Addressing Non-Ventilator Hospital-Acquired Pneumonia (NV-HAP): Impact on Sepsis, Mortality, and Hospital Metrics

Patient in intensive care on a ventilator

(Adobe Stock 335234520 by Kiryl Lis)

Hospital-acquired infections (HAIs) are significant concerns for patients in the health care setting. Despite several federal initiatives to reduce HAIs, they remain a challenge in hospital settings. The primary focus on HAIs includes catheter-associated urinary tract infections (CAUTIs), central line-associated bloodstream infections (CLABSIs), Clostridioides difficile Infections (CDI), surgical site infections (SSI) specific to colon surgeries and abdominal hysterectomies, and methicillin-resistant Staphylococcus aureus (MRSA) Bacteremia.¹

Programs such as the Centers for Medicare and Medicaid Service’s (CMS) Value-based Purchasing (VBP) utilize outcome measures for HAIs to create payment adjustments for hospitals' reimbursements. Higher-performing hospitals receive incentives, while lower-performing receive reductions.² Another initiative to reduce HAIs is the CMS hospital-acquired condition (HAC) penalty. This utilizes hospitals’ reporting of HAIs and expands to several other HACs.³ Hospitals in the lower-performing quartile are subject to another penalty, which is applied to the hospital’s Diagnosis Related Group (DRG) payments.³

Interestingly, one of the most common HAIs in hospitals has yet to be directly included in these program measures. Hospital-acquired pneumonia (HAP) and, more specifically, non-ventilator hospital-acquired pneumonia (NV-HAP) have numerous negative impacts on patients and health care facilities, similar to other HAIs.^4,5 These negative impacts include increased morbidity and mortality, prolonged hospitalization, increased health care costs, reimbursement penalties, and a negative impact on hospital reputation.

Prevalence of NV-HAP in the Acute Hospital Setting

The National Organization made a call to action to Prevent Hospital-Acquired Pneumonia (NOHAP), which estimated that 1 in every 100 hospitalized patients would be affected by NV-HAP.⁶ A published study on incidence, mortality, and cost trends in Medicaid beneficiaries from 2015 to 2019 showed that over the 5 years, NV-HAP incidence was 2.63 per 1,000 patient days.⁵ Comparing this 2.63 to some of the National Healthcare Safety Network (NHSN) reportable HAIs (Table 1), it is more than 4 times as prevalent.^1,5

Table 1 (From CDC 2022 National and State health care-associations Progress Report for acute care hospitals)

(Supplied by author)

NV-HAP’s Impact on Hospital Metrics

Understanding the impact of NV-HAP and making a business case for a prevention program starts with looking at the areas of impact. Hospitals are held in federal programs aiming to improve patient safety and quality of health care. While some of these programs don’t directly target NV-HAP, they do have underlying ties to many quality indicators that hospitals are concerned about. One area to consider is NV-HAP’s contribution to sepsis. A study looking at 2012 patient data showed that 36.3% of patients with NV-HAP developed sepsis, requiring even further care in the healthcare facility.8

At our hospital, we started by building the business case by understanding NV-HAP’s impact on other patient safety and quality metrics. Looking at our hospital’s internal data, we found that we had a 0.56 sepsis rate (per 1,000 patient days) in which the sepsis was documented as having a source infection of NV-HAP.

Two impactful measures associated with sepsis stand out. The first is the SEP-1 measure. This measure looks at sepsis management, holding hospitals accountable to the sepsis bundle, which includes initial lactate level measurement, blood cultures being drawn before antibiotics, antibiotic administration, and resuscitation with crystalloid fluids, all within 3 hours of the earliest diagnosis or testing identification. NV-HAP increases the sepsis risk, leading to more potential for fallout from the sepsis bundle.8 The second measure is the Patient Safety Indicator(PSI)13, which measures postoperative sepsis rate. Again, the risk associated with NV-HAP as the cause of sepsis infection adds to the risk of having a postoperative sepsis event.⁸ Both PSI 13 and SEP-1 are included in CMS’s star rating. PSI 13 falls under the more heavily weighted Safety of Care domain, which accounts for 22% of the overall grade. In contrast, SEP-1 falls under the Timely and Effective Care domain, contributing 12% to the overall ratings.9 Beyond reputation, SEP-1 performance has been added to the VBP as a measure along with the HAIs. mentioned above.^1,9

Beyond sepsis, we must consider the impact NV-HAP has on hospital mortality rates. During our initial study, we noted that our mortality rate of patients documented with NV-HAP was 0.32 per 1,000 patient days. From a reputational standpoint, hospital mortality is a category used to establish the CMS star rating similar to the Safety of Care. The Mortality domain makes up 22% of the rating, and the 30-day mortality rate for patients with pneumonia is a portion of that section.⁹

In addition to a potential penalty and negative impact on the hospital’s reputation, NV-HAP poses a greater risk to the patient’s length of stay (LOS). NV-HAP extends LOS by up to 15 days.⁶ This concerns hospitals because they mostly utilize the DRG, which pays according to diagnosis and treatment. Hospitals will receive a fixed amount, so an increase in LOS beyond that fixed amount is money lost. Note that there are utilities such as outlier payments, but hospitals will generally incur a net loss.

