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Non-ventilator health care-associated pneumonia (NV-HAP): Best practices for prevention of NV-HAP

      Although the latest research and data show decreases in many health care-associated infections, recent publications highlight the understated but significant burden of nonventilator hospital-acquired pneumonia (NV-HAP). This section presents best practices to prevent NV-HAP. Many of the tools and interventions address basic nursing care such as oral care, oral and nonoral alimentation, patient positioning and mobility, pharmacologic and immunologic controls. The section stresses the importance of working with an interdisciplinary caregiver team to address fundamental activities of daily living that mitigate risk of developing NV-HAP.

      Key Words

      Prevention of pneumonia is based on identifying categories of risk and putting programs in place to address the modifiable risks.
      • Tablan OC
      • Anderson LJ
      • Besser R
      • Bridges C
      • Hajjeh R
      Guidelines for preventing health-care-associated pneumonia, 2003: recommendations of CDC and the healthcare infection control practices advisorycommittee.
      The Centers for Disease Control and Prevention name 3 categories of risk: (1) Colonization of the oropharyngeal cavity, (2) conditions favoring aspiration, and (3) host factors that contribute to weakening of the body's own defenses. Based on the Centers for Disease Control and Prevention recommendations for pneumonia risk reduction, prevention should include strategies to reduce oral pathogens, decrease aspiration of oropharyngeal pathogens into the lungs, and support and strengthen the patient's own host defense mechanisms to the extent possible. While research on prevention of nonventilator health care-associated pneumonia (NV-HAP) for all types of patients is limited, the goal of this section is to outline the best available evidence for prevention.

      Drivers of preventive care

      Figure 1 is a Driver Diagram to highlight the relevant NV-HAP prevention strategies. Although normally used to test theories for improvement, a Driver Diagram
      • Bennett B
      • Provost L
      What's your theory? Driver diagram serves as tool for building and testing theories for improvement.
      may also provide a structure for understanding and communicating why certain strategies for prevention are recommended to address targeted areas of modifiable risk. For example, the Driver Diagram methodology is successfully used by Centers for Medicare and Medicaid Services–based partnerships through Hospital Improvement Innovation Networks.

      Centers for Medicare and Medicaid Services. Hospital improvement innovation networks. Available at:https://partnershipforpatients.cms.gov/about-the-partnership/hospital-engagement-networks/thehospitalengagementnetworks.html. Accessed December 7, 2019.

      Fig 1
      Fig. 1Driver diagram for NV-HAP prevention. Abbreviations: CDC, Centers for Disease Control and Prevention; HOB, head of bed; ICU, intensive care unit; NG, nasogastric; OG, orogastric.

