Hostname: page-component-8448b6f56d-xtgtn Total loading time: 0 Render date: 2024-04-18T12:07:12.737Z Has data issue: false hasContentIssue false
  • English
  • Français

A successful program preventing nonventilator hospital-acquired pneumonia in a large hospital system

Part of: BARRY FARR AWARD RECIPIENTS

Published online by Cambridge University Press:  15 January 2020

Cristine C. Lacerna ,
Donna Patey ,
Lawrence Block ,
Sejal Naik ,
Yulia Kevorkova ,
Jessica Galin ,
Melanie Parker ,
Robin Betts ,
Stephen Parodi  and
David Witt
Cristine C. Lacerna
Affiliation:
Kaiser Permanente Northern California, Risk and Patient Safety, Oakland, California
Donna Patey
Affiliation:
Kaiser Permanente Northern California, Risk and Patient Safety, Oakland, California
Lawrence Block
Affiliation:
Kaiser Permanente Northern California, Quality and Operations Support, Oakland, California
Sejal Naik
Affiliation:
Kaiser Permanente Northern California, Risk and Patient Safety, Oakland, California
Yulia Kevorkova
Affiliation:
Kaiser Permanente Northern California, Quality and Operations Support, Oakland, California
Jessica Galin
Affiliation:
Kaiser Permanente Northern California, Quality and Operations Support, Oakland, California
Melanie Parker
Affiliation:
Kaiser Permanente Northern California, Risk and Patient Safety, Oakland, California
Robin Betts
Affiliation:
Kaiser Permanente Northern California, Risk and Patient Safety, Oakland, California
Stephen Parodi
Affiliation:
The Permanente Medical Group, Executive Offices, Oakland, California
David Witt*
Affiliation:
Kaiser Permanente Northern California, Risk and Patient Safety, Oakland, California
*
Author for correspondence: David Witt, E-mail: david.j.witt@kp.org
Get access Rights & Permissions [Opens in a new window]

Abstract

Objective:

To develop and evaluate a program to presvent hospital-acquired pneumonia (HAP).

Design:

Prospective, observational, surveillance program to identify HAP before and after 7 interventions. An order set automatically triggered in programmatically identified high-risk patients.

Setting:

All 21 hospitals of an integrated healthcare system with 4.4 million members.

Patients:

All hospitalized patients.

Interventions:

Interventions for high-risk patients included mobilization, upright feeding, swallowing evaluation, sedation restrictions, elevated head of bed, oral care and tube care.

Results:

HAP rates decreased between 2012 and 2018: from 5.92 to 1.79 per 1,000 admissions (P = .0031) and from 24.57 to 6.49 per 100,000 members (P = .0014). HAP mortality decreased from 1.05 to 0.34 per 1,000 admissions and from 4.37 to 1.24 per 100,000 members. Concomitant antibiotic utilization demonstrated reductions of broad-spectrum antibiotics. Antibiotic therapy per 100,000 members was measured as follows: carbapenem days (694 to 463; P = .0020), aminoglycoside days (154 to 61; P = .0165), vancomycin days (2,087 to 1,783; P = .002), and quinolone days (2,162 to 1,287; P < .0001). Only cephalosporin use increased, driven by ceftriaxone days (264 to 460; P = .0009). Benzodiazepine use decreased between 2014 to 2016: 10.4% to 8.8% of inpatient days. Mortality for patients with HAP was 18% in 2012% and 19% in 2016 (P = .439).

Conclusion:

HAP rates, mortality, and broad-spectrum antibiotic use were all reduced significantly following these interventions, despite the absence of strong supportive literature for guidance. Most interventions augmented basic nursing care. None had risks of adverse consequences. These results support the need to examine practices to improve care despite limited literature and the need to further study these difficult areas of care.

Type
Original Article
Information
Infection Control & Hospital Epidemiology , Volume 41 , Issue 5 , May 2020 , pp. 547 - 552
Copyright
© 2020 by The Society for Healthcare Epidemiology of America. All rights reserved

