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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: 1 Gluch, J. (2009). Exploring the connection: The relationship between respiratory diseases and oral health. Dimension of Dental Hygiene, 7(10), 54-7. 2 Kalil, 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. 3 Kalsekar, 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. 4 Kaneoka, 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. 5 Munro, C. (2014). Oral health: Something to smile about! American Journal of Critical Care, 23(4), 282-288. 6 Quinn, 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. 7 Zimlichman, 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 26 p = .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 days 0.683 0.325 NV-HAP events per 1000 patient discharges 2.84 1.41 VAE/VAP events 56/12 49/3 VAP Cost ($40,144) 7 $481,728 $120,432 VAE rate per 1000 vent days 12.53 14.29 VAP rate per 1000 vent days 2.87 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-HAP VAP 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