      Primary driver #1: reduce pathogenic colonization of the oropharyngeal cavity

      Researchers have found a critical relationship between oral microflora and hospital-acquired pneumonia.
      • Gomes-Filho IS
      • Passos JS
      • Seixas da Cruz S
      Respiratory disease and the role of oral bacteria.
      • Scannapieco FA
      The oral microbiome: its role in health and in oral and systemic infections.
      • Scannapieco FA
      • Shay K
      Oral health disparities in older adults: oral bacteria, inflammation, and aspiration pneumonia.
      • Heo SM
      • Haase EM
      • Lesse AJ
      • Gill SR
      • Scannapieco FA
      Genetic relationships between respiratory pathogens isolated from dental plaque and bronchoalveolar lavage fluid from patients in the intensive care unit undergoing mechanical ventilation.
      During the first 48 hours of hospitalization, especially in the absence of regular oral care, changes occur in an individual's oral microbiota that are associated with virulent pneumonia-causing organisms.
      • Abele-Horn M
      • Dauber A
      • Bauernfeind A
      • et al.
      Decrease in nosocomial pneumonia in ventilated patients by selective oropharyngeal decontamination (SOD).
      Respiratory pathogens such as Staphylococcus aureus, Pseudomonas aeruginosa, Klebsiella pneumoniae, and Enterobacter cloacae colonize the dental plaque, and micro aspirations contribute to inoculation of virulent organisms into the lungs, even in healthy adults without obvious risk factors.
      • Gleeson K
      • Maxwell SL
      • Eggli DF
      Quantitative aspiration during sleep in normal subjects.
      • Huxley EJ
      • Viroslav J
      • Gray WR
      • Pierce AK
      Pharyngeal aspiration in normal adults and patients with depressed consciousness.
      • Didilescu AC
      • Skaug N
      • Marica C
      • Didilescu C
      Respiratory pathogens in dental plaque of hospitalized patients with chronic lung diseases.
      Recognition of this relationship between the oral microbiota and hospital-acquired pneumonia has led to a growing body of evidence that cleaning of the oral biofilm is the primary source control.
      • Baker D
      • Quinn B
      • Ewan V
      • Giuliano KK
      Sustaining quality improvement: long-term reduction of nonventilator hospital-acquired pneumonia.
      ,
      • Baker D
      • Quinn B
      (Hospital acquired pneumonia prevention initiative-2: incidence of nonventilator hospital-acquired pneumonia in the United States.
      Because pneumonia is often initiated from germs in the mouth,
      • Gomes-Filho IS
      • Passos JS
      • Seixas da Cruz S
      Respiratory disease and the role of oral bacteria.
      • Scannapieco FA
      The oral microbiome: its role in health and in oral and systemic infections.
      • Scannapieco FA
      • Shay K
      Oral health disparities in older adults: oral bacteria, inflammation, and aspiration pneumonia.
      • Heo SM
      • Haase EM
      • Lesse AJ
      • Gill SR
      • Scannapieco FA
      Genetic relationships between respiratory pathogens isolated from dental plaque and bronchoalveolar lavage fluid from patients in the intensive care unit undergoing mechanical ventilation.
      providing oral care with the right products and educational support addresses the most common modifiable risk factor and has the potential to improve health care quality and make health care safer for patients. However, nurses experience significant barriers in providing fundamental care, such as oral care, often due to a lack of easy-to-use effective products and educational materials. The available oral care protocol for acute care hospitals approved by the American Dental Association (ADA)
      • Quinn B
      • Baker DL
      Comprehensive oral care helps prevent hospital-acquired nonventilator pneumonia.
      outlines the types of oral care supplies needed for different types of patients (Table 1). For best practice, these supplies should be easily accessible in all hospital units for use by nurses and patients.
      Table 1American dental association–approved protocol for the use of evidence-based oral care in the acute care setting
      Oral care typeToolsProcedureFrequency
      Self/assist (may require setup)Soft-bristled toothbrush, toothpaste with fluoride, sodium bicarbonate (optional), alcohol-free antiseptic mouth rinse, mouth and lip moisturizer (nonpetroleum-based)Brush for 1-2 min with toothpaste, rinse with antiseptic; moisturize as needed.2-4 times/d
      Dependent/aspiration risk/nonventilatedSoft-bristled suction toothbrush, cleansing and alcohol-free antiseptic solution, mouth and lip moisturizer (nonpetroleum-based)Brush with suction for 1-2 minutes using liquid cleansing/antiseptic solution; moisturize as needed.2-4 times/d
      Dependent/ventilatedSoft-bristled or swab suction toothbrush, cleansing and alcohol-free antiseptic solution, mouth and lip moisturizer (nonpetroleum-based)Brush/swab with suction for 1-2 min using liquid cleansing/antiseptic solution; moisturize as needed.

      Optional: Brush/swab with suction 1 min with chlorhexidine 0.12%
      About every 4 h or 6 times/d

      Optional: Chlorhexidine 0.12% every 12 h
      Dentures or edentulate (not caps)Denture storage cup, denture brush, denture cleanser

      adhesive (optional)
      Remove and brush/rinse dentures; brush gums and mouth; may soak dentures at night with commercial cleanser.2 times/d

