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Chastity Warren, DNP, MSN/Ed, RN, CCRN
Mary Kathryn Medei, BSN, RN, CMSRN
Brooke Wood, BSN, RN, CMSRN
Debra Schutte, PhD, RN
A Nurse Driven Protocol to Reduce Hospital-Acquired
Pneumonia: An Evidence-Based Practice (EBP) Change
Practice Problem
Clinical Question
Aims/Objectives
• What is the impact of the EBP change on the incidence of HAP
including NV-HAP and VAP?
• What is the impact of the EBP change on nursing compliance with
oral care interventions
References: 1Gluch, J. (2009). Exploring the connection: The relationship between respiratory diseases and oral health. Dimension of Dental Hygiene, 7(10), 54-7. 2Kalil, A., Metersky, M., Klompas, M., Muscedere, J., Sweeney, D., Palmer, L., ... & El Solh, A. (2016). Management of adults with hospital-acquired and ventilator-associated pneumonia: 2016 clinical practice guidelines by the Infectious
Diseases Society of America and the American Thoracic Society. Clinical Infectious Diseases, 353. 3Kalsekar, I., Amsden, J., Kothari, S., Shorr, A., & Zilberberg, M. (2010). Economic and utilization burden of hospital-acquired pneumonia (HAP): A systematic review and meta-analysis. CHEST Journal, 138(4_MeetingAbstracts), 739A-739A. 4Kaneoka, A., Pisegna, J., Miloro, K., Lo,M., Saito, H., Riuqelme,
L., LaValley, M. & Langmore, S. (2015). Prevention of healthcare-associated pneumonia with oral care in individuals without mechanical ventilation: A systematic review and meta-analysis of randomized control trials. Infection Control and Hospital Epidemiology, 1-8. 5Munro, C. (2014). Oral health: Something to smile about! American Journal of Critical Care, 23(4), 282-288. 6Quinn, B., Baker, D.,
Cohen, S., Stewart, J., Lima, C., Parise, C. (2013).Basic nursing care to prevent non ventilator hospital-acquired pneumonia. Journal of Nursing Scholarship. 46(1), 11-19. 7Zimlichman, E., Henderson, D., Tamir, O., Franz, C., Song, P., Yamin, C., ... & Bates, D. (2013). Health care–associated infections: A meta-analysis of costs and financial impact on the US health care system. JAMA internal medicine,
173(22), 2039-2046.
Project Description
Pilot oral Care EBP change in a 600+ bed Level-1 trauma hospital improvement project
• Short-term kit
• Ergonomically appropriate toothbrush
• Alcohol free, anti-septic mouth rinse
• Baking soda toothpaste
• Mouth moisturizer
• Oral care swabs with baking soda
• 4 times daily
• At-risk kit
• Suction toothbrush
• 4 times daily
• Ventilator kit (already in use)
• Suction toothbrush & swabs
• 6 times daily
Process improvement
• Increased oral assessments & intervention (4-6 times daily)
• Improved swallow screen assessment
• Implementation of algorithm for kit identification
• Patient education handout inside short-term kit
• Detailed procedure list created in electronic documentation to improve workflow
• Mandatory nurse and patient care technician education fall of 2015 & spring 2016
provided to 1,438 nurse & PCT caregivers
• Rounding education in-services
• Dashboard reports created in electronic documentation for leadership to ensure
adherence to protocol
• Delta Dental Foundation gift of $175,000 removed barriers & paved the way!
Pre
N = 202
Post
N = 215
Chi-square
Analysis p <.05 statistically
significant
CI 95%
NV-HAP events 52 26p = .000354
NV-HAP cost ($28,008)3 $1,456,416 $728,208
Deaths in NV-HAP events 20 4 p = .037373
NV-HAP rate per 1000
patient days0.683 0.325
NV-HAP events per 1000
patient discharges2.84 1.41
VAE/VAP events 56/12 49/3
VAP Cost ($40,144)7 $481,728 $120,432
VAE rate per 1000 vent
days12.53 14.29
VAP rate per 1000 vent
days2.87 1.26
Protocol compliance by caregivers 76% Range 36-100% on units
*Calculated from documentation vs. product use vs. patient days
Nurses improved pneumonia outcomes by providing oral health
interventions for all adult patients admitted to the hospital which reduced
overall hospital costs, length of stay, and patient mortality
Nursing and Healthcare Implications
Project Results
In acute care patients (P), how would a nurse driven oral care
protocol with improved products (I) compared to no protocol/current
products (C) impact the incidence of HAPs and nursing compliance
on oral care interventions (O)?
