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July 13, 2022

How simple hygiene steps could prevent hospital-acquired pneumonia

Daily Briefing

    Pneumonia is a significant problem in hospitals and other health care facilities, killing up to 30% of infected patients every year—however, health experts say a simple strategy can drastically reduce the risk of infection and save thousands of lives, Brett Kelman writes for Kaiser Health News.

    Cheat sheet: Hospital-Acquired Condition Reduction Program

    Thousands of patients acquire pneumonia in the hospital every year

    Pneumonia is one of the most common infections patients acquire while in health care facilities, and of these cases, most are non-ventilator hospital-acquired pneumonia (NVHAP).

    According to the National Organization for NV-HAP Prevention, this type of pneumonia affects roughly 1 out of every 100 patients and kills between 15% and 30% of those who are infected. For patients who survive NVHAP, the infection often lengthens their hospital stay up to 15 days and increases their likelihood of being readmitted within a month or transferred to the ICU.

    This year, ECRI named NVHAP as one of its top safety concerns. And James Davis, an infection expert at ECRI, said the prevalence of NVHAP is likely "underestimated" since hospitals are not required to report it to the federal government. In addition, cases of NVHAP likely increased during the pandemic as hospitals were overwhelmed with Covid-19 patients.

    "We only know what's reported," Davis said. "Could this be the tip of the iceberg? I would say, in my opinion, probably."

    How improving oral hygiene can prevent NVHAP

    Pneumonia is caused by germs that trigger an infection in a patients' lungs, and NVHAP in particular is most often caused by bacteria in the mouth that is collected in the biofilm of unbrushed teeth. Patients who lie flat or remain immobile for extended periods are also at greater risk of NVHAP since bacteria is more likely to enter their lungs.

    To reduce the risk of NVHAP, many health experts recommend hospitals improve oral care, particularly through routine teeth brushing, to prevent bacteria from building up in patients' mouths. Elevating patients' heads and getting them out of bed regularly can also help reduce the risk of NVHAP.

    For example, a study of 21 Kaiser Permanente hospitals in California found that prioritizing oral care and getting patients mobile reduced rates of NVHAP by roughly 70%. Separately, a study at Orlando Regional Medical Center in Florida found that improving oral care reduced NVHAP rates by 85% for patients in a medical unit and by 56% for patients in a surgical unit.

    In addition, a 2016 pilot oral care program at a veterans' hospital in Salem, Virginia, successfully reduced NVHAP rates by 92%—preventing roughly 13 deaths over 19 months. The program, called the HAPPEN Initiative, has since been expanded to veterans' hospitals across the United States, and experts say it could be used as a model for other hospitals.

    According to Michelle Lucatorto, a nursing official who leads HAPPEN, the program teaches nurses how to effectively brush patients' teeth and provides education on how good oral care can prevent NVHAP. "Sometimes we are searching for the most complicated intervention," Lucatorto said. "We are always looking for that new bypass surgery, or some new technical equipment. And sometimes I think we fail to look at the simple things we can do in our practice to save people's lives."

    Health experts issue a 'call to action' against NVHAP

    "I'll tell you that today the vast majority of the tens of thousands of nurses in hospitals have no idea that pneumonia comes from germs in the mouth," said Dian Baker, a professor at Sacramento State who has spent over ten years studying NVHAP. According to Baker, hospitals often prioritize other tasks over brushing their patients' teeth and provide cheap, ineffective toothbrushes, which increases the risk of NVHAP.

    Last year, a group of researchers, including officials from CDC, the Veterans Health Administration, and the Joint Commission, published a "call-to-action" research paper that aimed to launch "a national healthcare conversation about NVHAP prevention."

    To better track the condition, some researchers have suggested creating a standardized surveillance definition of NVHAP, which could allow the federal government to later require cases be reported to encourage prevention.

    In addition, Sylvia Garcia-Houchins, the Joint Commission's director of infection prevention and control, said the organization is considering expanding its infection control standards for hospitals to include NVHAP and other conditions.

    According to Baker, she has spoken to hundreds of hospitals about the dangers of NVHAP and how to prevent it, but thousands more have still not made changes to reduce the risks of NVHAP for their patients.

    "We are not asking for some big, $300,000 piece of equipment," Baker said. "The two things that show the best evidence of preventing this harm are things that should be happening in standard care anyway—brushing teeth and getting patients mobilized." (Kelman, Kaiser Health News, 7/12)

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