2/20/2017. Are You Addressing the New #1 Patient Harm in Your Hospital? Pneumonia NOT Related to a Ventilator

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1 Barbara Quinn, RN, ANCS-BC Sutter Medical Center, Sacramento, CA Are You Addressing the New #1 Patient Harm in Your Hospital? Pneumonia NOT Related to a Ventilator The story of May and how we began this journey May is a 57 year old grandmother who develops nonventilator hospital acquired pneumonia (NV-HAP) Why does this keep happening? Em m awinnhealthy Elderly s.surrey.ac.u k/nu tri tio na nd b one /swiss. htm l 2 We were familiar with VAP but was NVHAP flying under the radar? How much non-v entilator pneumonia was occurring in the hospital? Was it happening in other hospitals? Could it be prev ented? If so, how? 1

2 Incidence of NV-HAP: Three hospital sy stems study (2012 used 2010 data) similar results from Kaiser and the VA Sutter Medical Center (2010 data): 24,482 patients; 94,247 patient days 1.25/1000 pt days & 0.49/100 pts 115 NV-HAP Most on Med/Surg Units Total estimated annual impact: $4.6 million 23 deaths 1035 days Quinn, B., Baker, D., et. al. (2014). Basic nursing care to prevent nonventilator hospital-acquired pneumonia. Journal of Nursing Scholarship. 4 Summary of Recent Literature NVHAP is a National Problem Incidence: 2/100 admitted patients HAP Top HAI in U.S. (60% NVHAP) Mortality: 14 to 30% Length of Stay: 4-16 days Cost: 28K 40K Readmission: 20% Sepsis: 40-50% The Next Frontier 9(3). Davis & Finely (2012). Penn Pt Safety Authority, Giuliano, et al. (2016) AORN Poster 2016 Magill, et.al. (2014) NEJM. 370(13), p Micek, et. al. (2016). CHEST, 150(5), See, et. al. (2016). ICHE, 37, doi: /ice U.S. hospitals 1300 NV-HAP Cases IMPACT HAPPI-2 Preliminary Analysis Same mortality, LOS, Readmission data In addition: 60% occurred on Med/Surg units 26% transferred to ICU 34% admitted from home were discharged to a higher level of care Quinn & Baker, Publication Pending

3 In Addition HAIs New on Top 10 Public Health Concerns in U.S. NVHAP: The New Frontier CDC (2015 Prevention Status Report Klompas (July 2016) HCHE By reducing NV-HAP we address quality goals of every healthcare organization: Mortality Length of stay 30 day Readmission Af fordability Sepsis ICU utilization Long term morbidity How can we prevent pneumonia? P9 3

4 Germs Reduce harmful pathogens with: Comprehensive oral care Aspiration Reduce aspiration with: Swallow assessments Head of bed elevated Oral/ Nasal gastric Tube Care Host Increase host resistance with: Early mobility *Keep patients warm during surgery Pulmonary toilet *Glucose control Limit use of acid suppressive meds Quinn & Baker. (2014). J Nsg Scholarship, 46(1), Prevent Hospital Acquired Pneumonia 11 Most Pneumonia Starts in the Mouth Microbiome of Oral Cavity 200 billion oral microbes species 48 hours for HAP pathogens in mouth o If aspirated =100,000,000 bacteria/ml saliva into lungs / Loesche, W. 2012/ Sacnnapieco et al. (1992).CritCareMed, 20:

5 Microaspiration At least 50% of healthy adults micro aspirate Elev ating the head of the bed does not prev ent all aspiration or micro aspirations Gleeson K, et al. (1997) Microaspiration during sleep in healthy subjects. Chest. 111: Photo from : -of-the-human-body-respiratory-system-pictures-2/picture-of-the-human-body -respiratory -system -pictures -2/ Who is at most risk? Who is not at risk? 14 Who is at-risk? ALL patients in the hospital therefore a standard of care is required Scatter plot example 15 5

6 Why Oral Care as Primary Intervention? Systematic Rev iew & Meta Analysis 5 RCTs: Oral care to prev ent NV-HAP Risk Reduction for NVHAP (P=.02) RR for fatal NV-HAP (P=.002) Kaneoka (2015) ICHE Prev of HCAP w oral care Underused care associated with the development of pneumonia* Missed Achieved ELEVATED HOB 34% 66% MOBILITY 59% 41% ORAL CARE 73% 27% IS/C&DB 84% 16% Coker et al. (2016). Obs oral hygiene provided by nurses elder adults. Geriatric Nsg, dx.doi.org/ /j.g erin urs e ) *Kalisch, B. (2013). Am J Med Qual. Missed nursing care leads to poor pt outcomes. *Data from Sutter H APPI 1 study 17 What have we learned? Pneumonia - occurring in nonventilated patients in All types of hospital systems Patients are at risk on ALL types of hospital units Costing significant number of liv es and dollars Opportunities for prevention are unused Prev entive care not completed 18 6

