Before the pandemic, non-ventilator hospital-acquired pneumonia (NV-HAP), which has been estimated to represent as much as one-fourth of all HAIs, was gaining some attention and traction as an underappreciated patient hazard.1 As the SARS-CoV-2 tsunami recedes, some infection preventionists and researchers are trying to heighten awareness again of the magnitude of NV-HAP in terms of patient safety and healthcare costs and resources.
“It is the number one hospital-acquired infection, but it’s not a required infection to report to the Joint Commission or with Centers for Medicare and Medicaid Services (CMS) reporting,” says JoAnn Brooks, RN, PhD, FCCP, FAAN, a leading NV-HAP researcher and system vice president of safety and quality at Indiana University Health. “The sad thing is if hospitals are not looking for it because it’s not a required reportable infection — I think down the road it will be — they have no idea how many of these infections they have in their facilities.”
According to the Joint Commission, NV-HAP is not “one of the National Database of Nursing Quality indicators for which hospitals are held accountable; nor is it one of the conditions that the CMS requires hospitals to report to the Centers for Disease Control and Prevention (CDC). … As a result, this leaves NV-HAP a healthcare-acquired condition without national tracking or accountability, [that is] most likely unaddressed by healthcare organizations.”2
After hospitals begin collecting data on NV-HAP, many are surprised at the level of the problem and the need for infection prevention.
“For some hospitals, that’s enough to get them on board — ‘Wow, we didn’t realize the number we actually had,’” Brooks says. “It’s a slow work in progress, but at least it’s moving forward.”
Moreover, there is persuasive evidence that a proactive oral hygiene program for hospitalized patients can prevent heavy bacterial accumulation in the mouth from aspirating down into the lungs and seeding a pneumonia infection.3-5
“One of the leading interventions is comprehensive oral care,” Brooks says. “Obviously, there are other things as well — patient mobility, head of bed [upright] — that all go hand-in-hand, but the number one is the oral care.”
Mortality Rate, Surveillance Woes
As has been widely observed, it can be difficult to extract data from the medical record to confirm a clinical diagnosis of NV-HAP, Brooks says.
“My comment about that is it may be difficult to extract, but it’s killing people,” she says.
To that point, a study of 284 hospitals, using an electronic surveillance definition applied to detailed clinical data, found an NV-HAP mortality rate of 22%, with an additional 8% discharged to hospice.6
“These findings suggest that NV-HAP is a common and deadly complication of hospitalization that could account for up to one in 14 hospital deaths,” the authors reported.
This report also reiterates Brooks’ point about the inherent difficulty of tracking NV-HAP infections using current CDC surveillance definitions.
There are “many subjective and ambiguous criteria that are complicated and difficult to apply in a clear and consistent manner, even for experienced clinicians,” they reported. “These include changes in oxygenation, the quality and quantity of respiratory secretions, and interpreting chest radiographs.”
Generally defined as onset of pneumonia at least 48 hours after a patient is admitted, NV-HAP affects more patients and has a similar mortality rate as its more clearly defined clinical cousin, ventilator-associated pneumonia (VAP). These infections also extend patient length of stay and run up considerable costs.7
Primary Prevention of NV-HAP
Given the lack of requirements to track and report NV-HAP, infection preventionists have focused on an established method of primary prevention: comprehensive oral hygiene care for hospitalized patients.
“We know that things like oral care and reducing the microbial load in the mouth helps to lower the risk of developing a pneumonia,” says Lisa Caffery, MS, BSN, RN, BC-Med-Surg, CIC, FAPIC, coordinator of infection prevention at Genesis Health System in Davenport, IA. “[These patients] are at risk of micro-aspirating, especially during hospital stays or in long-term care facilities if they’re not able to perform oral care themselves.”
Rapid accumulation of bacterial contamination of the mouth in patients that may have difficulty swallowing, coughing, and clearing their throats can lead to lung contamination that may reflect what is found in the mouth. A respiratory therapy study reported that dental plaque biofilms harbor commonly recognized pulmonary pathogens.8
“Healthy lung microbiota is heavily influenced by repeated micro-aspiration of oropharyngeal contents,” the authors reported. “It is not entirely known how aspiration of bacteria leads to infection in some patients and not others. It is likely a combination of factors, including the frequency and volume of aspirated material, efficacy of airway and lung clearance mechanisms, comorbid conditions, the patient’s immune system, [and] bacterial virulence.”