      Remove dentures while patient is sleeping
      Copyright C 2019. HealthCom Media. Used with permission. All rights reserved. AmericanNurseToday.com.
      The prevention of NV-HAP begins with patient assessment to identify the appropriate oral care procedure for each patient based on their ability to participate. Patients are then reassessed every 24 hours. The evidence-based oral care protocol endorsed by the ADA
      • Quinn B
      • Baker DL
      Comprehensive oral care helps prevent hospital-acquired nonventilator pneumonia.
      consists of:
      • Oral care assessment by an RN to determine (a) whether the patient needs a referral for further oral health assessment and (b) the type of oral care products needed (self-care, dependent care, and/or denture care)
      • Brushing the teeth with a soft-bristled, small-head toothbrush and plaque-removing toothpaste
      • Rinsing with an alcohol-free antiseptic mouthwash
      • Application of lip and mouth moisturizer (nonpetroleum-based)
      • Use of 24-hour suction toothbrush kits for high aspiration-risk patients who meet criteria established in the oral care protocol
      • For patients with dentures: Removal and soaking of the dentures; brushing of gums and mouth; preventing patients from sleeping with dentures in place
      Because most hospitals currently provide patients with inadequate oral care products that are ineffective in reducing the oral biofilm that causes NV-HAP, adoption of best practice requires that hospitals invest in evidence-based oral care products such as those identified in the ADA protocol (Table 1).
      • Quinn B
      • Baker DL
      Comprehensive oral care helps prevent hospital-acquired nonventilator pneumonia.
      Nurses need supplies that are evidence-based and easy to use, require minimal training, are cost-effective, and include patient and family education materials to support both compliance and self-care. As an interdisciplinary leader, nurses are uniquely positioned to lead the effort in NV-HAP reduction by addressing the most easily modifiable risk factors, including improved oral care for all patients.

      Primary driver #2: reduce aspiration

      A comprehensive pneumonia prevention program should include strategies to identify risk for aspiration and then implementation of a plan to reduce aspiration as much as possible. We are aware that patients on a ventilator are at high risk for aspiration around the endotracheal tube,
      • Smith CH
      • Logemann JA
      • Colangelo LA
      • Rademaker AW
      • Pauloski BR
      Incidence and patient characteristics associated with silent aspiration in the acute care setting.
      however, to prevent NV-HAP, it is important to anticipate the more common micro- or silent aspiration in the nonintubated patient. In addition to a normal physiology that includes microaspiration, hospitalization may contribute to additional aspiration risk for the following reasons: reduced mobility and supine positioning, medications that reduce the level of consciousness, and presence of nasogastric and orogastric tubes.
      • Torres A
      • Serra-Batlles J
      • Ros E
      • et al.
      Pulmonary aspiration of gastric contents in patients receiving mechanical ventilation: the effect of body position.
      • Langmore SE
      • Skarupski KA
      • Park PS
      • Fries BE
      Predictors of aspiration pneumonia in nursing home residents.
      • Metheny NA
      • Clouse RE
      • Chang Y-H
      • Stewart BJ
      • Oliver DA
      • Kollef MH
      Tracheobronchial aspiration of gastric contents in critically ill tube-fed patients: frequency, outcomes, and risk factors.
      • Gomes G
      The nasogastric feeding tube as a risk factor for aspiration and aspiration pneumonia.

