Non-ventilator-associated hospital acquired pneumonia (HAP) and hospital readmissions due to pneumonia negatively impact many thousands of patients every year and greatly impact the financial stability of hospitals regarding CMS and third-party insurance reimbursement and readmission-related penalties.
Of course, pneumonia cannot be completely eradicated. Many pneumonia readmissions are not preventable; even with appropriate treatment, approximately 1 in 6 pneumonia cases fails to resolve completely, and these patients may develop complications that require readmission to the hospital.1 However, it is critical to note that in a CMS study of 12 million participants2 the 30-day readmission rate for patients discharged after a pneumonia hospitalization was an alarming 20.1%, consistent with the rate reported in other studies.
In a 2015 paper, Joi Fox, et al described how infection preventionists at 12 LifePoint Health hospitals significantly reduced the rate of non-ventilator-related HAP through use of the safe practice bundles for post-operative patients and tube-fed patients.3 The reduction of non-ventilator associated HAPs is extremely impressive. One of the challenges identified by the LifePoint Health paper was the inconsistency in identifying other patients at risk for pneumonia. This challenge leads me to the topic of pneumonia prevention through electronic surveillance.
One of my passions as an infection preventionist is the prevention of non-ventilator associated pneumonia. I have to admit that this passion came about partially as a result of legislatively mandated public reporting of all HAIs by hospitals in Pennsylvania back in 2007/2008. Many infection preventionists remember that for decades, infection prevention focused on “targeted surveillance,” which included VAPs, CLABSIs, SSIs, CAUTIs. Hospital-wide surveillance of all HAIs was considered too labor intensive, and infection prevention resources were directed toward preventing and identifying the targeted HAIs noted above.
To be honest, before the Pennsylvania legislature mandated reporting of all HAIs, I had no idea what the occurrence of non-ventilator related hospital acquired pneumonia was at hospitals where I previously worked. What we found was alarming. We had one of the highest rates of non-ventilator-associated HAP in the state. A multidisciplinary pneumonia task force was formed, a root cause analysis was conducted, and a prevention bundle was developed for non-ventilated patients who were at risk for pneumonia.
In line with evidence-based literature on pneumonia, we found that post-op patients were not being ambulated adequately and oral care in the non-critical care nursing units was sometimes extremely sub-optimal. One particularly distressing finding was that in many cases, incentive spirometry was being ordered by the pulmonologist consulted to treat the patients’ pneumonia!
Where does electronic surveillance come into play? I had access to an electronic surveillance system (ESS) that automatically identified patients at risk for pneumonia, in real-time on the day of admission, as well as during the course of their hospitalization as the patient’s condition evolved. We used the ESS to identify patients with known pneumonia risks, including history of pneumonia, history of CVA, presence of an NG tube, textual recognition of chest tubes, and immobility due to post-op status. The ESS also alerted staff when a video swallow study was ordered − these patients were considered at risk of aspiration.
We then implemented a pneumonia prevention bundle, which included initiation of incentive spirometry, aggressive ambulation when medically appropriate, etc. Implementing the bundle was a culture change at the hospital. Through the real-time ESS alerts, we were able to intervene on patients before symptoms occurred. Over the course of approximately one year, the occurrence of non-ventilator-associated HAP was reduced from an average of five per month to one in six months (average daily census was about 110 patients).
Do you know the rate of non-ventilator associated pneumonia at your facility? Do you have a multidisciplinary approach for prevention? If you are using an ESS to support your surveillance program, investigate how you can optimize that system to identify patients at risk for pneumonia in a timely manner.
- Allaudeen N, Vidyarthi A, Maselli J, Auerbach A. Redefining readmission risk factors for general medicine patients. J Hosp Med. 2011 Feb;6(2):54–60
- Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009 Apr 2;360(14):1418–1428. Erratum in: N Engl J Med. 2011 Apr 21;364(16):1582
- Fox J, Frush K, Chamness C, Malloy J, Hyde S. Preventing hospital-acquired pneumonia (HAP) outside of the ventilator-associated pneumonia bundle. Prevention Strategist, Fall, 2015 – an APIC publication. http://www.apic.org/Resource_/TinyMceFileManager/Periodical_Images/Preventing_HAP_Fall2015.pdf