Pa Patient Saf Advis 2018 Sep;15(3).
A Second Breadth: Hospital-Acquired Pneumonia in Pennsylvania, Nonventilated versus Ventilated Patients
Critical Care, Emergency Medicine, Infectious Diseases, Nursing, Nutrition, Oncology, Orthopedics, Pediatrics, Pulmonary Medicine, Surgery
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​Authors

James Davis, MSN, RN, CIC, CCRN, HEM, FAPIC
Senior Infection Prevention Analyst

Edward Finley, BS
Data Analyst

Pennsylvania Patient Safety Authority

Corresponding Author
James Davis

Abstract

Research published in 2012 by Pennsylvania Patient Safety Authority analysts determined that nonventilator hospital-acquired pneumonia (NV-HAP) affected more people than ventilator-associated pneumonia (VAP) and was as lethal as, and more costly than, VAP. This article updates the Authority's original data set, using the same methods and outcome measures. Analysts queried the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN) for complete nosocomial pneumonia data sets from January 1, 2013, through December 31, 2016, inclusive of the total inpatient population for Pennsylvania acute-care facilities. Data sets from the Authority's original data (from January 1, 2009, through December 31, 2012) are included for comparison. The analysis found not only that NV-HAP continues to be as lethal as VAP but that it demonstrates higher incidence and is more costly as a whole.

Introduction

Research published in 2012 by the Pennsylvania Patient Safety Authority determined that nonventilator hospital-acquired pneumonia (NV-HAP) affected more people than ventilator-associated pneumonia (VAP) and was as lethal as and wholly more costly than VAP. Furthermore, the incidence of NV-HAP was on the rise in patients in conventional wards and was likely to be underreported.1

Since the original Authority work identifying and defining the impact of NV-HAP on Pennsylvania residents and healthcare facilities was published, U.S. researchers interested in furthering the body of knowledge for NV-HAP have focused on the condition. Subsequent publications have validated the Authority's original findings and identified new areas of impact.

Examples of NV-HAP research findings include the following:

  • Hospital-acquired pneumonia (HAP) accounts for about 21.8% of the burden of all hospital-associated infections meeting criteria of the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN). Of these HAP cases, 60.9% can be attributed to NV-HAP, and 39.1% can be attributed to VAP.2   
  • Mortality attributed to NV-HAP ranges from 13.1% to 30%.1-6
  • Additional length of stay associated with NV-HAP ranges from 4.0 to 15.9 days.6
  • Estimated NV-HAP acute-care treatment costs range from $28,008 to $40,000 per case.1,2,6,7

This article updates the Authority's original data set, using the same methods and outcome measures. The authors include prevention strategies proposed by other investigators that complement the Authority's original targeted interventions.  

Methods

Pennsylvania state law (Act 52 of 2007) requires that all acute-care healthcare-associated infections be reported through NHSN. Analysts queried NHSN for complete nosocomial pneumonia data sets from January 1, 2013, through December 31, 2016, inclusive of the total inpatient population for Pennsylvania acute-care facilities. Data sets from January 1, 2009, through December 31, 2012, are included for comparison. The original data set was expanded to include 20121 to provide equal time-series sets and to address changes to NHSN's VAP definition that occurred in January 2013.8

Analysts also extracted data for patients with nosocomial pneumonia who died during that period. The NHSN field "Died" was used to aggregate the number of patients with pneumonia who died, regardless of responses found in the "Contributed to death" field. Of those cases of NV-HAP and VAP, the number of patients who died was also extracted. Time-series data was aggregated into yearly subtotals.

Besides comparing NV-HAP versus VAP incidence and mortality, estimated costs of NV-HAP versus VAP cases are compared. The baseline estimated average cost per NV-HAP case (in 2010 dollars) is $28,008.9 The estimated average cost per VAP case is $37,442.9 Authority analysts accounted for inflation, adjusting yearly values to accurately present financial impact.10 Another outcome, distribution of NV-HAP cases by NHSN unit type, is based on aggregate data expressed in rate per 1,000 patient-days for January 1, 2013, through December 31, 2016.

