Hospital Acquired Pneumonia and Oral Care
Pneumonia is an infection of the lungs that causes inflammation of the air sacs, which may fill with fluid, typically caused by a bacteria or virus. Hospital acquired pneumonia (HAP) is the same infection of the lungs, however it is more commonly caused by a bacterium and is acquired by patients 48 hours or more after being admitted to the hospital and was not existing on admission. HAP is a major safety issue among patients as it the second most common hospital acquired infection (HAI), totaling to 25% of all HAI’s in the U.S. every year. Much focus is placed on ventilator associated pneumonia (VAP) with designated prevention policies from the National Safety Healthcare Network that require monitoring and interventions, however VAP makes up about 38% of HAP, placing about 3.5 million patients at risk every year. Meanwhile, nonventilator HAP (NV-HAP) accounts for the larger 60% of cases and does not require the same monitoring or interventions to prevent, placing approximately 35 million patients every year exposed to this infection. Though the mortality rate between NV-HAP and VAP is very similar at just above 18%, NV-HAP impacts more people, thus the overall expenses are nearly doubled and amount to about $40,000.00 more each patient. NV-HAP, as with nearly all hospital acquired infections, is more common in high-risk patients, such as those with serious hidden diseases, young children or older adults (65 years +), but it can and does happen on every kind of hospital unit. There are no specifications from regulatory agencies to record HAP in connection with patients who are not ventilated and there is not enough encouragement to make unsatisfactory oral care better, which is an alterable component to reduce the risk of this infection. Oral care is imperative, as in a matter of 4-6 short hours nearly 20 billion bacteria duplicate and patients can microaspirate, therefore decreasing this oral bacterium is vital to prevent NV-HAP.
Avoiding pneumonia in hospitals poses many trials. The main trial is a result of the lack of obligation of hospitals to record the amount of cases of pneumonia. Due to this, NV-HAP continues to be an undisclosed illness in hospitals. As Baker and Quinn (2018) analyzed, NV-HAP is underexamined, is a growing concern with more cases than NV-HAP, and preventative measures are often not implemented in acute care hospitals.
In hospitalized, non-ventilated adult patients will using extensive oral care procedures and training reduce the incidence of hospital acquired pneumonia compared to routine oral care during the period of hospitalization within 6 months?
Importance to Nursing
Nurses have vital roles in the care of patients; such as patient education, incorporating previous experiences, applying evidence-based practices and preventing any hospital acquired infections. Nurses are also advocating for their patients, with the ability to enhance the requirements for patient care. Every patient wants a safe environment and to leave the hospital free of any additional illnesses after hospital admission. As previously mentioned, the bacteria in the oral cavity rapidly multiplies, and it is noted that in 73% of NV-HAP cases, oral care was not logged 24 hours prior to the diagnosis. The nurse, as provided with the proper education and tools can provide proper oral care or teach and encourage oral care done by the patient to help reduce the prevalence of NV-HAP. With the prevention of NV-HAP the nurse is not only helping to avoid additional days spent in the hospital by the patient but also reducing the hospital care cost and mortality rates. By avoiding 1300 NV-HAP cases, an estimated $28,000-$40,000 per patient is saved, which would be an additional $36.4-$52.56 million in costs for the hospital on those patients. This would also equate to an additional 9,197-11,826 more inpatient days, placing the patients at additional risk for other issues. Nurses being advocates can greatly contribute to this initiative and make a change for the better regarding patient care and hospital costs.
