October 2017 issue of Hospital Infection Control & Prevention.)
In the 2018 published study, researchers conducted a retrospective chart review to identify 1,300 NV-HAP patients in the 21 participating hospitals. Most NV-HAP infections (73%) were acquired outside of the ICU. However, once patients acquired pneumonia in other hospital units, 19% had to be admitted to the ICU. Somewhat surprisingly, 27% of NV-HAP cases were already in intensive care, where rigorous efforts to prevent pneumonia in vented patients are typically in place.
“That is, patients in the ICU, not on the ventilator, are acquiring HAP despite the preventive emphasis for patients who are on a ventilator,” Quinn and colleagues reported.
In the 24 hours prior to diagnosis, most of the patients did not have the basic oral care and other measures associated with pneumonia prevention, they found. While pneumonia often is associated with elderly patients, the study found that 51% of NV-HAP cases were in patients younger than 66 years of age.
We asked Quinn to tell us more about her continuing mission to try to prevent this underappreciated threat to patient safety.
HIC: VAP prevention has certainly been emphasized for years, and appropriately so. What are some of the reasons NV-HAP has been an underrecognized infection?
Quinn: When patient harms really began to hit the airwaves and raise awareness back in the 1990s, [public health officials] chose to work on things that they had the most control over and would be the easiest to measure. When they started asking people to measure and improve, they needed to come with infections that they could identify easily and have clear metrics for. I think that is the reason they chose to first work on device-related infections, [like] VAP, catheter-associated UTIs, or central line infections.
We have made huge strides in reducing those. But I think now we are getting to the point — and several articles have pointed to this in the last few years — that is really time to move forward and look at other opportunities.
HIC: What are some of the challenges to preventing NV-HAP?
Quinn: NV-HAP is not a device-related infection. With VAP there is only one type of unit you have to monitor, and that is the ICU. That’s the only place you can have patients on a ventilator. You can take a quick peek and know how many patients are [at risk]. NV-HAP happens in every unit of the hospital and every patient is at some risk. It is a little hard to just look at somebody and determine if they are at risk or not. It’s a much more comprehensive and daunting task. And because it has not been required to be reported, people have been focusing on things that are required.
That’s human nature and that’s how we work. In a nutshell, that is why this has gone undiscovered and unseen for quite a while. Now, I think this is one of the big ones that has jumped out because the numbers [of infections] are so high.
HIC: How do interventions like oral care break the cycle that leads to pneumonia?
Quinn: If you look at the pathophysiology of pneumonia, what are the things that have to happen? One is that you have a pathogen in the mouth. It only takes 24 hours to get pathogenic bacteria in the mouth that can cause pneumonia. Number two, you need some type of aspiration, whether it is macro or micro. Even healthy people micro-aspirate. And then the third is that you have to have a patient in a compromised situation, where their immune system is down and things are not working properly. That’s why patients in the hospital are at higher risk. Then we set them up to aspirate even more by sedating them and keeping them in a bed.
Anybody who is in a hospital is there for a reason, but there are patients that are at greater risk than others. For example, elderly patients and patients with chronic conditions. But there are certain risk factors like germs in the mouth and micro-aspiration that every single patient is at risk for. That’s why we really think of this as a standard of care for every patient.
HIC: This could be considered labor-intensive by those currently not doing it, but do you see this oral cleaning and disinfection eventually becoming integrated into routine care?
Quinn: Yes, I think as the awareness increases. That has to be the first thing that happens with any change. People have to become aware that it is an issue. We have been working really hard — this is our third publication on this. There are other [researchers] coming forward.
HIC: You mentioned you have other research underway on this.
Quinn: We have another paper we are working on that is looking at the whole national database. We are finding the same thing [as this paper], and that is up for review right now before publication. We are trying to get the word out and increase awareness.
What we have found in the last few years in speaking with other people in healthcare, is that once people know about this they want to do something. It makes perfect sense. It is not highly technical and you don’t have to hire new people to do it. You just have to help the caregivers understand the importance of it, and do some change management and make sure they have what they need to be successful. [To begin], measure how many times you are brushing patients’ teeth and measure how many incidents of pneumonia you have.
HIC: You cited the lack of reporting. Would it help this effort to have some kind of required reporting of NV-HAP, say to the CDC’s National Healthcare Safety Network (NHSN)?
Quinn: For pneumonia in the NHSN, there are two categories. One is required, and that is VAP. For patients on a ventilator, there are certainly things you have to monitor and be working on. NV-HAP is sort of a category B — if you want to work on it you can, but they are not requiring it. So, until that moves up to category A there will be some limit to what we can do. But for something with this kind of incidence in every hospital in the U.S. we can look at trends. You don’t have to do the same type of surveillance that you do with device-related infections; you can just look at trends overall.
Rather than a required measure, I think of this more like a national patient safety goal from The Joint Commission. [For those] they say, “We are not going to tell you how to fix this, but when we come to accredit your institution we are going to be asking how are you looking at this and measuring it. How are you working to improve it and are you making progress?”
HIC: Have you suggested this idea to The Joint Commission?
Quinn: We have been in conversations with The Joint Commission. They have been working with us to try to get the awareness out there with the best plan of action for them to support this. We have also worked with the American Dental Association because oral care is sort of up their alley. So, we are getting there at the national level.
HIC: The CDC has a high standard of evidence for their guidelines, so this is not something as simple as getting them to issue recommendations for all hospitals?
Quinn: There is limited [medical] literature out there about how to prevent non-ventilator hospital acquired-pneumonia. There is a lot of literature on VAP, but it is very limited on NV-HAP. That’s one of the reasons here at Sutter Health we are getting ready to launch a systemwide initiative to do standardized oral care for every hospital patient. We are going to be tracking frequency of oral care and occurrence of NV-HAP. So, hopefully we will have a high-level implementation study to help contribute, but right now there is really a lack of those type of studies on this particular HAI.
HIC: Given the potential savings in lives and dollars, it would seem the CDC would certainly be receptive once it has sufficient data to support guidelines.
Quinn: Yes, we have been in contact with CDC. They are definitely interested and engaged, but again they are in a difficult position when there is not a lot of literature out there on exactly how to prevent this. I think they are interested in helping with the awareness issue, but we are really putting out a call for high-level implementation studies. I don’t believe we need to do randomized control trials. Who wants their mother to be in the group that doesn’t get comprehensive oral care? Most of the literature out there — even though it is not randomized control trials — shows that any oral care helps prevent pneumonia. I think we have evidence, but there are more studies we can do that will give this a high level of validity.
- Baker D, Quinn B. Hospital Acquired Pneumonia Prevention Initiative-2: Incidence of nonventilator hospital-acquired pneumonia in the United States. Am J Infect Control 2018;45(13):DOI: https://doi.org/10.1016/j.ajic.2017.08.036.