      Swallow screens

      Although most patients are at some risk for microaspiration and will benefit from oral care to reduce risk for pneumonia, additional precautions may be taken to prevent aspiration in high-risk patients, such as those with dysphagia. To identify patients at high risk for dysphagia, it is common to use a minimally invasive screening procedure that includes observation and a description of the patient response. This is normally a pass/fail procedure. Patients who pass can advance to normal feeding; those who fail are referred to a speech-language pathologist for more advanced evaluation.
      • Jiang JL
      • Fu SY
      • Wang WH
      • Ma YC
      Validity and reliability of swallowing screening tools used by nurses for dysphagia: a systematic review.
      Most bedside swallow screens have been studied in the hospitalized stroke population; 30% to 67% of these patients will have some degree of dysphagia.
      • Edmiaston J
      • Tabor Connor L
      • Loehr L
      • Nassief A
      Validation of a dysphagia screening tool in acute stroke patients.
      Patients with other neurodegenerative diseases such as Parkinson's disease, amyotrophic lateral sclerosis, Alzheimer's disease, and Huntington's disease may also benefit from a simple swallow screen. Patients on a ventilator for more than 2 days and then extubated are at risk for short-term postextubation dysphagia.
      • Perren A
      • Zürcher P
      • Schefold JC
      Clinical approaches to assess post-extubation dysphagia (PED) in the critically ill.
      To minimize aspiration in this patient population, a validated swallow screen protocol should be used prior to initiating oral food and fluid intake.
      American Association of Critical-Care Nurses
      AACN practice alert: preventing aspiration.
      The Massey bedside swallowing screen,
      • Massey R
      • Jedlicka D
      The Massey bedside swallowing screen.
      standardized swallowing assessment,
      • Perry L
      Screening swallowing function of patients with acute stroke. Part two: detailed evaluation of the tool used by nurses.
      and Yale swallow protocol
      • Suiter DM
      • Sloggy J
      • Leder SB
      Validation of the Yale swallow protocol: a prospective double-blinded videofluoroscopic study.
      are examples of such protocols.

      Head of bed elevation

      Another strategy to reduce aspiration is to elevate the head of bed. Although there are limited high-quality studies, there is expert agreement that supine positioning should be avoided in patients at risk for pneumonia.
      • Blot SI
      • Poelaert J
      • Kollef M
      How to avoid microaspiration? A key element for prevention of ventilator-associated pneumonia in intubated ICU patients.
      It is not known whether 45-degree elevation is more clinically beneficial than 25- to 30-degree elevation for pneumonia prevention, although a study by Torres showed that some aspiration still takes place in ventilated patients with the head of bed at 30 degrees.
      • Torres A
      • Serra-Batlles J
      • Ros E
      • et al.
      Pulmonary aspiration of gastric contents in patients receiving mechanical ventilation: the effect of body position.

      Nasogastric and orogastric tubes

      Because the presence of medical tubes in the oropharynx or nasopharynx increases the risk for aspiration,
      • Langmore SE
      • Terpenning MS
      • Schork A
      • et al.
      Predictors of aspiration pneumonia: how important is dysphagia?.
      assessment for continued use of such tubes should be completed each shift. The goal should be to discontinue the use of these tubes as soon as they are no longer clinically indicated.
      If the patient requires an orogastric/nasogastric tube for enteral nutrition, the 2016 American Association of Critical Care Nurses (AACN) Practice Alert on Aspiration Prevention
      American Association of Critical-Care Nurses
      AACN practice alert: preventing aspiration.
      recommends a set of practices that may reduce the ongoing risk for aspiration:
      • Semirecumbent positioning (30 to 45 degrees head of bed elevation) to reduce the aspiration of gastric contents
      • Judicial use of sedatives
      • Assessment of feeding tube placement every 4 hours
      • Assessment of feeding tolerance every 4 hours
      • No bolus feedings if the patient is at high risk for aspiration
      • Swallow evaluation after extubation

      Primary driver #3: strengthen host defenses

      Many risk factors for a weak host are not modifiable; to reduce risk, it is important to focus on interventions and strategies that are targeted to strengthen physiologic and immunologic defenses. General infection prevention practices across the continuum of care are summarized in Section 8 of this guide.

      Mobility

      The mobilization of hospitalized patients soon after admission has shown demonstrable benefit through a variety of outcome measures.
      • Pashikanti L
      • Von Ah D
      Impact of early mobilization protocol on the medical-surgical inpatient population: an integrated review of literature.
      Unfortunately, oftentimes hospitalized patients remain in bed even when capable of walking,
      • Wood W
      • Tschannen D
      • Trotsky A
      • et al.
      A mobility program for an inpatient acute care medical unit.
      leading to negative outcomes such as thrombosis, pneumonia, muscular and functional decline, delirium, and prolonged length of stay.
      • Veesart A
      • Ashcraft AS
      Get your patients moving—now!.
      Until recently, the emphasis for mobilization interventions was largely focused on patients in intensive care units (ICU), even though ICU patients are estimated to represent only about 10% of all acute care hospital beds.
      • Pashikanti L
      • Von Ah D
      Impact of early mobilization protocol on the medical-surgical inpatient population: an integrated review of literature.
      A 2019 study by Fazio and coauthors found that 87% to 100% of a patient's time in acute care was spent sitting or lying in the bed, and that immobility was associated with increased risk of death, decreased function, and cognitive impairment.
      • Fazio S
      • Stocking J
      • Kuhn B
      • et al.
      How much do hospitalized adults move? a systematic review and meta-analysis.
      Attention to mobility for patients during acute care hospitalization has been shown to decrease risk for NV-HAP.

