Pneumonia is the deadliest of all hospital-acquired infections in the United States, costs 3 billion dollars per year and is the leading cause of new antibiotic initiation in hospitals. Hospital-acquired pneumonia is classified as either ventilator-associated pneumonia (VAP) or non-ventilator hospital-acquired pneumonia (NVHAP). For the past 15 years, VAP has dominated our attention, resulting in the wide implementation of evidence-based prevention strategies that have successfully reduced VAP rates. NVHAP. On the other hand, impacts 1 in 100 hospitalized patients but remains poorly researched and underappreciated.
NVHAP’s relative obscurity is exacerbated by a lack of standard definition or diagnostic code that prevent reliable identification of NVHAP cases. More significantly, there is no national policy that recognizes NVHAP as a health care priority. NVHAP is not a required quality metric of the Centers for Disease Control and Prevention (CDC) or the Centers for Medicare and Medicaid Services (CMS). Without enforcement or financial incentives, hospitals have failed to measure, track, report, or implement prevention strategies to reduce NVHAP. It is time to turn our focus to NVHAP.
1. Etiology of NVHAP
NVHAP is primarily caused by the microaspiration of bacteria from the oropharyngeal cavity, but viruses like influenza and respiratory syncytial virus (RSV) are also common sources. Climbing rates of multi-drug resistant organisms escalate concerns for the dangers of NVHAP. Unlike VAP, which is predominately found in intensive care units (ICUs), NVHAP affects patients across all hospital units, including the young and healthy. Although patients with advanced age, immunocompromised status, and comorbid health conditions are especially vulnerable, we now understand that all hospital patients face some risk of NVHAP. Therefore, NVHAP prevention requires a universally applied approach. Additional research is needed to understand the pathogenesis of NVHAP and the factors that make patients susceptible.
2. Economic and health burdens of NVHAP
The economic and health burdens of NVHAP now exceed those of VAP. Economic burdens include prolonged length of stay, increased ICU utilization, hospital readmission and greater health care costs. Patients with NVHAP require an additional 4 to 15.9 days in the hospital, and up to 56% of patients require transfer to the ICU. Twenty percent of NVHAP survivors are readmitted within 30 days. Estimates of associated health care costs range from $28,000 to $40,000.
NVHAP also leads to significant mortality, sepsis, mechanical ventilation, and long-term care needs. NVHAP mortality rates are between 13.9 and 19%. While these rates fall below VAP-associated mortality, absolute NVHAP deaths are higher due to its greater incidence. Patients with NVHAP face an 8.4 greater odds of death than equally sick non-NVHAP patients. The risk of sepsis is comparable between NVHAP and VAP, but because many of these patients receive their initial care outside of ICUs, these patients may face delayed diagnosis and treatment. Patients with NVHAP also face high rates of mechanical ventilation. Finally, approximately 25% of NVHAP survivors are discharged to long-term care facilities rather than their homes, decreasing post-discharge quality of life.
These severe economic and health burdens are emphasized in a recent matched cohort study comparing U.S. veterans who acquired NVHAP to similar veterans who did not. The 1-year mortality rate was 47.8% for veterans with NVHAP, compared to 21.4% among those without. The odds of developing sepsis were 34 times higher in veterans with NVHAP, and veterans who developed NVHAP faced a mean of $100,858 in additional health care costs over 12 months.
3. Current prevention strategies
Even without regulatory requirements, hospitals can stand up for patient safety today. Solutions are available to assist hospitals to more accurately and immediately identify NVHAP cases using simple electronic health record extraction data. Hospitals should also begin implementing oral care, early mobility, and dysphagia management interventions. Oral care is an especially promising strategy that offers prevention based on source control and is a low-cost approach that can be used for all patients. Oral care strategies include increasing the frequency of teeth brushing, performing appropriate denture care, applying mouth moisturizers, and improving the availability of high-quality oral care supplies.
Encouragingly, intentional NVHAP prevention using existing strategies has already demonstrated effectiveness. A recent randomized cluster-control unit trial demonstrated that enhanced oral care can reduce NVHAP rates by as much as 85%. An NVHAP quality initiative at Kaiser Permanente in Northern California also achieved significant reductions in lost lives and antibiotic usage. Additional research into evidence-based prevention strategies is needed, but we can begin reducing NVHAP rates now.
4. Calls for policy changes
Health care professionals and patient safety advocacy groups have demanded the recognition and reduction of NVHAP. In 2019, the Association for Professionals in Infection Control and Epidemiology (APIC) wrote a position paper urging hospitals to address NVHAP. This was followed by an entire supplemental journal dedicated to providing resources to decrease NVHAP. In June 2021, the National Organization to Prevent Hospital-Acquired Pneumonia (NOHAP) published a call to action to bring NVHAP into the national health care conversation. The Joint Commission responded by issuing a patient safety alert describing current NVHAP prevention strategies and safety considerations. Most recently, the ERCI identified NVHAP as one of the top 10 leading patient concerns for 2022.
Collectively, these publications have made the following demands:
- Broad recognition of the importance of NVHAP prevention
- Establishment of a consensus definition for NVHAP that is recognized by researchers and key stakeholders including the CDC, CMS, and The Joint Commission
- Rigorous research into the pathogenesis of NVHAP, especially patient risk factors
- Development of cost-effective, evidenced-based NVHAP reduction strategies
- Implementation of systematic workflow changes to bring NVHAP reduction strategies into routine patient care
- Enforcement of NVHAP surveillance and outcome assessment by health care institutions
- Mandated reporting of NVHAP to the CDC
- Integration of NVHAP into CMS pay-for-performance programs
Recognition of the danger of NVHAP is the first step to addressing this underappreciated and under-reported problem. We’ve highlighted the severity of the health and economic burdens of this disease. But recognition is not enough. It is time to turn our collective focus to the rigorous research of NVHAP, intensive development of prevention strategies, and the implementation of critical policies. Hospitals should be held accountable for tracking, measuring, and reducing NVHAP. The body of literature about NVHAP reduction strategies is still growing, but we already have several tools at our disposal, and hospitals must execute NVHAP reduction today.
Dian Baker is a nurse practitioner. Ellen Benjamin is a nurse and post-graduate student. Karen K. Giuliano is a critical care nurse and associate professor.
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