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Davis, J, Finley, E. The breadth of hospital-acquired pneumonia: nonventilated versus ventilated patients in Pennsylvania. PA Patient Saf Advis 2012;9:99–105.Google Scholar
Magill, SS, Edwards, JR, Bamberg, W, et al. Multistate point-prevalence survey of health care-associated infections. N Engl J Med 2014;370:1198–1208.CrossRefGoogle ScholarPubMed
American Thoracic Society. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med 2005;171:388–416.CrossRefGoogle Scholar
Leu, HS, Kaiser, DL, Mori, M, Woolson, RF, Wenzel, RP. Hospital-acquired pneumonia: attributable mortality and morbidity. Am J Epidemiol 1989;129:1258–1267.CrossRefGoogle ScholarPubMed
Passaro, L, Harbarth, S, Landelle, C. Prevention of hospital-acquired pneumonia in non-ventilated adult patients: a narrative review. Antimicrob Resist Infect Control 2016;5:43.CrossRefGoogle ScholarPubMed
Wren, SM, Martin, M, Yoon, JK, Bech, F. Postoperative pneumonia-prevention program for the inpatient surgical ward. J Am Coll Surg 2010;210:491–495.CrossRefGoogle ScholarPubMed
Kazaure, HS, Martin, M, Yoon, JK, Wren, SM. Long-term results of a postoperative pneumonia prevention program for the inpatient surgical ward. JAMA Surg 2014;149:914–918.CrossRefGoogle ScholarPubMed
McAuley, SM, Price, RJG, Phillips, G, et al. Interventions to prevent non-critical care hospital acquired pneumonia—a systemic review. Eur Geriatric Med 2015;6:336–340.CrossRefGoogle Scholar
Klompas, M. Hospital-acquired pneumonia in nonventilated patients: the next frontier. Infect Control Hosp Epidemiol 2016;37:825–826.CrossRefGoogle ScholarPubMed
Roulson, J, Benbow, EW, Hasleton, PS. Discrepancies between clinical and autopsy diagnosis and the value of post mortem histologya meta-analysis and review. Histopathology 2005;47:551–559.CrossRefGoogle ScholarPubMed
Russell, CD, Koch, O, Laurenson, IF, O’Shea, DT, Sutherland, R, Mackintosh, CL. Diagnosis and features of hospital-acquired pneumonia: a retrospective cohort study. J Hosp Infect 2016;92:273e279.CrossRefGoogle ScholarPubMed
Rotstein, C, Evans, G, Born, A, et al. Clinical practice guidelines for hospital-acquired pneumonia and ventilator-associated pneumonia in adults. Can J Infect Dis Med Microbiol 2008;19:19–53.CrossRefGoogle ScholarPubMed
Ewig, S, Welte, T, Chastre, J, Torres, A. Rethinking the concepts of community-acquired and health-care-associated pneumonia. Lancet Infect Dis 2010;10:279–287.CrossRefGoogle ScholarPubMed
Wooten, DA, Winston, LG. Risk factors for methicillin-resistant Staphylococcus aureus in patients with community-onset and hospital-onset pneumonia. Respir Med 2013;107:1266–1270.CrossRefGoogle ScholarPubMed
Schreiber, MP, Chan, CM, Shorr, AF. Resistant pathogens in nonnosocomial pneumonia and respiratory failure: is it time to refine the definition of health-care-associated pneumonia? Chest 2010;137:1283–1288.CrossRefGoogle ScholarPubMed
Horan, TC, Andrus, M, Dudeck, MA. CDC/NHSN surveillance definition of healthcare-associated infection and criteria for specific types of infections in the acute care setting. Am J Infect Control 2008;36:309–332.CrossRefGoogle ScholarPubMed
Wipf, JE, Lipsky, BA, Hirschmann, JV, et al. Diagnosing pneumonia by physical examination: relevant or relic? Arch Intern Med 1999;159:1082–1087.CrossRefGoogle ScholarPubMed
Wolfensberger, A, Meier, AH, Kuster, SP, Mehra, T, Meier, M-T, Sax, H. Should International Classification of Diseases codes be used to survey hospital-acquired pneumonia? J Hosp Infect 2018;99:81–84.CrossRefGoogle ScholarPubMed
Roquilly, A, Marret, E, Abraham, E, Asehnoune, K. Pneumonia prevention to decrease mortality in intensive care unit: a systematic review and meta-analysis. Clin Infect Dis 2015;60:64–75. di:10.1093/cid/ciu740.CrossRefGoogle ScholarPubMed
Obiora, E, Hubbard, R, Sanders, RD, Myles, PR. The impact of benzodiazepines on occurrence of pneumonia and mortality from pneumonia: a nested case-control and survival analysis in a population-based cohort. Thorax 2013;68:163–170.CrossRefGoogle Scholar
Taipale, H, Tolppanen, AM, Koponen, M, et al. Risk of pneumonia associated with incident benzodiazepine use among community-dwelling adults with Alzheimer disease. CMAJ 2017;189:E519–E529.CrossRefGoogle ScholarPubMed
Alexiou, VG, Ierodiakonou, V, Dimopoulos, G, Falagas, ME. Impact of patient position on the incidence of ventilator-associated pneumonia: a meta-analysis of randomized controlled trials. J Crit Care 2009;24:515–522.CrossRefGoogle ScholarPubMed