Results

Table 1 shows the number of NV-HAP and VAP cases for 2009 through 2016 from NHSN. Although NV-HAP is as lethal as VAP, NV-HAP demonstrates higher incidence.

The table also includes the percentages of patients with NV-HAP and VAP who died. The difference in mortality percentages for patients with NV-HAP and VAP are not statistically significant; see Figure 1.

Table 1. Pennsylvania Nosocomial Pneumonia Incidence and Number of Patients with NV-HAP or VAP Who Died​ ​ ​ ​
YearNumber of NV-HAP PatientsNumber of NV-HAP Patients Who DiedPercentage of Patients with NV-HAP Who Died (Confidence Interval)Number of VAP PatientsNumber of VAP Patients Who DiedPercentage of Patients with VAP Who Died (Confidence Limit)
20091,97736418.41 (16.52–20.3)92216317.68 (14.96–20.39)
20101,84836619.81 (17.78–21.83)73714419.54 (16.35–22.73)
20111,78031817.87 (15.9–19.83)64312719.75 (16.32–23.19)
20121,62030718.95 (16.83–21.07)57111219.61 (15.98–23.25)
20131,52828518.65 (16.49–20.82)76716020.86 (17.63–24.09)
20141,41925618.04 (15.83–20.25)90119922.09 (19.02–25.16)
20151,42727719.41 (17.13–21.7)91221823.90 (20.73–27.08)
20161,38028020.29 (17.91–22.67)98022122.55 (19.58–25.52)

Note: Data as reported to the National Healthcare Safety Network (NHSN). The NHSN field "Died" was used to aggregate the number of patients with NV-HAP or VAP who died regardless of responses found in the "Contributed to death" field.

NV-HAP, Nonventilator hospital-acquired pneumonia; VAP, ventilator-associated pneumonia.

 

Figure 1. Pennsylvania Nosocomial Pneumonia Cases, Percentage of Patients Who Died

 

Table 2 compares the estimated total costs for NV-HAP and VAP cases. NV-HAP wholly is more costly than VAP.

Table 2. Estimated Total Yearly Cost of NV-HAP and VAP Cases in Pennsylvania ​ ​ ​
YearNV-HAP CasesTotal Cost for NV-HAP Cases*VAP CasesTotal Cost for VAP Cases*
20091,977$53,955,118922$33,638,285
20101,848$51,758,784737$27,594,754
20111,780$50,667,789643$24,468,079
20121,620$47,462,290571$22,363,860
20131,528$45,480,874767$30,519,528
20141,419$42,903,380901$36,417,564
20151,427$43,106,716912$36,829,241
20161,380$42,259,340980$40,118,681

Note: Cases identified in the National Healthcare Safety Network (NHSN) database.

The estimated average cost per NV-HAP case is $28,008. The estimated average cost per VAP case is $37,442.

NV-HAP, nonventilator hospital-acquired pneumonia; VAP, ventilator-associated pneumonia.

* Average costs are derived from Kalsekar I, Amsden J, Kothari S, et al. Economic and utilization burden of hospital-acquired pneumonia (HAP): a systematic review and meta-analysis. Chest. 2010 Oct;138 (4 Suppl):739A, and adjusted for inflation before and after 2010 based on the U.S. Department of Labor. Bureau of Labor Statistics. Consumer Price Index for All Urban Consumers (CPI-U) Inflation Calculator.

 

Table 3 shows the distribution of NV-HAP cases by NHSN unit type for years 2013 through 2016. This data is intended to identify and prioritize high-risk patient populations, to facilitate effective deployment of infection-prevention efforts and resources.