Caffery presented the results of a three-year project to reduce NV-HAP at the 2023 conference of the Association for Professionals in Infection Control and Epidemiology (APIC). Despite the considerable disruption of the pandemic, the implementation of a comprehensive oral care program and other measures saved the hospital approximately $1 million by preventing 30 infections over the intervention period compared to the baseline rate. Before the project began, 2018 claims data for the hospital system showed a staggering cost of $6 million caused by 170 NV-HAPs, which led to 16 patient deaths.
“Our length of stay was four and a half days, but for a patient who developed a HAP, it went up to nine and a half days,” Caffery reported at APIC. “It increased our length of stay significantly. Many of those went on to develop sepsis, which then added more days to that.”
A key intervention in the program was bringing in a dental hygienist to conduct staff training so they better understood the issue and could prompt or assist patient toothbrushing. The hygienist explained the “whys” for oral care and techniques for achieving best results, she says. The program continues, with patient care techs taking the lead in educating and helping patients.
“It’s no secret in healthcare that there’s a shortage of nurses and other professionals — there’s a lot of pressure on staff to do a lot of things,” Caffery tells Hospital Infection Control & Prevention. “One of those is helping a patient do oral care or asking the patient if they need help to brush their teeth. We’ve empowered our patient care techs to do this. [They] talk to the patients and their families about why it’s important to brush your teeth, whether you’re in the hospital or when you go home.”
Toothbrushes Unopened, Missing
Before the program began Caffery and colleagues assessed oral care supplies in 112 patient rooms, finding that 49% either did not have a toothbrush (37%) or had a toothbrush in an unopened package (11%), according to her findings presented at APIC.
In a recently published study, Brooks and colleagues found similar missing and unused toothbrushes as well as microbial contamination on brushes in use.9
In a toothbrush sampling that was conducted in 136 acute care hospitals and medical centers from November 2018 through February 2022, the researchers reported a total of 5,340 patient rooms surveyed.
“Of the rooms included, 46% (2,455) of patients did not have a toothbrush available or had not used a toothbrush (still in the package and/or toothpaste not opened),” the authors noted. “All hospitals had at least one positive toothbrush culture, and 124 of 136 hospitals (91%) had at least one positive multidrug-resistant organism found on a toothbrush.”
The types of organisms identified on the toothbrushes included vancomycin-resistant Enterococcus and methicillin-resistant Staphylococcus aureus.
“We really don’t have the data on what is the appropriate way to store a toothbrush in a hospital setting,” Brooks says. “Unfortunately, right now, you find them thrown in an inside drawer, laying in an emesis basin, on top of somebody’s hairbrush, or next to the toilet.”
Caffery says when she became aware of Brooks’ findings, she stressed educating staff to make sure toothbrushes are not stored in a bathroom, particularly by the toilet.
“Historically in hospitals, toothbrushes have often been stored in in a bathroom, on the ledge of a sink,” Caffery says. “When you flush the toilet, the spray could contaminate the toothbrush.”
Another point of emphasis is using a toothbrush recommended by the American Dental Association (ADA), Brooks says, adding that the small brushes common in hospital admission kits are woefully inadequate.
“Fortunately, when I’m out talking to hospitals, we do have some around the country that are replacing that little non-toothbrush in the admission kit with an actual ADA-approved toothbrush,” she says. “We have been moving in the right direction.”
Upgrading toothbrush quality in Caffery’s program led to wrangling with hospital purchasing over a six-cent toothbrush upgrade to a better 10-cent brush.
“It was like, ‘Are you kidding me, we’re arguing over four cents,’ but we argued over four cents,” she told infection prevention colleagues at APIC.
As more evidence emerges of patient risk, it may revive a 2020 call to action on NV-HAP by healthcare leaders and organizations.10 They identified the need to energize a national healthcare conversation about NV-HAP, educate patients about prevention measures, encourage more research to overcome obstacles, and challenge healthcare systems and insurers to implement and support these efforts.
Of course, the pandemic silenced that call, as well any number of given initiatives in healthcare, since it was all hands on deck for COVID-19.
SHEA Hospital Survey
A survey of members of the Society for Healthcare Epidemiology of America (SHEA) Research Network (SRN), conducted between Oct. 14, 2020, and April 2, 2021, primarily netted response from 88% infection preventionists. The overall survey results, which represented academic centers (85%) and community hospitals (12%), revealed that 24% of respondents did not monitor incidence of NV-HAP and 58% did not have a “universal oral care policy.”11
In other pneumonia prevention measures they fared better, with 85% of respondents reporting early patient mobility programs and routinely keeping the head of the bed upright.
