Running head: Hospital-acquired Pneumonia: Deadly Yet Preventable

Hospital-acquired
Pneumonia: Deadly Yet
Preventable
WOODWARD
Hospital-acquired Pneumonia: Deadly Yet Preventable 1

Abstract

Two types of pneumonia can be acquired in a hospital setting. Ventilator-acquired pneumonia

(VAP) develops most commonly in patients in the ICU who are using a ventilator. Non-

ventilator hospital-acquired pneumonia (NV-HAP) is pneumonia which develops in the hospital

by patients who are not on a ventilator. Both results in thousands of deaths and millions of

dollars lost each year. Despite CDC guidelines of prevention and well known risk factors for

each subset of pneumonia, death and monetary hardship still occur. VAP is considered to be

more expected and less preventable than NV-HAP depending on the length of time the patient

requires a ventilator. Still, research shows NV-HAP as being nearly as critical, and just as costly

as VAP. Yet less attention is given to NV-HAP. Research shows that more tracking of NV-HAP

may be key in increasing prevention.

According to the CDC, hospital-acquired pneumonia (HAP) is the most common

nosocomial infection in acute care hospitals. In 2011, out of nearly 722,000 nosocomial

infections, 157,500 were pneumonia (Healthcare-associated Infections, 2016). Giuliano, Baker,

and Quinn found that HAP “occurs at a rate of up to 21 cases per 1,000 hospital admissions”

and that “NV-HAP and VAP combined accounted for 21.8% of all HAIs in the United States

during 2011” (Giuliano, Baker, & Quinn, 2017, p. 1). Two types of hospital-acquired pneumonias

can occur. Ventilator-associated pneumonia (VAP) is pneumonia that develops in a person who

is on a ventilator. The tubing acts as easy transport for bacteria to get straight into the

patient’s lungs. This occurs primarily in hospital ICUs. However, recent research is showing an

increase in non-ventilator hospital-acquired pneumonia in the ICU, “the department previously

identified as most at risk for pneumonia, and with protocols in place to prevent ventilator-

associated pneumonia, is the ICU. However, in our study we found that 27.3% of NV-HAP cases

were identified among ICU patients. That is, patients in the ICU, not on the ventilator, are

acquiring HAP despite the preventive emphasis for patients who are on a ventilator” (Baker &

Quinn, 2017, p. 4). The other type of pneumonia is simply hospital-acquired pneumonia (HAP)

or non-ventilator hospital-acquired pneumonia (NV-HAP). Because VAP specifically requires the

patient to be on a ventilator, NV-HAP is more common with roughly 35 million patients at risk

as opposed to only roughly 4 million being at risk for VAP (Baker & Quinn, 2017).

In 2011, nearly 75,000 patients with a hospital-acquired infection died in the hospital

(Healthcare-associated Infections, 2016). That means just over 10% of patients with an HAI

died. Any loss of life should be taken seriously. But when discussing infections that patients

acquire in a hospital, the numbers are astounding. Not only numbers in terms of lives lost, but
Hospital-acquired Pneumonia: Deadly Yet Preventable 3

also financially. Both ventilator and non-ventilator pneumonias are very costly, “both NVHAP

and VAP are associated with substantial clinical and economic burdens, including prolonged

hospital length of stay (LOS), higher overall health care costs, and increased morbidity and

mortality” (Giuliano, Baker, & Quinn, 2017, p. 1). One study found that non-ventilator

pneumonia “was associated with a greater overall economic burden” and that “the total cost

for NV-HAP cases was $156 million compared with $86 million for VAP” (Giuliano, Baker, &

Quinn, 2017, p. 1). These infections are preventable, but still result in thousands of deaths each

year.

A study by the CDC found that hospital-acquired infections were very preventable,

“steps can be taken to control and prevent HAIs in a variety of settings. Research shows that

when healthcare facilities, care teams, and individual doctors and nurses, are aware of infection

problems and take specific steps to prevent them, rates of some targeted HAIs (e.g., CLABSI)

can decrease by more than 70 percent” (Healthcare-associated Infections, 2016). The CDC does

provide guidelines for prevention of hospital infections. The fact that so many deaths still occur

each year begs the question are these guidelines ineffective or are they not being followed?

Risk factors have been identified and guidelines have been created for prevention of

HAP. Several studies have researched common risk factors for HAP. The hospital unit the

patient is on has an impact. According to Sopena et al, “two-thirds of the patients developed

pneumonia in medical wards. The incidence of HAP was higher in medical department than in

surgical departments (4% vs 2.8%), particularly in internal medicine (8.4%)” and “this study

shows that patients with malnutrition, chronic renal failure, anemia, depressed consciousness,

higher Charlson comorbidity index, previous thoracic surgery, and previous hospital admission
Hospital-acquired Pneumonia: Deadly Yet Preventable 4

are at greater risk for HAP outside the ICU, with an incidence of 2.45 cases/1,000 discharges.

We also found that HAP has a high morbidity and mortality, with increased length of stay and

increased rate of discharge to a skilled nursing facility” (Sopena et al., 2014, p. 40). Until

recently, VAP has been considered the more serious subset of pneumonia. The CDC has

prevention methods specifically tailored to VAP.

