Prevention of Non-Ventilator
Hospital Acquired Pneumonia
(NV-HAP)
ANN-MICHELLE SHERMAN RN, BSN, CMSRN
WSU MSN- EDUCATION PRACTICUM PROJECT
JANET FREY APRN
Objectives
 State the significance of non-ventilator hospital
acquired pneumonia (NV-HAP)
 Name 3 nurse driven interventions to prevent NVHAP
 Demonstrate proper technique for IS utilization
 Explain impact oral care has on prevention of NVHAP
Pneumonia
Pneumonia
Background
 Under-reported, under studied


VAP – well defined prevention measures
NV-HAP – studies focus on post surgical and immunocompromised
 Defined


Pneumonia occurring > 48 hours after admission
Criteria for HAP (CDC)
Cxr – new infiltrate, cavitation or consolidation
 Immune response – temp > 100.4, leukopenia (<4,000), leukocytosis
>12,000, AMS in those >70 yo
 S&S – new purulent sputum, change in sputum, increased secretions,
increased suctioning requirement, new or worsening cough, dyspnea,
tachypnea, rales, worsening gas exchange (O2 sat)
 Mechanical ventilation not in place 48 hours prior to pneumonia
diagnosis

Background
 At risk population

3 Common condition categories
1.
Enhanced colonization of oropharynx or stomach
 Use of antacids – gastro pulmonary route
• Alkalization of stomach provides environment for bacterial growth
Micro aspiration - oropharyngeal colonization
Conditions that favor aspiration
 Decreased CNS

2.
• Impaired cough, gag and swallowing
 Disease process
 Medications
3.

Host factors
 Age
Outliers
Risk analysis does not provide enough sensitivity and specificity
 NV-HAP found outside the risk parameters and in all hospital units

Background
 Significance
 18.9 – 29% mortality
 Cost


$28K-$109K
Increased length of stay

4-9 days
 Spread of infection
 surface contact
 Droplets

Infectious secretions from a sneeze
 linger in air for hours
4 Interventions
 Missed opportunities for nursing intervention
 Elevated head of bed


Mobility


59% not mobilized each shift
Oral care


34%
73% did not receive each shift
IS/C&DB

84% did not receive coaching
4 Interventions
 Nursing leads the way!
 Simple interventions can significantly impact your
patient!
Oral care
1.

Decreases oral bacteria
Early ambulation
Elevate head of bed > 30 degrees
Incentive spirometer
2.
3.
4.

For patients who have IS ordered
4 interventions
 Oral care – simple intervention
 Dental plaque provides microhabitat for growth of bacteria



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Colonization of bacteria causing pneumonia has been found in oral cavity
Mechanical pathway from mouth to lungs provides easy access for bacteria
Up to 45% are silent or micro aspirators
Hospitalized patients are often immunosuppressed, have poor
cough or multiple comorbidities
Wide variances in practice (HOB, swab, brush)
 NV-HAP prevention
 May be reduced by improving oral care
 Toothbrush removes plaque, swabs don’t
 Brush 1-2 minutes
 Frequency - ?


Current standard is 2x/day
Antiseptic mouth wash
4 Interventions
 Early Mobilization and Ambulation
 Walking to the bathroom is not ambulation
 Encourage those who are able to walk in the hall
 NV-HAP prevention
 Mobilizes secretions
 Opens collapsed alveoli
•
Increases lung capacity
4 Interventions
 Head of Bed elevation
 30-45%
 Patients in prolonged supine position are at risk for GERD
 Elevation of head of bed promotes esophageal drainage of
secretions by gravity
 For all patients meals should be eaten while upright in chair to
decrease aspiration risk
o
If getting out of bed is contraindicated, place bed in most upright
position
 NV-HAP prevention
 Prevents aspiration
IS simulation
 Pre-brief
 Tickets
 Simulation of techniques to prevent pneumonia
 Incorporation of current knowledge
IS Scenario
 58 yo female patient is 3 hours post op right hip
replacement for RA. PMH: COPD, current smoker,
RA, anxiety. You enter room to do your assessment.
VS 124/63, HR 82 regular, RR 16, temp 100.2, pain
2/10. Lungs sounds are coarse crackles, skin warm
and dry, peripheral pulses 2+, right hip dressing is
dry and intact.
 Debrief

Mosby’s skills

Incentive spirometer
4 Steps to Prevention
 IS
 NV-HAP prevention
• Q 1 hour while awake - May increase frequency if desired
• Prevents atelectasis (collapsing of alveoli)
• Keeps secretions from pooling in alveoli
4 Interventions
 IS
 Instructions for use
1.
2.
3.
4.
5.
6.
7.
8.
Identify patient target volume using chart packaged with IS
Have patient sit upright in bed or chair
Place lips tightly around mouthpiece
Take in slow deep breath - maintain constant flow
At maximal inspiration hold breath for 5 seconds
Allow rest between IS breaths to prevent hyperventilation
Perform IS 10 x/hour while awake (more if patient is willing)
Enlist family to provide support and coach patients
Conclusion
 HAP occurs in non-ventilated patients
 Patients on all units are at risk
 Improved identification and prevention
 Decreased mortality
 Increased quality of life
 Better patient outcomes
 Fiscal savings
 Decreased length of hospital stays
 Impact of nursing actions
 Don’t miss your chance to prevent pneumonia
References
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Curtis, L. (2008). Review: Prevention of hospital-acquired infections: review of non-pharmacological interventions.
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Fortaleza, C., Abati, P., Batista, M., & Dias, A. (n.d). Risk Factors for Hospital-Acquired Pneumonia in Nonventilated
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Mehta, Y., Gupta, A., Todi, S., Myatra, S. N., Samaddar, D. P., Patil, V., & ... Ramasubban, S. (2014). Guidelines for
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Niederman, M. S. (2010). Hospital-Acquired Pneumonia, Health Care-Associated Pneumonia, Ventilator-Associated
Pneumonia, and Ventilator-Associated Tracheobronchitis: Definitions and Challenges in Trial Design. Clinical
Infectious Diseases, 51S12-S17. doi:10.1086/653035
Robertson, T., & Carter, D. (2013). Oral intensity: Reducing non-ventilator-associated hospital-acquired pneumonia in
care-dependent, neurologically impaired patients. Canadian Journal Of Neuroscience Nursing, 35(2), 10-17.
Quinn, B., Baker, D. L., Cohen, S., Stewart, J. L., Lima, C. A., & Parise, C. (2014). Basic Nursing Care to Prevent
Nonventilator Hospital-Acquired Pneumonia. Journal Of Nursing Scholarship, 46(1), 11-19. doi:10.1111/jnu.12050