Sustaining Quality Improvement: Long-Term Reduction of Nonventilator Hospital-Acquired Pneumonia.

BACKGROUND: Hospital-acquired pneumonia is now the number one hospital-acquired infection. Hospitals have addressed ventilator-associated pneumonia; however, patients not on a ventilator acquire more pneumonia with significant associated mortality rates. LOCAL PROBLEM: In our hospital, non-ventilator-associated pneumonia was occurring on all types of units. METHODS: The Influencer Model was used to reduce nonventilator hospital-acquired pneumonia rates. Statistical process control R and X-bar-charts were monitored monthly. INTERVENTIONS: After a gap analysis, an interdisciplinary team implemented enhanced oral care before surgery and on the units, changed tube management, and monitored stress ulcer medication. RESULTS: We achieved a statistically significantly reduction (P = .01) in pneumonia rates that have been sustained over 4 years. CONCLUSIONS: Sustaining change requires (a) a continued team-based, collaborative approach, (b) ongoing stakeholder and executive leadership engagement, (c) monitoring that easy-to-use protocols and required equipment remain in place, and (d) embedded analytics to monitor results over a prolonged period.

Basic nursing care to prevent nonventilator hospital-acquired pneumonia.

PURPOSE: Nonventilator hospital-acquired pneumonia (NV-HAP) is an underreported and unstudied disease, with potential for measurable outcomes, fiscal savings, and improvement in quality of life. The purpose of our study was to (a) identify the incidence of NV-HAP in a convenience sample of U.S. hospitals and (b) determine the effectiveness of reliably delivered basic oral nursing care in reducing NV-HAP. DESIGN: A descriptive, quasi-experimental study using retrospective comparative outcomes to determine (a) the incidence of NV-HAP and (b) the effectiveness of enhanced basic oral nursing care versus usual care to prevent NV-HAP after introduction of a basic oral nursing care initiative. METHODS: We used the International Statistical Classification of Diseases and Related Problems (ICD-9) codes for pneumonia not present on admission and verified NV-HAP diagnosis using the U.S. Centers for Disease Control and Prevention diagnostic criteria. We completed an evidence-based gap analysis and designed a site-specific oral care initiative designed to reduce NV-HAP. The intervention process was guided by the Influencer Model (see Figure) and participatory action research. FINDINGS: We found a substantial amount of unreported NV-HAP. After we initiated our oral care protocols, the rate of NV-HAP per 100 patient days decreased from 0.49 to 0.3 (38.8%). The overall number of cases of NV-HAP was reduced by 37% during the 12-month intervention period. The avoidance of NV-HAP cases resulted in an estimated 8 lives saved, $1.72 million cost avoided, and 500 extra hospital days averted. The extra cost for therapeutic oral care equipment was $117,600 during the 12-month intervention period. Cost savings resulting from avoided NV-HAP was $1.72 million. Return on investment for the organization was $1.6 million in avoided costs. CONCLUSIONS: NV-HAP should be elevated to the same level of concern, attention, and effort as prevention of ventilator-associated pneumonia in hospitals. CLINICAL RELEVANCE: Nursing needs to lead the way in the design and implementation of policies that allow for adequate time, proper oral care supplies, ease of access to supplies, clear procedures, and outcome monitoring ensuring that patients are protected from NV-HAP.

Nursing and Maslow's Hierarchy: A Health Care Pyramid Approach to Safety and Security During a Global Pandemic.

The COVID-19 pandemic of 2020 tested health care organizations in ways many had never experienced. In response to new problems, nurses and other staff needed creative solutions that would allow them to quickly and safely provide care. Nurses concurrently experienced stressors to their personal needs. The authors collected examples of creative problem-solving through staff interviews and reflected on Maslow's hierarchy of needs to consider how nurse's needs were being met throughout the pandemic. Recognizing that basic needs must be addressed before an individual can ascend the levels to eventual self-realization, the authors share how one health care organization quickly and successfully met the patient care requirements while supporting nurses basic needs like safety and trust.

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.

Daily rapid rounds: decreasing length of stay and improving professional practice.

Many hospital leaders are struggling with how to decrease patients' length of stay while maintaining appropriate care. The authors provide a transfer able model for daily rounds that can be used on many units to help decrease length of stay while improving communication, collaboration, and coordination. No increase in staff is required, and nursing satisfaction improves.

Hospital Acquired Pneumonia Prevention Initiative-2: Incidence of nonventilator hospital-acquired pneumonia in the United States.