To help prevent VAP, the CDC currently recommends the following:

 Keep the head of the patient’s bed raised between 30 and 45 degrees unless

other medical conditions do not allow this to occur.

 Check the patient’s ability to breathe on his or her own every day so that the

patient can be taken off of the ventilator as soon as possible.

 Clean their hands with soap and water or an alcohol-based hand rub before and

after touching the patient or the ventilator.

 Clean the inside of the patient’s mouth on a regular basis.

 Clean or replace equipment between use on different patients.

While these guidelines exist to help prevent VAP, what about NV-HAP? Baker and Quinn state,

“among HAIs, nonventilator HAP (NV-HAP) is emerging as a major patient safety concern that is

associated with higher costs than VAP and is equally as dangerous” (Baker & Quinn, 2017, p. 1).

Where is the system failing? According to Baker and Quinn prevention is working,

“since 2008, monitoring and prevention for device-associated infections, including ventilator

associated pneumonia (VAP), catheter-associated urinary tract infections, and central line–

associated bloodstream infections, have resulted in significant decreases in both the incidence
Hospital-acquired Pneumonia: Deadly Yet Preventable 5

and cost of device-associated infections. Currently, only 25% of HAIs result from the 3 most

common device-associated infections, and VAP is responsible for only 38% of all HAP cases”

(Baker & Quinn, 2017, p. 1). Yet thousands of deaths and millions of dollars are still lost each

year. The prevention guidelines are simple, and the risk factors are well known and studied.

While the CDC provides prevention guidelines Baker and Quinn state “the CDC recommends a

focus on modifiable risk factors for prevention. However, our study suggested that a narrow

focus on patient-specific risk factors for NV-HAP prevention would limit the full potential impact

of NV-HAP prevention. Previous studies support that the impact of NV-HAP goes beyond

specific patient risk groups and occurs on all types of hospital units and departments” (Baker &

Quinn, 2017, p. 4). So what is the problem? Baker and Quinn, again, write “pneumonia

prevention presents several challenges. A primary challenge is that NV-HAP remains a hidden

harm in hospitals because there are no requirements in the United States to track hospital wide

rates of pneumonia. To overcome this challenge, hospitals should consider the growing body of

evidence which supports NVHAP as a common HAI, and—as demonstrated in our study—it

occurs in all types and sizes of hospitals and on all types of units” (Baker & Quinn, 2017, p. 5).

This sentiment is shared by Giuliano, Baker, and Quinn, “currently, NV-HAP is not widely

monitored as a preventable HAI because hospitals are not required to report or implement

standards to decrease the incidence of NV-HAP. Findings from our study indicate that more

national epidemiologic data are needed to further define the scope and influence of NV-HAP”

(Giuliano, Baker, & Quinn, 2017, p. 5). According to these two studies, more accurate tracking

and reporting of HAP is critical to successful prevention. Along with this, new standards in

preventing non-ventilator pneumonia may be necessary, as it has long been considered the less
Hospital-acquired Pneumonia: Deadly Yet Preventable 6

impactful of the two pneumonias. The guidelines provided by the CDC do seem to be helping

prevention, but it isn’t enough. More evidence is needed, and, again, more observation of HAP,

as stated by Giuliano, Baker, and Quinn, “pragmatic studies are needed to determine the safest

and most effective methods for NV-HAP prevention. In the meantime, hospitals can and should

monitor NV-HAP rates and use the current, best-available evidence for NV-HAP prevention”

(Giuliano, Baker, & Quinn, 2017, p. 5).

References

Baker, D., & Quinn, B. (2017). Hospital Acquired Pneumonia Prevention Initiative-2: Incidence of

nonventilator hospital-acquired pneumonia in the United States. American Journal Of

Infection Control, doi:10.1016/j.ajic.2017.08.036

Giuliano, K. K., Baker, D., & Quinn, B. (2017). The epidemiology of nonventilator hospital-

acquired pneumonia in the United States. American Journal Of Infection Control,

doi:10.1016/j.ajic.2017.09.005

Healthcare-associated Infections. (2016, October 25). Retrieved October 31, 2017, from

https://www.cdc.gov/hai/surveillance/index.html

Imran, M., Amjad, A., & Haidri, F. R. (2016). Frequency of hospital acquired pneumonia and its

microbiological etiology in medical intensive care unit. Retrieved October 31, 2017, from

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5017084/

Sopena, N., Heras, E., Casas, I., Bechini, J., Guasch, I., Pedro-Botet, M. L., & ... Sabrià, M. (2014).

Risk factors for hospital-acquired pneumonia outside the intensive care unit: a case-

control study. American Journal Of Infection Control, 42(1), 38-42.

doi:10.1016/j.ajic.2013.06.021
Hospital-acquired Pneumonia: Deadly Yet Preventable 8

Uvizl, R., Kolar, M., Herkel, T., Vobrova, M., & Langova, K. (2017). Possibilities for modifying risk

factors for the development of hospital-acquired pneumonia in intensive care patients:

results of a retrospective, observational study. Biomedical Papers Of The Medical

Faculty Of The University Palacky, Olomouc, Czechoslovakia, 161(3), 303-309.

doi:10.5507/bp.2017.019