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Pneumonia is an infection of the lungs that can occur due to bacterial, viral, or fungal pathogens, and is typically marked by symptoms such as a cough, fever, and difficulty breathing (Keet, 2018).  Non-ventilator associated hospital-acquired pneumonia (NV-HAP) is a lung infection that is not associated with a patient who is mechanically ventilated but who does develop pneumonia 48 hours after hospital admission. The patient doesn’t show signs or symptoms of having the infection prior to admission. NV-HAP is one of the most common hospital acquired infections in the United States (Quinn & Baker, 2015).

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Studies show that within 48 hours of hospital admission, changes in oral bacterial colonization occur in patients. While even healthy people “micro-aspirate” while sleeping, in hospitalized patients, the micro-aspirations combined with decreased mobility and changes in the oral flora create an ideal environment for microbes to flourish in the pulmonary tract (Quinn & Baker, 2015). Poor oral hygiene and dental decay, whether prior to or during admission, increases the patient’s risk for developing non-ventilator associated hospital-acquired pneumonia (NV-HAP). Dental plaque is composed of a complex population of more than 700 different bacterial species which may serve as a reservoir for respiratory pathogens in hospitalized patients (Talley, Lamb, Harl, Lorenz & Green, 2016).  Hospitals are striving to meet National Healthcare Safety Network (NHSN) requirements; yet monitoring and interventions to prevent non-ventilator HAP (NV-HAP) aren’t required (Quinn & Baker, 2015).

Who, Where, When, How and Why
Patients of all ages in any hospital unit can develop NV-HAP as early as 48 hours after admission. Factors that make a patient at a higher risk include the elderly, preexisting health conditions, suppressed immune system, nasal or gastric tubes, use of proton pump inhibitors, swallowing disorders, aspiration history, oral suctioning, continuous NPO status, bi-level positive airway pressure masks, and tracheostomy (Talley et al., 2016).

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NV-HAP causes unnecessary patient suffering, mortality as high as 20% to 30%, and significantly increased length and cost of hospital stay. As reported by the American Thoracic Society and the Infectious Diseases Society of America, treatment of NV-HAP costs approximately $40,000 per patient (Talley et al., 2016). According to the Centers for Disease Control and Prevention (CDC), pneumonia is the leading infectious cause of death in children under the age of 5. The American Journal of Infection Control states that 32.6 to 35.4 million US patients are at risk for NV-HAP each year (Keet, 2018). NV-HAP patients are at greater risk for readmission within 30 days than patients without hospital acquired infections (Quinn & Baker, 2015).

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Nurse's current roles
Nursing interventions to prevent NV-HAP include oral care, early and frequent mobilization, deep breathing and coughing exercises, assessing the patient’s aspiration risk, elevating the head of the bed, diagnosis and treatment of dysphagia, respiratory physiotherapy, stopping Proton Pump Inhibitors (PPI) if reasonable and promoting lung expansion by using an incentive spirometer. The Centers for Disease Control and Prevention (CDC) notes that Streptococcus pneumoniae is a common cause of bacterial pneumonia, and recommends the pneumococcal conjugate vaccine to prevent these infections for all children younger than 2 years old, all adults 65 years or older, and individuals 2 through 64 years old who have certain medical conditions (Keet, 2018). It is part of our job to educate parents and caregivers about these vaccinations and the importance of receiving them.

Importance of Nurse's involvement

Nurses are the health care member that comes into most contact with the patients and can most easily implement these interventions. The rate of NV-HAP per 100 patient days decreased from 0.49 to 0.3 (38.8%) after implementation of an oral care program. The overall number of cases of NV-HAP was reduced by 37% during a 12-month intervention period. In addition, an estimated eight lives were saved, $1.72 million in costs were avoided, and 500 extra hospital days were averted (Talley et al., 2016).

Challenges or Barriers?
There are challenges to improving the outcome for hospitalized patients and decreasing their risk of developing NV-HAP. One example is that some nurses stated they avoided oral care for patients with known aspiration risk for fear they’d aspirate (Quinn & Baker, 2015). In some hospitals, there is a lack of necessary supplies to perform effective oral care, some hospitals only have a oral-care protocol for ventilated patients, lack of education and lack of a place to document oral care (Quinn & Baker, 2015). Patients who are recovering from surgery and some just from being hospitalized, may lack the energy needed to perform self oral care or may refuse the help. Nurses also have to fit the oral care into their already busy schedule for each patient along with teaching and enforcing the use of incentive spirometers, and mobilizing the patient.

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Something I have seen a lot in my clinical experience, is the lack of incentive spirometer use. I am usually the person to go get one and show the patient the correct way to use it, the importance of using it and encouraging the teach back method to ensure it will be effective. I have never once seen a nurse perform oral care on a patient and it is rare that I have seen them walk with them. My recommendations are as follows:

Implement a risk assessment tool, highlighting the patients who are at a higher risk of developing NV-HAP

Put an incentive spirometer (ICS) in the patient's room before they are even admitted or transferred to the unit and make the ICS teaching a part of the admission process.

Part of the admission process would be to assess the patient's ability to perform oral care, what supplies are needed, how often it should be done and if any teaching is necessary.

Another part of the admission should be to assess the patient's mobility and barriers or supplies needed to assist.The nurse and health care team can coordinate together and make a plan to help mobilize the patient together.

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How to Use an Incentive Spirometer - Nemours KidsHealth

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Patient Education
I have heard too many stories of patients either dying or getting incredibly sick by preventable circumstances and illnesses.  As mentioned before, I have taken it upon myself to do a lot of patient teaching when it comes to using incentive spirometers and explaining the importance of doing so. I encourage family members and friends to help remind the patient as well. Something else I have helped patients with on several occasions is oral care. I have heard patients say that they have no appetite and do not want to eat because "nothing tastes right". I suggest oral care, help them perform it or get the supplies needed. Most of the time afterwards, not only does the patient feel so much better and clean, the food doesn't taste as bad or different as it did before. This can help prevent poor nutrition, weight loss, dehydration and electrolyte imbalances.

Teamwork, organization and prioritization
I understand that every member of the health care team has their own individual tasks to complete, that are equally as important as the nurses, but they should all be striving towards one goal, to care for the patient. An effective plan can be implemented by working together with other members such as the CNA, Respiratory, Occupational or Speech therapists, the doctors, other nurses, charge nurses, family members of the patient, the person who orders and stocks the supplies, dietary, etc. Making a list or setting aside times for the interventions needed ensures the patient is getting the most and best medical attention possible.

Leadership
I will be able to continue on throughout my career while building on the concepts mentioned above. The most important thing is to "do no harm" so by leading by example and using these interventions, I am confident that I will indeed help the patient to the best of my ability.

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There are so many illnesses, diseases and problems in health care. It is part of our job to prevent harm, promote health and safety, educate patients and each other and to keep up with the ever-growing health care field. By doing these things, nurses and other members of the health care team can continue to use interventions to decrease the amount of non-ventilator associated hospital acquired pneumonia. This will not only improve lives but save them as well.