BACKGROUND: Because nonventilator hospital-acquired pneumonia (NV-HAP) is understudied, our purpose was to determine the incidence, overall burden, and level of documented pneumonia preventive interventions of NV-HAP in 24 U.S. hospitals. METHODS: This retrospective chart review extracted NV-HAP cases as per the 2014 ICD-9-CM codes for pneumonia not present on admission and the 2013 Centers for Disease Control and Prevention case definition. Patient demographic data, outcomes, and documented preventive interventions were also collected. RESULTS: We found 1,300 NV-HAP patients who acquired NV-HAP (rate, 0.12-2.28 per 1,000 patient days) across the 21 hospitals that completed the data collection. Most NV-HAP infections (70.8%) were acquired outside of intensive care units (ICUs); 18.8% required transfer into the ICU. In the 24 hours prior to diagnosis, most of the patients did not have fundamental hospital care associated with pneumonia prevention. CONCLUSIONS: This multicenter, nationwide study highlights the significant burden of NV-HAP in the U.S. acute care hospital setting. We found that NV-HAP occurred on every hospital unit, including in younger, healthy patients. This indicates that although some patients are clearly at higher risk, all patients carry some NV-HAP risk. Therapeutic interventions aimed at NV-HAP prevention are frequently not provided for patients in acute care hospitals.

The epidemiology of nonventilator hospital-acquired pneumonia in the United States.

BACKGROUND: Nonventilator hospital-acquired pneumonia (NV-HAP) is among the most common hospital-acquired infections. The purpose of our study was to quantify the incidence and influence of NV-HAP in the United States using a national dataset. METHODS: The 2012 US National Inpatient Sample dataset was used to compare an NV-HAP group to 4 additional group cohorts: pneumonia on admission, general hospital admissions, matched on mortality and disease severity, and ventilator-associated pneumonia (VAP). The main outcome was NV-HAP incidence. The secondary outcome was to compare hospital length of stay, total hospital charges, and mortality between the NV-HAP group and the 4 additional group cohorts. RESULTS: The overall incidence of NV-HAP was 1.6%, which represents a rate of 3.63 per 1,000 patient-days. NV-HAP was associated with increased total hospital charges, a longer hospital length of stay, and greater likelihood of death in comparison to all groups except patients with VAP. CONCLUSION: NV-HAP is an underappreciated and serious patient safety issue, resulting in significant increases in cost, length of stay, and mortality. Efforts toward prevention of NV-HAP should be raised to the same level of concern as VAP prevention.

Use of a field-to-stroke center helicopter transport program to extend thrombolytic therapy to rural residents.

BACKGROUND AND PURPOSE: Giving stroke victims who reside outside communities with hospitals that can administer tissue plasminogen activator (rtPA) access to thrombolytic therapy is a challenge. Helicopter transport to a stroke center is a potential way to make rtPA available to these communities. We examined the experience of the Shands-Jacksonville Acute Stroke Transport Program, a field-to-stroke center helicopter transport program that serves rural counties in the northeastern Florida/southeastern Georgia region. METHODS: Prospectively collected data of 111 consecutive helicopter transports to Shands-Jacksonville, from an 11-county region, over a 3-year period were reviewed. RESULTS: Eighty-five patients (76%) had a cerebrovascular event. Forty-seven patients (42%) had an ischemic stroke, 19 (17%) had a transient ischemic attack, and 19 (17%) had a hemorrhagic stroke. Thrombolytic therapy was administered to 18 ischemic stroke patients (38%), with 15 being treated intravenously. Three patients who arrived beyond the 3-hour window were treated intra-arterially. Average field-to-hospital distance for all patients was 29.4 miles (range, 11 to 90 miles). Most patients (n=65) arrived within 135 minutes from symptom onset. CONCLUSIONS: A helicopter-based transport system can link a rural region to a stroke center and promote access to thrombolytic therapy.

Implementation and evaluation of electronic clinical decision support for compliance with pneumonia and heart failure quality indicators.

PURPOSE: The ability of an automated system used to identify pneumonia and heart failure (HF) patients in real time and prompt clinical interventions was evaluated. SUMMARY: An automated system evaluated all adult patients with an emergency department (ED) visit or hospital admission for possible pneumonia in real time for 31 days. Two quality-indicator alerts were sent to appropriate clinicians for possible interventions. The system evaluated all hospitalized adult patients for HF for 30 days. A list of possible HF patients printed every 12 hours and was used for possible interventions. Pneumonia and HF identification accuracy was assessed by comparison with discharge diagnosis. Compliance with quality indicators was assessed using three pneumonia and three HF indicators. The effect was measured by comparing compliance data and the number of monthly quality indicators in the top decile seven months before and after implementation. There were 3053 ED visits and 986 inpatient admissions during the pneumonia study. The system sensitivity for pneumonia ED identification was 89% and the specificity was 86%. The sensitivity for pneumonia admissions was 92% and the specificity was 90%. There were 1037 inpatient admissions during the HF study. The sensitivity for HF identification was 94% and the specificity was 90%. Sixty-seven percent of the six indicators studied increased the percentage of months in the top decile after implementation. The average increase was 26%. CONCLUSION: An automated system effectively identified pneumonia and HF patients in real time. The system prompted interventions, which helped increase compliance with national quality indicators.