Pneumonia
HCAP
NHAP HAP
NV-HAPVAP
CAP
Inflammation or infection of the lungs
Community acquired Pneumonia-not acquired
in a hospital or long-term care facility.
Hospital acquired Pneumonia–after 2
calendar days of admission
Ventilator associated pneumonia-acquired in a
hospital setting after 2 calendar days of admission & intubation/ventilation.
Non-ventilator hospital acquired pneumonia-in a
hospital setting after 2 calendar days of admission
Nursing home acquired
Pneumonia
Health-Care acquired Pneumonia - hospital
or long-term care facility
• HAP (hospital-acquired pneumonia) responsible for 22% of all
hospital-acquired infections (HAI)(2)
• Significant added risk of mortality, as much as 20-30%(6)
• Added cost of $40,000 per episode(2)
• $40,144 for ventilator-associated pneumonia (VAP)(7)
• $28,008 for non-vented hospital-acquired pneumonia
• (NV-HAP)(3)
• Increased length of hospital stay of up to 7-9 days(7;3)
• Two primary connections between oral care & pneumonia are
colonization of bacteria & release of enzymes(4)
• Colonized bacteria in mouth & on dental plaque includes
Streptococci species; Haemophilus influenza; Staphylococcus
aureus; Enterobacter of the approximate 700 types(4;5)
• Release of enzymes & cytokines through an inflammatory
process which facilitates adherence of bacteria to teeth and
mucosa(1)
• Lack of standardized oral care interventions & micro aspiration by
patient of bacteria into airway leads to development of pneumonia
• Lack of quality, evidence-based products available
• Lack of standardized, evidence-based protocol/procedure to drive
nurse practice & patient education
Project Methodology
• Setting: Adult inpatient units at Sparrow Lansing
• Sample: Charts reviewed for November-May of 2014/2015 &
2015/2016 for any adult patient who had an ICD 9 or 10 code for
pneumonia
• Identified NV-HAP using Centers for Disease Control & Prevention
(CDC) algorithm for clinically defined pneumonia
• 2 or more serial chest x-rays (one for underlying cardiac or
respiratory disease)
• One of the following: fever; leukopenia; change in LOC for adults
>70 years old
• 2 of the following: sputum; cough; tachypnea, dyspnea, bronchial
breath sounds; increased oxygen requirements
• Information obtained from the Infection Prevention department for VAP
ICD-9 ICD-10 Definition
486 J18.9 Pneumonia, organism unspecified
482.1 J15.1 Pneumonia due to pseudomonas
482.41 J15.211 Methicillin susceptible pneumonia due to staphylococcus aureus
484.42 J15.212 Methicillin resistant pneumonia due to staphylococcus aureus
484.7 J17 Pneumonia in other systemic mycoses
482.2 J14 Pneumonia due to Hemophilus influenza
481 J13 Pneumococcal pneumonia
482.83 J15.6 Pneumonia due to other gram-negative bacteria
480.8 J12.89 Pneumonia due to other virus not elsewhere classified
484.6 B44.0 Pneumonia in aspergillosis
482.0 J15.0 Pneumonia due to Klebsiella pneumonia
482.82 J15.5 Pneumonia due to E. Coli
483.8 J16.8 Pneumonia due to other specified organism
482.39 J15.4 Pneumonia due to other streptococcus
Descriptive Statistics Pre Post
Charts reviewed 202 215
Patient discharges 18,298 18,394
Patient days 76,189 79,802
Ventilator days 3851 3578