Implementing a fundamental nursing skills bundle can reduce risk.
- Hospital-acquired pneumonia (HAP) is a serious complication of an acute care admission, particularly for patients noted to be at risk.
- HAP can be reduced when infection prevention measures are followed and nursing care is delivered following evidence-based practice guidelines.
- The use of a fundamental skill bundle when delivering patient care may improve patient outcomes in the acute care setting.
Hospital-acquired pneumonia (HAP), which includes ventilator-associated pneumonia (VAP) and nonventilator hospital-acquired pneumonia (NVHAP), is a well-documented hospital complication that’s diagnosed when patients demonstrate signs and symptoms of pneumonia 48 or more hours after hospital admission; VAP is diagnosed when signs and symptoms of pneumonia appear 48 hours after intubation.
HAP, an inflammatory condition of the lung parenchyma, has the highest mortality rate of any hospital-acquired infection (HAI) in the United States. VAP comprises about 38% of HAP cases; NVHAP is underreported as a hospital complication.
Consequences of HAP include prolonged lengths of stay in the hospital, expensive medical treatments, and discharge to a long-term care facility. Avoiding these consequences depends on nursing care that is based on a fundamental nursing skills bundle and delivered in conjunction with an interprofessional team.
Causes and risk factors
The most common cause of HAP is aspiration of microorganisms that originate in the patient’s nasal, oropharyngeal, and gastric flora. Several factors place patients at risk for aspiration, including dysphagia, coughing, and altered mental status as a result of stroke, seizures, or substance use disorder. For patients who’ve had a stroke, pneumonia resulting from aspiration is a leading cause of death.
Other patients at risk for aspiration include those with neuromuscular diseases (such as Parkinson’s disease and muscular dystrophy), mouth sores, esophageal blockages due to tumor or radiation treatment, neurologic changes (for example, alteration of the glossopharyngeal nerve after a stroke), chronic pulmonary disease (which can result in poor cough or inspiratory effort), and GI conditions that cause severe nausea and vomiting. In addition, patients receiving proton pump inhibitors to increase the pH of gastric secretions may instead experience reduced pH. These more acidic secretions may allow microorganisms in the gut to proliferate, potentially causing HAP if vomit is aspirated.
Even healthy patients may experience aspiration. Almost half of healthy individuals have episodes of silent aspiration during sleep, which they tolerate without significant disease progression. But when they’re hospitalized and their health status is compromised, their risk for developing pneumonia increases.
HAP also can be acquired from pathogens transmitted via healthcare workers and hospital equipment. For this reason, all healthcare workers must strictly adhere to infection prevention standards, especially when caring for patients in the acute care setting, who are at a greater risk for developing pneumonia because they may be immunocompromised or malnourished, at an advanced age, or have multiple comorbidities.
Assessment and diagnosis
HAP is the second most common HAI after catheter-associated urinary tract infections. Patients on any unit in the hospital can develop NVHAP, which can result in transfer to intensive care.
To prevent HAP, nurses should be alert for aspiration symptoms and intervene quickly and appropriately. Signs of respiratory distress—such as stridor, tachypnea, tachycardia, and drop in oxygen saturation—warrant immediate nursing interventions. Pain when swallowing, a feeling that food is getting stuck in the throat, and difficulty swallowing should alert nurses to possible dysphagia. Early HAP diagnosis can be achieved with pulse oximetry, chest x-ray, complete blood count with differential, and sputum culture.
Several fundamental therapeutic nursing interventions—adhering to infection prevention standards, elevating the head of the bed 30 to 45 degrees to prevent aspiration, ensuring good oral hygiene (cleaning teeth, gums, tongue, dentures), increasing patient mobility with ambulation to three times a day as appropriate, encouraging coughing and deep breathing, and instructing patients in the use of incentive spirometry—are associated with reducing HAP risk. Most hospitals don’t routinely monitor this fundamental nursing intervention skills bundle to ensure effective HAP prevention, so nurses should take the lead in strategizing the implementation of these care protocols.
Infection prevention standards
Hospitalization in acute care settings impacts patients’ immune response, so hospital staff must follow infection prevention measures to lower the risk of developing HAIs, including HAP. Hand hygiene is an effective measure to prevent HAI and frequently is the focus of staff education. Studies show that access to bedside antiseptic hand scrubs contributes to an increase in hand hygiene adherence, which can lead to an overall reduction in HAIs. In addition, face masks can be effective at reducing transmission of airborne pathogens such as those that cause pneumonia and influenza. Also, healthcare worker influenza vaccination is key to preventing HAP; antiviral prophylaxis should be provided to patients during a flu outbreak.
Head of bed elevation
Elevating the head of the bed is a simple intervention that may reduce aspiration risk. Raising the head of the bed to at least 30 degrees as a deterrent to microaspiration in patients on a ventilator has been well documented; some research suggests that 45 degrees is ideal for these patients. However, aspiration not associated with a ventilator is common in acute care patients, making aspiration risk assessment vital to safe nursing practice. If the assessment reveals that a patient is at risk for aspiration, elevating the head of the bed should be included in an HAP nursing intervention bundle.
For patients with an altered mental status, including those with lethargy or sedation, the head of the bed should be elevated to at least 30 degrees when they are at rest. If tolerated, increasing the head of the bed to high Fowler’s position during mealtimes and when administering medications can help prevent aspiration.
When caring for patients with a nasogastric tube for feeding, nurses should follow the evidence-based practice of ensuring that an x-ray has verified tip placement before feeding and maintain the head of the bed at more than 30 degrees at all times. Nurses also should document a thorough abdominal assessment, including measuring residual feeding, and talk to the healthcare provider about using a prokinetic agent such as metoclopramide, which has been shown to help reduce aspiration in patients with a feeding tube.
