A Successful Bundled Intervention to Reduce Hospital-Acquired Pneumonia: Sustainability Still an Issue

Abstract

Background: Hospital-acquired pneumonia (HAP) is one of the most common healthcare-associated infections (HAIs). Interventions based on the identification of patients at risk for aspiration with subsequent application of multidisciplinary measures, such as speech therapy follow-up, head elevation, oral hygiene, and patient and family education can be effective in reducing the incidence of HAP. In 2016, the step-down unit of our institution experienced an increase in the incidence of HAP with 21 cases. A root-cause analysis showed that most of them were related to comorbidities that increased aspiration risk. We conducted an study to decrease the incidence of HAP through a multidisciplinary bundled intervention. Methods: We conducted a quasi-experimental study in a 45-bed step-down unit from January 2016 to June 2019. In January 2017, we conducted an educational intervention with all the unit team, reinforcing practices of bed head elevation and oral hygiene. In June 2018, we observed inconsistencies in practice and conducted a second intervention with another round of educational training and a bundled intervention consisting of the following elements: identification of patients at risk for aspiration at admission by a speech therapy evaluation, bed-head elevation, oral hygiene, feeding guidance individualized to each patient by a nutritionist and a speech therapist, patient and family education with a printed material, signaling of aspiration risk in a care plan board within the room and development of a sialorrhea treatment protocol. HAP surveillance was conducted in accordance to CDC definitions and was reported as number of HAP cases per 1,000 patient days. Results: Our first intervention decreased the incidence of HAP in the first semester of 2017 from 1.03 to 0.29 (graph) but was not sustained. The incidence started to increase in the second semester of 2017 and reached a high incidence of 1.87 HAP per 1,000 patient days in the first semester of 2018. The second bundled intervention succeeded in decreasing HAP incidence to 0.57 in the second semester of 2018 and 0.23 in the first semester of 2019. Conclusions: An educational intervention combined with a bundled intervention focused on strategies to reduce the risk of aspiration succeeded in decreasing the incidence of HAP in a step-down unit. However, the sustainability of improvements remains challenging.

Funding: None

Disclosures: None