Lawrence, VA, Cornell, JE, Smetana, GW. American College of P. Strategies to reduce postoperative pulmonary complications after noncardiothoracic surgery: systematic review for the American College of Physicians. Ann Intern Med 2006;144:596–608.CrossRefGoogle Scholar
Qaseem, A, Snow, V, Fitterman, N, et al. Risk assessment for and strategies to reduce perioperative pulmonary complications for patients undergoing noncardiothoracic surgery: a guideline from the American College of Physicians. Ann Intern Med 2006;144(8):57.CrossRefGoogle ScholarPubMed
Stolbrink, M, McGowan, L, Saman, H, et al. The early mobility bundle: a simple enhancement of therapy which may reduce incidence of hospital-acquired pneumonia and length of hospital stay. J Hosp Infect 2014;88:34–39.CrossRefGoogle ScholarPubMed
Lipp, RW, Schnedl, WJ, Hammer, HF, Kotanko, P, Leb, G, Krejs, GJ. Effects of postprandial walking on delayed gastric emptying and intragastric meal distribution in longstanding diabetics. Am J Gastroenterol 2000;95:419–424.CrossRefGoogle ScholarPubMed
Metheny, N. Minimizing respiratory complications of nasoenteric tube feedings: state of the science. Heart Lung 1993;22:213–223.Google ScholarPubMed
Metheny, NA, Meert, KL, Clouse, RE. Complications related to feeding tube placement. Curr Opin Gastroenterol 2007;23:178–182.CrossRefGoogle ScholarPubMed
Klompas, M. Editorial commentary: evidence vs instinct for pneumonia prevention in hospitalized patients. Clin Infect Dis 2015;60:76–78.CrossRefGoogle ScholarPubMed
Koebnick, C, Langer-Gould, AM, Gould, MK, et al. Sociodemographic characteristics. Perm J 2012;16:37–41.CrossRefGoogle ScholarPubMed
Drakulovic, MB, Torres, A, Bauer, TT, Nicolas, JM, Nogue, S, Ferrer, M. Supine body position as a risk factor for nosocomial pneumonia in mechanically ventilated patients: a randomised trial. Lancet 1999;354:1851–1858.CrossRefGoogle ScholarPubMed
Niel-Weise, BS, Gastmeier, P, Kola, A, Vonberg, RP, Willie, JC, van der Broek, PJ. An evidence-based recommendation on bed head elevation for mechanically ventilated patients. Crit Care 2011;1(2):R111.CrossRefGoogle Scholar
Fourrier, F, Dubois, D, Pronnier, P, et al. Effect of gingival and dental plaque antiseptic decontamination on nosocomial infections acquired in the intensive care unit: a double-blind placebo-controlled multicenter study. Crit Care Med 2005;33:1728–1735.CrossRefGoogle ScholarPubMed
DeRiso, AJ, 2nd, Ladowski, JS, Dillon, TA, Justice, JW, Peterson, AC. Chlorhexidine gluconate 0.12% oral rinse reduces the incidence of total nosocomial respiratory infection and nonprophylactic systemic antibiotic use in patients undergoing heart. Chest 1996;109:1556–1561.CrossRefGoogle ScholarPubMed
Li, L, Ai, Z, Li, L, Zheng, X, Jie, L. Can routine oral care with antiseptics prevent ventilator-associated pneumonia in patients receiving mechanical ventilation? An update meta-analysis from 17 randomized controlled trials. Int J Clin Exp Med 2015;8:1645–1657.Google ScholarPubMed
Metheny, NA, Schnelker, R, McGinnis, J, et al. Indicators of tube site during feedings. J Neurosci Nurs 2005;37:320–325.CrossRefGoogle ScholarPubMed
Herzig, SJ, Howell, MD, Ngo, LH, Marcantonio, ER. Acid-suppressive medication use and the risk for hospital-acquired pneumonia. JAMA 2009;301:2120–2128.CrossRefGoogle ScholarPubMed
Eom, CS, Jeon, CY, Lim, JW, Cho, EG, Park, SM, Lee, KS. Use of acid-suppressive drugs and risk of pneumonia: a systematic review and meta-analysis. CMAJ 2011;183:310–319.CrossRefGoogle ScholarPubMed
Loeb, M, McGeer, A, McArthur, M, Walter, S, Simor, AE. Risk factors for pneumonia and other lower respiratory tract infections in elderly residents of long-term care facilities. Arch Intern Med 1999;159:2058–2064.CrossRefGoogle ScholarPubMed
Rosière, J1, Vader, JP, Cavin, MS, et al. Appropriateness of respiratory care: evidence-based guidelines. Swiss Med Wkly 2009;139:387–392.Google ScholarPubMed
Lindstrom, D, Sadr Azodi, O, Wladis, A, et al. Effects of a perioperative smoking cessation intervention on postoperative complications: a randomized trial. Ann Surg 2008;248:739–745.CrossRefGoogle ScholarPubMed
Mills, E, Eyawo, O, Lockhart, I, Kelly, S, Wu, P, Ebbert, JO. Smoking cessation reduces postoperative complications: a systematic review and meta-analysis. Am J Med 2011;124:144–158.CrossRefGoogle ScholarPubMed
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;148:740–745.CrossRefGoogle ScholarPubMed