Table 3. Distribution of NV-HAP Cases, Pooled Mean per 1,000 Patient-Days (Based on Aggregate Data for Pennsylvania, 2013 through 2016) ​ ​ ​ ​
Unit*FacilitiesNV-HAP CasesPatient-DaysPooled Mean†,‡
Acute/Critical Care ​ ​ ​ ​ ​
Trauma12625892,3960.700
Surgery11477908,2160.525
Oncology medical/surgical24076,6970.522
Neurosurgical9304720,3030.422
Medical247752,028,7080.382
Cardiothoracic305621,550,7930.362
Long-term acute care350189,4970.264
Medical/surgical1171,8837,212,2600.261
Cardiac19222963,7480.230
Prenatal1211,5660.173
Neurologic418106,3480.169
Burn427194,8240.139
Respiratory2659,1800.101
Medical/surgical pediatric536693,5490.052
Nursery19751,800,2030.042
Step-down nursery9351,077,7200.032
Cardiothoracic pediatric39331,4090.027
Medical pediatric0025,3220.000
Surgery pediatric0010,4840.000
Ward ​ ​ ​ ​ ​
Stroke11085,7640.117
Pulmonary661698,6340.087
Neurosurgical324452,9440.053
Medical5361211,976,9370.051
Surgical383316,433,8640.051
Genitourinary15103,4840.048
Medical/surgical1221,28529,471,9250.044
Telemetry241182,824,9880.042
Rehabilitation411293,982,1740.032
Orthopedic24842,909,7770.029
Gynecology24140,3790.028
Neurologic717682,5170.025
Gerontology1177,7340.013
Behavioral4011610,670,5650.011
Surgical pediatric11115,9050.009
Trauma orthopedic13334,1860.009
Antenatal 11117,7040.008
Labor & delivery44546,4180.007
Medical pediatric25838,0510.006
Labor & delivery/postpartum551,077,7580.005
Rehabilitation pediatric11204,7610.005
Behavioral health pediatric11261,3560.004
Postpartum10112,740,9310.004
Medical/surgical pediatric451,530,6520.003
Behavioral health adolescent11681,0880.001
Nursery121,908,7070.001
Ear/nose/throat007360.000
Orthopedic pediatric00113,1780.000
Vascular surgery0031,9260.000
Jail00155,1760.000
Ward—Oncology ​ ​ ​ ​ ​
Leukemia/lymphoma214110,5500.127
Hematology/oncology173432,865,6830.120
Hematopoietic stem cell transplant237317,8540.116
Hematology/oncology pediatrics00551,6960.000
Specialty Care Area ​ ​ ​ ​ ​
Solid organ transplant pediatric14128,6150.031
Long-term acute care pediatric0022,8600.000
Step-down Unit ​ ​ ​ ​ ​
Adult605558,272,6440.067
Pediatric11415,7070.002
Nursery0071,5420.000
Long-term acute care221843,867,3890.048

Note: Data as reported to the National Healthcare Safety Network (NHSN).

NV-HAP, nonventilator hospital-acquired pneumonia.

* Units are based on NHSN classifications.

Pooled mean = total cases ÷ total patient-days x 1,000.

‡  Per 1,000 patient-days.

Discussion

Both NV-HAP and HAP continue to be problematic for acute-care patients in Pennsylvania. Many healthcare providers are unaware of the importance of good dental care in preventing both NV-HAP and HAP. Li and co-authors noted that "the teeth are the only nonshedding surfaces in the body, and bacterial levels can reach more than 1011 microorganisms per mg of dental plaque [biofilm]."11 The presence of subgingival biofilm serves as a continual and enormous bacterial load.11 Poor oral hygiene increases plaque load, increasing enzyme levels in saliva.11 As a consequence of the plaque load, increased levels of oral proteolytic enzymes change the lining of the mouth, increasing attachment and colonization by exogenous and/or endogenous pathogenic bacteria.12 The oral cavity is a source as well as a reservoir for pathogenic bacteria in both planktonic and biofilm states.

Dental-biofilm removal is mainly accomplished by using dentifrice-containing compounds, such as detergents, abrasives, and antimicrobials, which require mechanical tooth brushing to be effective.13 Given the characteristics of dental biofilm, part of a comprehensive NV-HAP prevention program includes tooth and tongue brushing with toothpaste.

Other preventive measures include protecting the patient from macro and micro aspiration and strengthening host defenses to infection.1,6,7,14 Figure 2 provides selected interventions to prevent NV-HAP. Figure 3 provides the Hospital-Acquired Pneumonia Prevention Initiative (HAPPI) oral care protocol designed by researchers at Sutter Medical Center and California State University, Sacramento, and approved by the American Dental Association Board of Trustees in 2017. The HAPPI research developed a targeted oral-care protocol that specifies patient type, equipment, procedure, and frequency for oral care.