“Most SRN members (76%) do not track NV-HAP as a secondary hospital-acquired infection in patients with COVID-19,” the authors reported.
Infection preventionists have kept the issue on the map while the healthcare system recovers from the pandemic, Brooks says.
“Infection preventionists have been leaders in bringing this forward,” she says. “In many places they are trying to raise awareness. We need to at least look at our prevalence of NV-HAP and what type of oral care is being provided. I’ll tell you, it’s all over the board. You can have the best comprehensive oral care protocol, but it’s got to be followed by everybody, on every patient, every time.”
Brooks is well-aware of the time and resource constraints on infection preventionists, and lauds those who are leading this fight.
“Having worked with many infection preventionists and talked with them over time, I know they’re already doing 150% every day,” she says. “The idea of them bringing forward one more thing to be monitoring — I know it’s hard for them to do. But many of them are moving forward in bringing this to their clinical leaders, to their physicians, and to their board of directors.”
Help may be on the way in the form of a Joint Commission standard or a hospital safety goal, based on the quick safety alert on NV-HAP in 2021, Cafferty suspects.2
“I would not be surprised to see this become a standard,” she at APIC. “If you read the quick safety information, you’ll see they’re starting to think about a standard in there somewhere.”
In the quick safety memo, the Joint Commission cited current NV-HAP prevention strategies such as comprehensive oral care, patient mobility, elevation of the head of the bed, and educating the patient and family members.
Additional prevention measures listed by the Joint Commission include:
• reducing the use of acid-suppressing medications;
• minimizing sedation;
• performing dysphagia screening in high-risk patients;
• using modified diets and feeding strategies for patients with abnormal swallowing;
• following standardized processes to place and manage feeding tubes; and
• breathing exercises.
REFERENCES
- Magill SS, O’Leary E, Janelle SJ, et al. Changes in prevalence of health care-associated infections in U.S. hospitals. N Engl J Med 2018;379:1732-1744.
- Joint Commission. Preventing non-ventilator hospital-acquired pneumonia. Quick Safety, Issue 61. Published September 2021. https://www.jointcommission.org/-/media/tjc/newsletters/quick-safety-61-nvha-pneumonia-final-9-3-21.pdf
- Warren C, Medei MK, Wood B, Schutte D. A nurse-driven oral care protocol to reduce hospital-acquired pneumonia. Am J Nurs 2019;119;44-51.
- Munro S, Haile-Mariam A, Greenwell C, et al. Implementation and dissemination of a Department of Veterans Affairs oral care initiative to prevent hospital-acquired pneumonia among nonventilated patients. Nurs Adm Q 2018;42:363-372.
- Lacerna CC, Patey D, Block L, et al. A successful program preventing nonventilator hospital-acquired pneumonia in a large hospital system. Infect Control Hosp Epidemiol 2020;41:547-552.
- Jones BE, Sarvet AL, Ying J, et al. Incidence and outcomes of non-ventilator-associated hospital-acquired pneumonia in 284 US hospitals using electronic surveillance criteria. JAMA Netw Open 2023;6:e2314185.
- Giuliano KK, Baker D, Quinn B. The epidemiology of nonventilator hospital-acquired pneumonia in the United States. Am J Infect Control 2018;46:322-327.
- Gaeckle NT, Pragman AA, Pendleton KM, et al. The oral-lung axis: The impact of oral health on lung health. Respir Care 2020;65:1211-1220.
- DeJuilio P, Powers J, Soltis LM, Brooks J. Multisite evaluation of toothbrushes and microbial growth in the hospital setting. Clin Nurse Spec 2023;37:83-89.
- Munro SC, Baker D, Giuliano KK, et al. Nonventilator hospital-acquired pneumonia: A call to action. Infect Control Hosp Epidemiol 2021;42:991-996.
- Baker DL, Giuliano KK. Prevention practices for nonventilator hospital-acquired pneumonia: A survey of the Society for Healthcare Epidemiology of America (SHEA) Research Network (SRN). Infect Control Hosp Epidemiol 2022;43:379-380.
In the pandemic aftermath, with lean resources and nurse staffing in shortfall, there remains this stubborn fact: The most prevalent healthcare-associated infection has no reporting requirements nor well understood incentives to adopt evidence-based prevention practices.
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