HAP is most commonly caused by gram-negative bacilli and Staphylococcus aureus that may flourish in the oral cavity of patients in acute care settings. Research has shown that standardized oral care reduces bacteria in the mouth, and several studies have reported a significant decrease in HAP with an effective twice-daily oral brushing program. (See Oral care tips.)
Most nursing schools teach oral care, but providing it and helping patients perform it is reported to be very low. Evidence also suggests that oral care is poorly documented by nursing staff, which may indicate that staff education is needed to improve adherence and documentation. Linking oral care to nursing assessment and educating staff on this best practice for preventing pneumonia may improve patient outcomes and reduce HAP in acute care settings.
Studies also have shown that HAP prevention in surgical patients should begin with oral care before intubation. This nursing intervention may reduce microbial growth in the oral airway postoperatively when done in conjunction with other bundle interventions. Educating staff on this practice and adding specific oral care guidelines to the preoperative checklist may help reduce this postop complication.
Early and intensive mobility interventions reduce the incidence of HAP and the effects of deconditioning that accompany prolonged bed rest. Elderly patients and those with chronic diseases are at high risk for functional decline in as little as 72 hours if they’re on unnecessary bed or chair confinement. Unfortunately, although evidence supports early mobilization to reduce HAP, most patients still spend more than 60% of their time in bed. Barriers to early mobility include lack of time, concerns about patient safety, patients’ physiologic instability, lack of appropriate equipment to safely transfer patients, and insufficient personnel to assist with ambulating.
Nurses can take an active role in assessing safe patient transfers and ambulation to reduce fall risk. For example, they can complete the Banner Mobility Assessment Tool (BMAT) to assess basic balance and mobility. The BMAT is a valid and reliable tool for nurses to use at the bedside to determine patient mobility and the appropriate safety equipment needed to assist in transfers and early ambulation.
After patient safety is established, interventions such as getting the patient out of bed at least three times a day has been shown to significantly reduce the incidence of HAP. Adequate pain control is necessary to achieve patient mobility goals. Having an individualized schedule of analgesics and avoiding oversedation before getting out of bed may help patients meet mobility goals. Nurses should partner with physical therapy to develop safe interventions, such as supervised walking programs, to reduce the effects of prolonged bed rest.
Coughing, deep breathing, and incentive spirometry
Coughing, deep breathing, and incentive spirometry have long been essential components in preventing NVHAP in postoperative patients. Because more than half of NVHAP patients are on a medical unit, adding these nursing interventions for nonsurgical patients as well is helpful.
Coughing and deep breathing improve the expectoration of secretions and increase chest wall expansion to help reduce NVHAP. And some evidence suggests that controlled inspiration using incentive spirometry can improve oxygenation and reduce pulmonary complications. However, no clear guidelines exist for the routine use of incentive spirometry in preventing NVHAP.
The incentive spirometer may act as a physical reminder to patients that coughing and deep breathing are important to prevent pulmonary infections. But protocols for the use of incentive spirometers vary widely among nurses and respiratory therapists, leading to reports of patient confusion. Therefore, a combination of the interventions discussed (patient education, elevation of the head of bed, early ambulation, oral care, coughing and deep breathing, and incentive spirometry) appears to be the best way to prevent NVHAP.
Resources, education, and collaboration
Many of the interventions to prevent HAP are part of basic evidence-based nursing practice. Because of this, nurses can take the lead in developing and implementing prevention strategies within their scope of practice and monitor outcomes.
Nurse leaders should provide the appropriate resources—equipment and personnel—so staff can achieve HAP reduction outcomes. Resources may include proper oral care equipment (such as electric suction toothbrushes, mouthwash, dental floss, and denture care items) and safe and effective mobility tools (such as gait belts, slide sheets, and proper lifting equipment). In addition, nurses must be properly educated in the use of any new or unfamiliar equipment so they feel confident about its use and are more likely to use it. Designating team champions on acute care units to assist in achieving HAP prevention goals also may help encourage staff intervention adherence.
Healthcare organizations should provide education workshops to promote the use of fundamental interventions to reduce HAP. Including patients and family in the education process and the plan of care upon admission also may help improve outcomes.
According to Klompas and colleagues, a multidisciplinary team approach to prevention is the most effective strategy in reducing VAP; the same is true for NVHAP. This approach includes a comprehensive team of physicians; nurses; physical, speech, and respiratory therapists; nutritionists; and pharmacologists. Bedside nurses are in an excellent position to take the lead in initiating this type of team collaboration and communicating with the interprofessional healthcare team on the most effective HAP prevention protocols. (See Interprofessional collaboration.)
HAP is an underreported and understudied complication of hospitalization with significant patient morbidity and mortality. It’s responsible for increases in hospital costs, lengths of stay, and discharges to long-term care facilities.
Several fundamental nursing interventions have been associated with decreasing HAP risk; however, no standardized protocols exist for effectively monitoring and documenting them. A fundamental skills bundle that includes best practices for infection prevention, oral care, early mobility, elevation of the head of the bed, and coughing and deep breathing may help improve outcomes, especially for high-risk patients. Staff education about these protocols may increase buy-in at the unit level. Nursing’s focus should be on educating staff and ongoing research for these preventive strategies while also working with patients, families, and an interprofessional team of healthcare providers, and to emphasize the interventions’ importance.
The authors work at West Chester University in West Chester, Pennsylvania. Carolyn D. Meehan is an associate professor of nursing and prelicensure program coordinator. Catherine McKenna is a clinical skills lab coordinator.
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