Figure 2. Selected Interventions to Prevent Nonventilator Hospital-Acquired Pneumonia

Figure 3. Oral Care Protocol to Prevent Hospital-Acquired Pneumonia (reprinted with permission)

For preventive interventions to be successful, they need to be performed at specified frequencies. In a large, multicenter, nationwide study, in regard to hospital care performed in the 24 hours before NV-HAP diagnosis, Baker and Quinn found evidence of limited compliance, as follows:14

  • Oral care ≥2 times was not documented for 58.6% of patients.
  • Most patients (64.5%) had documented head-of-bed elevation to 30 to 45 degrees, whereas 35.5% did not.
  • If permitted, 28.7% of patients were out of bed twice in a 24-hour period, and 55.4% were out of bed fewer than two times (15.9% were not allowed mobility intervention).

  • Incentive spirometry was not documented for 81.8%, nor were cough and deep breathing exercises (67.4%), in the 24-hour period before pneumonia diagnosis.

The poor performance of basic NV-HAP prevention methods is unfortunate and likely signals the need for improved workflows, systems, tools, and human resources to deliver the care that is needed to prevent the condition. The job of prevention should fall upon all care providers, not just nurses and patient care assistants. Perhaps enlisting respiratory therapists, speech and swallowing therapists, and dental professionals could help ensure prevention tasks are performed at appropriate intervals.

The dental professional's participation is of paramount importance. Adachi and co-authors correlated weekly dental cleaning by a hygienist with fewer cases of fever and fatal pneumonia in the nursing home setting.15 Similarly, Abe and co-authors noted a reduction in influenza infection in older patients because of weekly professional dental cleaning.16 Perhaps, for HAP prevention, the dental professional should play an active role in the hospital and other healthcare settings.

Limitations and Data Nuances

NHSN's VAP criteria-definition changes occurred in January 2013,8 which, unfortunately, renders impossible direct comparisons between VAP and NV-HAP for the time periods before and after the change. Analysts did not calculate for analysis the pooled mean for NHSN events for the time periods before or after the criteria change, because the totals would be incomparable.

Analysis by patient-days may underestimate the true rate of NV-HAP because this metric potentially lowers rates because of extensions of length of stay related to NV-HAP. Authority analysts did not have access to unit-level-specific admissions by location type for this analysis—hence, the use of patient-days by location type.

Comparison of Table 1 from this article with Table 1 from the original Authority article1 reveals few differences, likely due to institutional edits over time. Regardless, the outcomes are the same for this updated data compared with the original data.

Conclusion

Both NV-HAP and VAP continue to be problematic for acute-care patients in Pennsylvania. NV-HAP affects more patients, contributes to more deaths, and increases costs more than VAP. Focusing care on bacterial reservoirs and the oral portal of entry is the most realistic approach for preventing NV-HAP. Improving oral hygiene is essential in preventing NV-HAP (and VAP). Staff compliance with interventions, as noted herein, and helping all patients to get HAPPI care is likely to prevent extra lengths of stay, save money, and prevent premature deaths.

