ANN-MICHELLE SHERMAN RN, BSN, CMSRNWSU MSN- EDUCATION PRACTICUM PROJECT

JANET FREY APRN

Prevention of Non-Ventilator Hospital Acquired Pneumonia

(NV-HAP)

Objectives

State the significance of non-ventilator hospital acquired pneumonia (NV-HAP)

Name 3 nurse driven interventions to prevent NV-HAP

Demonstrate proper technique for IS utilization

Explain impact oral care has on prevention of NV-HAP

Pneumonia

Pneumonia

Background

Under-reported, under studied VAP – well defined prevention measures NV-HAP – studies focus on post surgical and

immunocompromisedDefined

Pneumonia occurring > 48 hours after admission Criteria for HAP (CDC)

Cxr – new infiltrate, cavitation or consolidation Immune response – temp > 100.4, leukopenia (<4,000),

leukocytosis >12,000, AMS in those >70 yo S&S – new purulent sputum, change in sputum, increased

secretions, increased suctioning requirement, new or worsening cough, dyspnea, tachypnea, rales, worsening gas exchange (O2 sat)

Mechanical ventilation not in place 48 hours prior to pneumonia diagnosis

Background

At risk population 3 Common condition categories

1. Enhanced colonization of oropharynx or stomach Use of antacids – gastro pulmonary route

• Alkalization of stomach provides environment for bacterial growth Micro aspiration - oropharyngeal colonization

2. Conditions that favor aspiration Decreased CNS

• Impaired cough, gag and swallowingDisease processMedications

3. Host factors Age

Outliers Risk analysis does not provide enough sensitivity and specificity NV-HAP found outside the risk parameters and in all hospital units

Background

Significance 18.9 – 29% mortality Cost

$28K-$109K Increased length of stay

4-9 days

Spread of infection surface contact Droplets

Infectious secretions from a sneeze linger in air for hours

4 Interventions

Missed opportunities for nursing intervention Elevated head of bed

34% Mobility

59% not mobilized each shift Oral care

73% did not receive each shift IS/C&DB

84% did not receive coaching

4 Interventions

Nursing leads the way!Simple interventions can significantly impact

your patient!1. Oral care

Decreases oral bacteria

2. Early ambulation3. Elevate head of bed > 30 degrees4. Incentive spirometer

For patients who have IS ordered

4 interventions

Oral care – simple intervention Dental plaque provides microhabitat for growth of bacteria

Colonization of bacteria causing pneumonia has been found in oral cavity Mechanical pathway from mouth to lungs provides easy access for bacteria

Up to 45% are silent or micro aspirators Hospitalized patients are often immunosuppressed, have

poor cough or multiple comorbidities Wide variances in practice (HOB, swab, brush)

NV-HAP prevention May be reduced by improving oral care Toothbrush removes plaque, swabs don’t Brush 1-2 minutes Frequency - ?

Current standard is 2x/day

Antiseptic mouth wash

4 Interventions

Early Mobilization and Ambulation Walking to the bathroom is not ambulation Encourage those who are able to walk in the hall

NV-HAP prevention Mobilizes secretions Opens collapsed alveoli

• Increases lung capacity

4 Interventions

Head of Bed elevation 30-45% Patients in prolonged supine position are at risk for

GERD Elevation of head of bed promotes esophageal

drainage of secretions by gravity For all patients meals should be eaten while upright in

chair to decrease aspiration risko If getting out of bed is contraindicated, place bed in most

upright position

NV-HAP prevention Prevents aspiration

IS simulation

Pre-brief Tickets Simulation of techniques to prevent pneumonia Incorporation of current knowledge

IS Scenario

58 yo female patient is 3 hours post op right hip replacement for RA. PMH: COPD, current smoker, RA, anxiety. You enter room to do your assessment. VS 124/63, HR 82 regular, RR 16, temp 100.2, pain 2/10. Lungs sounds are coarse crackles, skin warm and dry, peripheral pulses 2+, right hip dressing is dry and intact.

Debrief Mosby’s skills

Incentive spirometer

4 Steps to Prevention

ISNV-HAP prevention• Q 1 hour while awake - May increase frequency if

desired• Prevents atelectasis (collapsing of alveoli)• Keeps secretions from pooling in alveoli

4 Interventions

IS Instructions for use

1. Identify patient target volume using chart packaged with IS

2. Have patient sit upright in bed or chair3. Place lips tightly around mouthpiece4. Take in slow deep breath - maintain constant flow5. At maximal inspiration hold breath for 5 seconds6. Allow rest between IS breaths to prevent

hyperventilation7. Perform IS 10 x/hour while awake (more if patient is

willing)8. Enlist family to provide support and coach patients

Conclusion

HAP occurs in non-ventilated patientsPatients on all units are at riskImproved identification and prevention

Decreased mortality Increased quality of life Better patient outcomes Fiscal savings Decreased length of hospital stays

Impact of nursing actions Don’t miss your chance to prevent pneumonia

References

Curtis, L. (2008). Review: Prevention of hospital-acquired infections: review of non-pharmacological interventions. Journal Of Hospital Infection, 69(Special edition: Surveillance of Hospital Acquired Infection), 204-219. doi:10.1016/j.jhin.2008.03.018

Echevarría, I. M., & Schwoebel, A. (2012). Development of an Intervention Model for the Prevention of Aspiration Pneumonia in High-Risk Patients on a Medical-Surgical Unit. MEDSURG Nursing, 21(5), 303-308.

Fortaleza, C., Abati, P., Batista, M., & Dias, A. (n.d). Risk Factors for Hospital-Acquired Pneumonia in Nonventilated Adults. Brazilian Journal Of Infectious Diseases, 13(4), 284-288.

Mehta, Y., Gupta, A., Todi, S., Myatra, S. N., Samaddar, D. P., Patil, V., & ... Ramasubban, S. (2014). Guidelines for prevention of hospital acquired infections. Indian Journal Of Critical Care Medicine, 18(3), 149-163. doi:10.4103/0972-5229.128705

Niederman, M. S. (2010). Hospital-Acquired Pneumonia, Health Care-Associated Pneumonia, Ventilator-Associated Pneumonia, and Ventilator-Associated Tracheobronchitis: Definitions and Challenges in Trial Design. Clinical Infectious Diseases, 51S12-S17. doi:10.1086/653035

Robertson, T., & Carter, D. (2013). Oral intensity: Reducing non-ventilator-associated hospital-acquired pneumonia in care-dependent, neurologically impaired patients. Canadian Journal Of Neuroscience Nursing, 35(2), 10-17.

Quinn, B., Baker, D. L., Cohen, S., Stewart, J. L., Lima, C. A., & Parise, C. (2014). Basic Nursing Care to Prevent Nonventilator Hospital-Acquired Pneumonia. Journal Of Nursing Scholarship, 46(1), 11-19. doi:10.1111/jnu.12050