Literature Review
There have not been any specific research studies on the topic of additional nurse training and extensive oral care procedures to prevent NV-HAP. Very few studies have been done on oral care and nonventilated hospital acquired pneumonia, as much focus is placed on ventilated associated pneumonia. The few that have been conducted have many of the same researchers involved. A single arm intervention study was conducted using Veterans Affairs (VA) medical facilities with the first location being in Salem, VA, starting in the CLC units, progressing to the medical surgical units and then to the second location in Houston. This study consisted of a total of 14,396 patient days which lasted from 2002-2012 and was used to establish the total number of occurrences of the disease prior to using only standard care and the success using a standard oral care protocol. During the first year the results showed that the prevalence of the disease decreased by 92%, saved the lives of 13 people, avoided 71 possible cases and averted possible costs of $2.84 million . This was a significant decrease in numbers by simply adding in an oral care routine twice daily. These results show that there is an astounding correlation to oral care and developing hospital acquired pneumonia. Preceding the study, the locations did not have the proper knowledge in NV-HAP prevention, nor was oral care implemented or reported routinely outside of intensive care.
The next two research studies were done by the same researchers as initiative one and two starting in 2015. The first study examines the sources and repercussions of NV-HAP
that are left unevaluated explaining the reason that fundamental nursing and oral care is important to keep this illness from occurring. Quinn and Baker (2015) state that studies have shown that the oral bacteria changes in patients within 48 hours of being admitted to the hospital and that even healthy patients can microaspirate while laying flat on the back in combination with different drugs that put the central nervous system down. All these things in combination with a patient that has declined mobility and a lack of proper oral care is an optimal condition to allow bacteria to thrive. Surveys of the nurses also show that they are unaware of any correlation of poor oral care and pneumonia, that it is considered a means of increased comfort for patients. In 2012 a nurse initiative was started in a hospital in California to prevent HAP simply by promoting oral care. Within a year the rate of NV-HAP had dropped 60% and saved the hospital $2 million. The researchers were able to create a team, address the lack of supplies, revise oral care conduct, increase documentation and educate the staff. The HAPPI team noted that patients were 49% less likely to pickup NV-HAP than patients the year prior to above mentioned interventions.
The second initiative presents very effective data that assists in the prevalence of NV-HAP, the general difficulty and the overall degree of charted preventative interventions in 21 different hospitals throughout the U.S.The National Study Advisory Board supervised the project and hospitals were selected by convenience sampling and approved by the advisory council, including meeting the inclusion criterion. Charts were extracted using specific codes for pneumonia and cross checked with the CDC definitions. Between the 21 hospitals it was discovered that 1300 patients had inherited NV-HAP, of those 70.8% were not in ICU and 18.8% were transferred into the ICU. It was also noted that most of these patients did not receive any oral care within 24 hours previous to being diagnosed.
Additional studies on NV-HAP would be relevant as it is much more common than VAP, where most of the focus and regulations seem to be placed. These few studies show a great deal of data that validate that oral care is extremely crucial in preventing NV-HAP.
References
- Baker, D., & Quinn, B. (2018). Hospital Acquired Pneumonia Prevention Initiative-2: Incidence of nonventilator hospital-acquired pneumonia in the United States. American Journal of Infection Control, 46(1), 2–7. https://doi.org/10.1016/j.ajic.2017.08.036 (primary)
- El-Rabbany, M., Zaghlol, N., Bhandari, M., & Azarpazhooh, A. (2015). Prophylactic oral health procedures to prevent hospital-acquired and ventilator-associated pneumonia: A systematic review. International Journal of Nursing Studies, 52(1), 452-464. doi:10.1016/j.ijnurstu.2014.07.010 (secondary)
- Munro, S., & Baker, D. (2018). Reducing missed oral care opportunities to prevent non-ventilator associated hospital acquired pneumonia at the Department of Veterans Affairs. Applied Nursing Research, 44, 48-53. doi:10.1016/j.apnr.2018.09.004 (primary)
- Quinn, B., & Baker, D. L. (2015). Comprehensive oral care helps prevent hospital-acquired nonventilator pneumonia: a nurse-led prevention initiative proved that oral care is far more than just a comfort measure. American Nurse Today, 10(3), 18+. Retrieved from http://link.galegroup.com.ezlib.gatewaycc.edu:2048/apps/doc/A411615948/AONE?u=mcc_gateway&sid=AONE&xid=d5c77416 (primary)
