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Non-ventilator health care-associated pneumonia (NV-HAP): Putting it all together

      Abstract

      This section highlights the necessary steps to implement a robust plan to connect surveillance and prevention strategies for nonventilator health care-associated pneumonia (NV-HAP) as described in previous sections. In addition to specific NV-HAP strategies, the importance of general infection prevention principles that are common to all settings for prevention of all health care-associated infections are reviewed. The section also provides an overview of a step-wise model to develop a comprehensive NV-HAP surveillance plan. A sample case review form is included.

      Key Words

      Despite the challenges, there are opportunities to reduce the incidence of non-ventilator health care-associated pneumonia (NV-HAP) through appropriate interventions targeted to specific patient populations, and by identifying improvement opportunities and conducting health care-associated surveillance on high-risk populations or high-risk patients to study and identify trends.

      Basic infection prevention practices

      While this guide focuses on preventing NV-HAP specifically, the importance of general infection prevention principles that are common to all settings for prevention of all health care-associated infections cannot be overstated. These strategies, which are part of any robust infection prevention program, include the following:
      •  A robust hand hygiene program
      •  Safe injection practices
      •  Patient and staff immunization programs
      •  An active antimicrobial stewardship program
      •  Culturing stewardship
      •  Appropriate surgical prophylaxis
      •  Recommended preoperative skin prep
      •  Chlorohexidine bathing for specific populations
      •  Early recognition and initiation of transmission-based precautions and containment procedures based on the disease and pathogens
      •  Patient and family education
      •  Implementation of evidence-based guidelines for central line care, urinary catheter care, and prevention of multidrug-resistant organisms.

      Surveillance

      The limitations of current pneumonia definitions make routine identification of NV-HAP difficult and may limit an organization's ability to conduct meaningful surveillance. Experts agree that we need a new definition that can be used to identify cases through capture of electronic medical record data. A recent study by Ji et al highlighted in Sections 1 and 8 of this guide identified various candidate measures associated with the clinical definition of pneumonia.
      • Ji W
      • McKenna C
      • Ochoa A
      • et al.
      Development and assessment of objective surveillance definitions for nonventilator hospital-acquired pneumonia.
      Their analysis led to a potential surveillance definition that includes worsening oxygenation, at least three days of new antibiotics, fever or abnormal white blood cell count, and orders for chest imaging. The incidence rate per 100 admissions (0.6) in that study was consistent with other investigators’ estimations of NV-HAP in the acute care setting. Although further testing is needed, this approach holds promise for the future (Fig 1).
      Fig 1
      Fig 1Form to review NV-HAP cases in an oncology unit. Created by Linda Greene.
      Surveillance for NV-HAP is challenging. Use of the National Healthcare Safety Network (NHSN)

      Centers for Disease Control and Prevention National Healthcare Safety Network. Pneumonia (PNEU). Available form. https://www.cdc.gov/nhsn/forms/57.111_PNEU_BLANK.pdf. Accessed November 4, 2019.

      will provide consistency in the acute care setting. Limiting manual surveillance to specific areas or populations is a good starting point until the Centers for Disease Control and Prevention develops low-burden surveillance options for NV-HAP.

      Essential elements of an NV-HAP program

      The following is an overview of a potential NV-HAP surveillance and prevention program:
      • 1
        Identify the patient population to follow.
      • 2
        Identify risk for pneumonia in the specific population.
      • 3
        Determine global risk reduction strategies as well as risk mitigation strategies that may be unique to that population.
      • 4
        Assess current guidelines, policies, and procedures and determine the need for any additional policies or guidelines.
      • 5
        Consider developing a bundle to identify the top five to seven priorities.
      • 6
        Educate staff on essential bundle elements.
      • 7
        Develop a monitoring tool to assess compliance with the bundle.
      • 8
        Determine a surveillance strategy to capture NV-HAP data.
      •  Determine the standardized definition that will be used (acute vs long-term care).
      •  Identify how data will be captured.
      •  Identify who will collect the data.
      •  Determine how data will be analyzed and aggregated.
      • 9
        Conduct an analysis of individual cases to determine trends as well as opportunities for improvement.
      In summary, NV-HAP presents both a challenge and an opportunity as we intensify our efforts to ensure that our patients are protected from harm while receiving the best and safest care possible.
      Key Points
      • To improve the study and reporting of nonventilator health care-associated pneumonia (NV-HAP), better surveillance definitions and methods are needed.
      • Opportunities for prevention of NV-HAP exist in standardizing basic patient care practices and ensuring compliance.
      • Surveillance for NV-HAP will assist in providing ongoing information regarding risks and opportunities for improvement and will help guide further research.

      References

        • Ji W
        • McKenna C
        • Ochoa A
        • et al.
        Development and assessment of objective surveillance definitions for nonventilator hospital-acquired pneumonia.
        JAMA Netw Open. 2019; 2 (e1913674-e1913674)
      1. Centers for Disease Control and Prevention National Healthcare Safety Network. Pneumonia (PNEU). Available form. https://www.cdc.gov/nhsn/forms/57.111_PNEU_BLANK.pdf. Accessed November 4, 2019.