7 I don t mind change; I just don t like to be changed Recommendations to Address NV-HAP & Post op pneumonia at your facility: Use a scientific model to change behavior Measure baseline NV-HAP Gather an interdisciplinary team Select Interventions based on Gap Analysis findings & EBP Recommendations to Address NV-HAP & Post op pneumonia at your facility: Focus on one intervention at a time, beginning with the most modifiable risk factors Monitor process and outcome measures; calculate ROI Provide feedback to staff and leadership Celebrate and share your successes 7

8 JAN 2010 FEB 2010 MAR 2010 APR 2010 MAY 2010 JUN 2010 JUL 2010 AUG 2010 SEP 2010 OCT 2010 NOV 2010 DEC 2010 MAY 2012 JUN 2012 JUL 2012 AUG 2012 SEP 2012 OCT 2012 NOV 2012 DEC 2012 JAN 2013 FEB 2013 MAR 2013 APR 2013 MAY 2013 JUN 2013 JUL 2013 AUG 2013 SEP 2013 OCT 2013 NOV 2013 DEC 2013 JAN 2014 FEB 2014 MAR 2014 APR 2014 MAY 2014 JUL 2014 AUG 2014 SEP 2014 OCT 2014 NOV 2014 DEC 2014 Number of non-ventilator HAP cases 2/20/2017 NV-HAP 70% from baseline! Control chart for non-ventil at or HAP January 2010 to December Oral care for all 16 Baseline adult pts UCL Documentatio n NGT standar ds Pharmacy starts PPI protocol Started oral care prior to surgery 8 revised M ean Mandatory Education for Nurse Assistants LCL 22 Post operative NV-HAP (all adult inpatient surgery) Incidence 6 months pre oral care vs. 6 months after Post Op NV-HAP M ar - Ju ly 1 4 Aug 14 -Ja n Return on investment: What does prevention mean? Between May 2012 and December 2014 we avoided 164 cases of NV-HAP 31 lives saved $5.9 million not spent extra days in the hospital avoided 8

9 NV-HAP #1 hospitalacquired infection, costing patient lives and dollars NV-HAP can be prev ented and harm to patients reduced Monitoring for NV-HAP and prevention programs must rise to the same level of attention as other HAIs 26 Courage One must always be aware, to notice, even though the cost of noticing is to become responsible. Thylias Moss 9

10 References ATS (2005). Guidelines on the management of adults with HAP. Am J Resp Crit Care Med, 171, CDC (2003). Guidelines for preventing HCA HAP. Drakulovic MB. et. al. (1999) Supine body position as a risk factor for nosocomial pneumonia in mechanically ventilated patients: a ra ndomised trial. Lancet. 354: El Sohl, et. Al. (2004). Colonization of dental plaques: a reservoir of respiratory pathogens for hospital-acquired pneumonia in institutionalized elders. Chest. 126(5), Garrouste-Orgeas M. et al. (1997) Oropharangeal colonization. Am J Respir Crit Care Med ;156: Gleeson K, et al. (1997) Microaspiration during sleep in healthy subjects. Chest. 111: Grenny, J. et.al. (2013 ) Influencer: the power to change anything. Vital Smarts. McGraw Hill Publishing. Kollef, et. al. (2005). Epidemiology and outcomes of health-care-associated pneumonia: results from a large USS database of culture-positive pneumonia. CHEST. 128(6), Langmore, S. et.al. (1998). Predictors of aspiration pneumonia: how important is dysphagia? Dysphagia. 13, Overend, TJ, et al. (2001) The effect of incentive spirometry on postoperative pulmonary complications: a systematic review. Chest, 120(3): Pennsylvania Dept. of Public Health (2010). HAIs in Pennsylvania hospitals 2009 technical report. Resar R, Griffin FA, Haraden C, Nolan TW. Using Care Bundles to Improve Health Care Quality. IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; (Available on Schmitz, et. al. (2008). Effects of oral care on hospital-acquired pneumonia in the intermediate care setting. Poster 20 thnational Forum on Quality Improvement in Health Care. Terezakis E, Needleman I, Kumar N, Moles D, Agudo E.(2011) The impact of hospitalization on oral health: a systematic review. J Clin Periodontol ; 38: doi: /j x x. Van Nieuwenhoven CA, et al. (2006) Feasibility and effects of the semirecumbent position to prevent VAP: A randomized study. Crit Care Med, 34: Watando A. et al. (2004) Daily oral care and cough reflex sensitivity in elderly nursing home patients. Chest, 2004; 126: Yoneyama, et. (2002) Oral care reduces pna in nursing homes. Al. JAGS,50: Micek et al. (2016). Case control study NVHAP on Patient outcomes, published first online, Chest, April 2016 Barnes, C. (2014). Dental hygiene intervention to prevent PNA. J EB Dental Practice, 145:p/ Munro, C.L., Grap, M.J., Jones, D.J., McClish, D.K., & Sessler, C.N.(2009). CHX Tb, prevent NV HAP change in flora. Am JCritC are 18,