      Craig TM, Lingaas JL, Reisner RC, Smith MC. Prevention of hospital-acquired pneumonia: an integrative review. Poster Presentation at the Research and Scholarship Symposium, April 1, 2015. Available at:https://digitalcommons.cedarville.edu/cgi/viewcontent.cgi?article=1209&context=research_scholarship_symposium. Accessed December 7, 2019.

      A 2013 systematic review of inpatient mobilization found that mobilizing hospitalized patients contributed to improved psychological, social, and physical outcomes, including a reduction in pneumonia.
      • Kalisch BJ
      • Lee S
      • Dabney BW
      Outcomes of inpatient mobilization: a literature review.
      Stolbrink et al tested the effectiveness of an early mobility bundle for medical patients and found that NV-HAP incidence was significantly lower in the intervention group (P < .0001).
      • Stolbrink M
      • McGowan L
      • Saman H
      • et al.
      The early mobility bundle: a simple enhancement of therapy which may reduce incidence of hospital-acquired pneumonia and length of hospital stay.
      Unless it is contraindicated, early mobility should be an important part of basic care and best practice for all hospitalized patients.

      Nutrition

      Adequate nutrition during acute care hospitalization contributes to decreases in skin injuries, infections (including pneumonia), and length of stay, whereas malnutrition is a significant risk factor for pneumonia in hospitalized patients not in the ICU.
      • Sopena N
      • Heras E
      • Casas I
      • et al.
      Risk factors for hospital-acquired pneumonia outside the intensive care unit: a case-control study.
      During a typical ICU stay, patients receiving enteral nutrition often do not receive the prescribed amount of nutrition or calories, and in one study, ICU patients received less than 50% their prescribed goal.
      • McClave SA
      • Taylor BE
      • Martindale RG
      • et al.
      Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.).
      All patients at risk for malnutrition should be screened for their nutritional requirements, and their plan of care should include strategies to ensure that their nutritional needs are met.

      Stress ulcer prophylaxis stewardship

      Acid suppression may lead to a loss of the protective bacteriostatic effects that are naturally provided by gastric acid. When combined with antibiotic use, acid suppression is also linked to a higher risk of Clostridioides difficile infection.
      • Marchina S
      • Doros G
      • Modak J
      • Helenius J
      • Aycock DM
      • Kumar S
      Acid suppressive medications and risk of pneumonia in acute stroke patients: systematic review and meta analysis.
      In a study of stroke patients receiving stress ulcer prophylaxis (SUP), researchers found a positive relationship between the use of proton pump inhibitors and pneumonia development during acute care hospitalization.
      • Herzig SJ
      • Doughty C
      • Lahoti S
      • et al.
      Acid suppressive med use in acute stroke and hospital-acquired pneumonia.
      SUP use is common in many ICU patients and is often continued even when the risk of gastric bleeding subsides. In another study of enterally fed ICU patients, Huang et al found that while there was no apparent benefit to receiving SUP while receiving enteral feeding, there was a measurable increased risk for pneumonia.
      • Huang HB
      • Jiang W
      • Wang CY
      • Qin HY
      • Du B
      Stress ulcer prophylaxis in intensive care unit patients receiving enteral nutrition: a systematic review and meta-analysis.
      Further research on implementation strategies to reduce overuse of proton pump inhibitors is needed. One strategy is to use the electronic medical record to prompt discontinuation of proton pump inhibitors when a patient is transferred from the ICU to a lower level of care; another option is for pharmacists to automatically discontinue proton pump inhibitor use with an approved protocol when the patient no longer meets clinical criteria.

