The ROUTE to Reducing Patient Harm: Preventing Hospital Acquired Pneumonia in Northern California


David Witt, MD, FIDSA; Donna Patey, RN, CNS

Background: A mortality review of hospitalized patients undertaken in 2008 identified hospital acquired pneumonia (HAP) as the most common hospital-acquired infection and a significant contributor to disability and death in Northern California Kaiser Permanente Medical Centers. A subsequent review performed in 2012 showed that patients with HAP had longer hospital lengths of stay (an average of two weeks), were more likely to be discharged to skilled nursing facilities instead of home, and were six times more likely to die in the hospital.
Methods: Literature was reviewed, and the best-performing units were visited to build a bundle of evidence-based interventions that were implemented across nonintensive care unit adult care with the goal of preventing HAP. The bundle elements are: R: Respiratory (incentive spirometer use) and Reduced Sedation, O: Oral Care (preoperative and twice-a-Chlorhexidine mouthwash and tooth brushing), U: Up (head of bed elevated 30 degrees, out of bed for meals, ambulating 20 feet or more twice a day), T: Tube Care (gastric feeding), and E: Education. An operational definition for HAP was introduced to measure outcomes along with implementation and process measures. Process measures reported were ambulation, sedation use (specifically benzodiazepines), and preoperative chlorhexidine oral rinse use.
Results: A 66% decrease in HAP incidence rates was noted across the Region: The rate decreased from 7.1/1000 to 2.4/1000 patient admissions between 2011 to 2016. Twice a day ambulation demonstrated a 138% increase in frequency from 2013 to 2016. During that time, an estimated 308 deaths were avoided and 22,944 patient days were saved by preventing 1648 HAP cases. This saved the organization approximately $72,640,704.
Discussion: Identifying patients at risk for HAP, providing standardized physician’s orders for prevention strategies, and facilitating documentation supported consistent and reliable bundle implementation and led to profound patient benefits. Other tools, such as a daily ambulation report, helped managers on medical/surgical/telemetry units recognize patients who did not have elements of the bundle in place.
Conclusion: A targeted multidisciplinary approach can significantly reduce HAP in acute care hospitals.


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