Notes

  1. Davis J, Finley E. The breadth of hospital-acquired pneumonia: nonventilated versus ventilated patients in Pennsylvania. Pa Patient Saf Advis. 2012 Sep;9(3):99-105. Also available: http://patientsafety.pa.gov/ADVISORIES/Pages/201209_99.aspx.
  2. Magill SS, Edwards JR, Bamberg W, Beldavs ZG, Dumyati G, Kainer MA, Lynfield R, Maloney M, McAllister-Hollod L, Nadle J, Ray SM, Thompson DL, Wilson LE, Fridkin SK, Emerging Infections Program Healthcare-Associated Infections and Antimicrobial Use Prevalence Survey Team. Multistate point-prevalence survey of health care-associated infections. N Engl J Med. 2014 Mar 27;370(13):1198-208. Also available: http://dx.doi.org/10.1056/NEJMoa1306801. PMID: 24670166
  3. Micek ST, Chew B, Hampton N, Kollef MH. A case-control study assessing the impact of non-ventilated hospital-acquired pneumonia on patient outcomes. Chest. 2016;150:991-2.
  4. Sopena N, Heras E, Casas I, Bechini J, Guasch I, Pedro-Botet ML, Roure S, Sabrià M. Risk factors for hospital-acquired pneumonia outside the intensive care unit: a case-control study. Am J Infect Control. 2014 Jan;42(1):38-42. Also available: http://dx.doi.org/10.1016/j.ajic.2013.06.021. PMID: 24199911
  5. See I, Chang J, Gualandi N, Buser GL, Rohrbach P, Smeltz DA, Bellush MJ, Coffin SE, Gould JM, Hess D, Hennessey P, Hubbard S, Kiernan A, O'Donnell J, Pegues DA, Miller JR, Magill SS. Clinical correlates of surveillance events detected by National Healthcare Safety Network pneumonia and lower respiratory infection definitions - Pennsylvania, 2011-2012. Infect Control Hosp Epidemiol. 2016 Jul;37(7):818-24. Also available: http://dx.doi.org/10.1017/ice.2016.74. PMID: 27072043
  6. Giuliano KK, Baker D, Quinn B. The epidemiology of nonventilator hospital-acquired pneumonia in the United States. Am J Infect Control. 2018 Mar;46(3):322-7. Also available: http://dx.doi.org/10.1016/j.ajic.2017.09.005. PMID: 29050905
  7. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med. 2005 Feb 15;171(4):388-416. PMID: 15699079
  8. National Healthcare Safety Network (NHSN) Patient Safety Component Manual. Atlanta (GA): Centers for Disease Control and Prevention (CDC); 2018 Jan. Device Associated Module: Ventilator-Associated Event (VAE). p. 10.2-10.44. Also available: https://www.cdc.gov/nhsn/pdfs/pscmanual/10-vae_final.pdf.
  9. Kalsekar I, Amsden J, Kothari S, et al. Economic and utilization burden of hospital-acquired pneumonia (HAP): a systematic review and meta-analysis. Chest. 2010 Oct;138(4 Suppl):739A.
  10. Consumer Price Index for All Urban Consumers (CPI-U): Inflation calculator. [internet]. Washington (DC): U.S. Department of Labor, Bureau of Labor Statistics; [accessed 2018 Apr 04]. Available: https://www.bls.gov/data/inflation_calculator.htm.
  11. Li X, Kolltveit KM, Tronstad L, Olsen I. Systemic diseases caused by oral infection. Clin Microbiol Rev. 2000 Oct;13(4):547-58. PMID: 11023956
  12. Childs WC, Gibbons RJ. Selective modulation of bacterial attachment to oral epithelial cells by enzyme activities associated with poor oral hygiene. J Periodontal Res. 1990 May;25(3):172-8. PMID: 2141877
  13. Sanz M, Serrano J, Iniesta M, Santa Cruz I, Herrera D. Antiplaque and antigingivitis toothpastes. In: van Loveren C, editor(s). Toothpastes. Basel (Switzerland): Karger; 2013. p. 27-44. Monographs in Oral Science; vol. 23.
  14. Baker D, Quinn B. Hospital Acquired Pneumonia Prevention Initiative-2: Incidence of nonventilator hospital-acquired pneumonia in the United States. Am J Infect Control. 2018 Jan;46(1):2-7. Also available: http://dx.doi.org/10.1016/j.ajic.2017.08.036. PMID: 29050903
  15. Adachi M, Ishihara K, Abe S, Okuda K, Ishikawa T. Effect of professional oral health care on the elderly living in nursing homes. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2002 Aug;94(2):191-5. PMID: 12221387
  16. Abe S, Ishihara K, Adachi M, Sasaki H, Tanaka K, Okuda K. Professional oral care reduces influenza infection in elderly. Arch Gerontol Geriatr. 2006 Sep-Oct;43(2):157-64. Also available: http://dx.doi.org/10.1016/j.archger.2005.10.004. PMID: 16325937
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