      Glycemic control

      Hyperglycemia is associated with an increased inflammation and susceptibility to infection.
      • Kittelson K
      Glycemic control: a literature review with implications for perioperative nursing practice.
      ,

      Weintrob AC, Sexton DJ. Susceptibility to infections in persons with diabetes mellitus. UpToDate Website.Available at:https://www.uptodate.com/contents/susceptibility-to-infections-in-persons-with-diabetes-mellitus. Published July 2018. Accessed December 7, 2019.

      In a study by Jeon, hospitalized patients with glucose levels greater than 180 mg/dL were associated with pneumonia in hospitalized patients.
      • Jeon CY
      • Furuya EY
      • Smaldone A
      • Larson EL
      Post-admission glucose levels are associated with healthcare-associated bloodstream infections and pneumonia in hospitalized patients with diabetes.
      In a cluster randomized trial, early identification and aggressive management of blood glucose level in patients with diabetes reduced the incidence of infection in noncritically ill patients.
      • Kyi M
      • Colman PG
      • Wraight PR
      • et al.
      Early intervention for diabetes in medical and surgical inpatients decreases hyperglycemia and hospital-acquired infections: a cluster randomized trial.

      Immunizations

      Immunizations to prevent influenza and pneumococcal disease are underused in the United States, especially among adults age 65 years and older. The Advisory Committee on Immunization Practices recommends screening and immunizing hospitalized patients to increase the rate of vaccination.

      Centers for Disease Control and Prevention. Advisory Committee on Immunization Practices (ACIP). Available at: https://www.cdc.gov/vaccines/acip/index.html. Accessed December 7, 2019.

      To protect at-risk patients from influenza, it is recommended that all US patients over the age of 6 months receive the influenza vaccine. The Advisory Committee on Immunization Practices also recommends following guidelines for pneumococcal vaccines.

      Centers for Disease Control and Prevention. Advisory Committee on Immunization Practices (ACIP). Available at: https://www.cdc.gov/vaccines/acip/index.html. Accessed December 7, 2019.

      Although immunizing patients during hospitalization does not provide immediate benefit, missing this opportunity to protect patients from influenza and pneumococcal disease may significantly raise their risk of morbidity and mortality after discharge. A 3-year surveillance program in Canada found that patients receiving the influenza vaccine had a statistically and clinically significant lower risk for hospitalization and complications from the flu.
      • Nichols MK
      • Andrew MK
      • Hatchette TF
      • et al.
      Influenza vaccine effectiveness to prevent influenza-related hospitalizations and serious outcomes in Canadian adults over the 2011/12 through 2013/14 influenza seasons: a pooled analysis from the Canadian Immunization Research Network (CIRN) Serious Outcomes Surveillance (SOS Network).
      People with diabetes are at especially high risk for infection and complications from influenza and pneumococcal disease. Vaccinations are effective in reducing death and complications for patients with diabetes and are recommended by experts.
      • Husein N
      • Woo V
      Influenza and pneumococcal immunization.
      Key Points
      • All hospitals should have initiatives to target the identified risk factors of oropharyngeal colonization, prevent aspiration of pathogens into the lungs, and strengthen host defenses.
      • Routine oral care following an evidence-based oral care protocol should be a fundamental part of patient care to reduce NV-HAP risk related to oropharyngeal colonization.
      • To reduce aspiration risk, hospitals should implement protocols for swallow screens, head of bed elevation, and use of medical and feeding tubes via the oropharyngeal tract.
      • Strategies to strengthen host defenses include early mobility protocols, ensuring adequate nutrition, stress ulcer prophylaxis stewardship, measures to assess and control blood glucose, and patient immunization programs.
      • Nurses and other frontline care providers are in the key position to drive improvement of this very important area of patient safety. It is essential that they have the resources and training to provide preventive care.

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