Non-ventilator associated hospital acquired pneumonia (NV-HAP) risk among hospitalized veterans before and during the COVID-19 pandemic.

BACKGROUND: Among hospitalized US Veterans, the rate of non-ventilator associated hospital acquired pneumonia (NV-HAP) decreased between 2015 and 2020 then increased following the onset of 2019-nCoV (COVID-19). METHODS: Veterans admitted to inpatient acute care for ≥48 hours at 135 Department of Veterans Affairs Medical Centers between 2015 and 2021 were identified (n = 1,567,275). Non-linear trends in NV-HAP incidence were estimated using generalized additive modeling, adjusted for seasonality and patient risk factors. RESULTS: The incidence rate (IR) of NV-HAP decreased linearly by 32% (95% CI: 63-74) from 10/1/2015 to 2/1/2020, translating to 337 fewer NV-HAP cases. Following the US onset of the COVID-19 pandemic in February 2020, the NV-HAP IR increased by 25% (95% CI: 14-36) among Veterans without COVID-19 and 108% (95% CI: 178-245) among Veterans with COVID-19, resulting in an additional 50 NV-HAP cases and $5,042,900 in direct patient care costs 12-months post admission. DISCUSSION: This increase in NV-HAP rates could be driven by elevated risk among Veterans with COVID-19, decreased prevention measures during extreme COVID-19 related system stress, and increased patient acuity among hospitalized Veterans during the first year of the pandemic. CONCLUSIONS: Basic nursing preventive measures that are resilient to system stress are needed as well as population surveillance to rapidly identify changes in NV-HAP risk.

The association between non-ventilator associated hospital acquired pneumonia and patient outcomes among U.S. Veterans.

BACKGROUND: Non-ventilator associated hospital acquired pneumonia (NV-HAP) affects approximately 1 in 100 hospitalized patients yet risk-adjusted outcomes associated with developing NV-HAP are unknown. METHODS: Retrospective cohort study with propensity score matched populations (NV-HAP vs no NV-HAP), using ICD-10 codes for bacterial pneumonia not present on admission. Outcomes included the patient level probability of NV-HAP developing among acute care non-transfer admissions in 133 Veterans Affairs hospitals and subsequent mortality, length of stay, inpatient sepsis, and 12-month costs. RESULTS: NV-HAP occurred in 0.6% of Veteran admissions. Among admissions that developed NV-HAP, the mean length of stay of 26.3 days (6.72 days among non-NV-HAP), 30-day mortality was 18.4% (4.5% among non-NV-HAP), 1-year mortality was 47.8% (21.4% among non-NV-HAP), and total median 12-month direct medical costs were $138,136.32 ($64,357.21 among non-NV-HAP). Inpatient sepsis occurred in approximately 20% of NV-HAP admissions (0.7% among non-NV-HAP). Data available at admission was insufficient to identify high and low risk patient groups. CONCLUSIONS: NV-HAP is associated with severely worse patient outcomes and increased costs of care up to 12 months post-episode. Since population risk stratification is not feasible, prevention efforts should be directed at the full population of hospitalized Veterans.

Non-ventilator associated hospital acquired pneumonia incidence and health outcomes among U.S. veterans from 2016-2020.

Among 1,635,711 Veteran acute care admissions (FY2016-2020), the risk of non-ventilator associated hospital acquired pneumonia (NV-HAP) was 1.26 cases per 1,000 hospitalized days and decreased linearly over time with an uptick in cases in the last year coinciding with the onset of the covid-19 pandemic. Veterans who develop NV-HAP experience remarkably higher 30-day and 1-year mortality, longer length of stay, and higher rates of inpatient sepsis. Monitoring and prevention measures may substantially reduce negative outcomes.

Nurse-led triage of new sleep referrals is associated with lower risk of potentially contraindicated sleep testing: a retrospective cohort study.

BACKGROUND: The volume of specialty care referrals often outstrips specialists' capacity. The Department of Veterans Affairs launched a system of referral coordination to augment our workforce, empowering registered nurses to use decision support tools to triage specialty referrals. While task shifting may improve access, there is limited evidence regarding the relative quality of nurses' triage decisions to ensure such management is safe. OBJECTIVE: Within the specialty of sleep medicine, we compared receipt of contraindicated testing for obstructive sleep apnoea (OSA) between patients triaged to sleep testing by nurses in the referral coordination system (RCS) relative to our traditional specialist-led system (TSS). METHODS: Patients referred for OSA evaluation can be triaged to either home sleep apnoea testing (HSAT) or polysomnography, and existing guidelines specify patients for whom HSAT is contraindicated. In RCS, nurses used a decision support tool to make triage decisions for sleep testing but were instructed to seek specialist oversight in complex cases. In TSS, specialists made triage decisions themselves. We performed a single-centre retrospective cohort study of patients without OSA who were referred to sleep testing between September 2018 and August 2019. Patients were assigned to triage by RCS or TSS in quasirandom fashion based on triager availability at time of referral. We compared receipt of contraindicated sleep tests between groups using a generalised linear model adjusted for day of the week and time of day of referral. RESULTS: RCS triaged 793 referrals for OSA evaluation relative to 1787 by TSS. Patients with RCS triages were at lower risk of receiving potentially contraindicated sleep tests relative risk 0.52 (95% CI 0.29 to 0.93). CONCLUSION: Our results suggest that incorporating registered nurses into triage decision-making may improve the quality of diagnostic care for OSA.