The cost of care for patients with NV-HAP is estimated to be between $28,000-$40,000.¹⁰ Looking at our hospital’s average total payment amount for the DRG code 193 Simple Pneumonia with Major Complication and Comorbidity (MCC) of$9,793.35, we could see a loss greater than $18,000. Extrapolating that to 2.63 per 1,000 patient days, hospitals stand to lose hundreds of thousands of dollars over a year.^5.11 In the 2013 paper "Basic Nursing Care to Prevent Nonventilated HAP," it was estimated that preventing even 100 cases of NV-HAP could save $4 million, 700 to 900 hospital days, and the lives of 20-30 patients.¹² The financial impact of NV-HAP can be calculated by looking at average payment versus cost of care.

Experience Addressing Sepsisvia NV-HAP

Our hospital understood that NV-HAP had to prioritize outpatient outcomes, which had increased our LOS, but we wanted to understand its impact on our facility. Understanding the literature around reducing NV-HAP utilizing oral care, we set out to determine the relationship between an oral care bundle, including Stryker’s Sage Self Oral Care, and our NV-HAP outcomes, including sepsis and mortality.^13,14

Six months (6/5/21 to 12/31/21) after our implementation, we observed a reduction in NV-HAP of 58%, a reduction in sepsis with a source documented as NV-HAP of 41%, and a reduction in mortality documented as NV-HAP of 50%.¹⁵ Since completing this study, we have focused on compliance to drive consistency in our success. Looking at our year-over-year data since implementation, our NV-HAP rate went from 1.07 in 2020 to 0.80 in 2021 (year of implementation), 0.57 in 2022 (first full year of implementation), and 0.54 in 2023 (second full year of implementation). This consistency has further supported the importance of the oral care program.

Conclusion

NV-HAP poses a significant risk to patients by increasing the risk of developing sepsis and increased risk of mortality.5,8 Hospitals should consider the full impact of NV-HAP on their facilities when determining priority HAC/HAI reduction goals. We were able to see significant improvements in our separation and mortality rates from the implementation of an oral care bundle.¹⁵

References

1. Current HAI progress report. CDC. Published 2022. Accessed September 4, 2024. https://www.cdc.gov/healthcare-associated-infections/php/data/progress-report.html
2. The Hospital Value-Based Purchasing (VBP) Program. CMS. Published 2024. Accessed September 4, 2024. https://www.cms.gov/medicare/quality/value-based-programs/hospital-purchasing#:~:text=The%20Hospital%20VBP%20Program%20rewards,quality%20of%20care%20they%20deliver
3. Hospital-acquired conditions. CMS. Published 2024. Accessed September 4, 2024. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond
4. Magill SS, Edwards JR, Bamberg W, et al. Multistate point-prevalence survey of health care-associated infections. N Engl J Med. 2014;370(13):1198-1208. doi:10.1056/NEJMoa1306801
5. Giuliano KK, Baker D, Thakkar-Samtani M, et al. Incidence, mortality, and cost trends in nonventilator hospital-acquired pneumonia in Medicaid beneficiaries, 2015-2019. Am J Infect Control. Published online June 19, 2022. Accessed September 4, 2024. doi:10.1016/j.ajic.2022.06.016
6. Munro S, Baker D, Giuliano K, et al. Nonventilator hospital-acquired pneumonia: A call to action. Infect Control Hosp Epidemiol. Published online June 9, 2021. Accessed September 4, 2024. doi:10.1017/ice.2021.239
7. 2022 National and State HAI Progress Report – Acute Care Hospitals [Excel]. CDC. Published 2022.
8. Giuliano KK, Baker D. Sepsis in the context of nonventilator hospital-acquired pneumonia. Am J Crit Care. 2020;29(1):54-61. doi:10.4037/ajcc2020402
9. Overall Hospital Quality Star Rating. CMS. Published 2024. Accessed October 4, 2024. https://data.cms.gov/provider-data/topics/hospitals/overall-hospital-quality-star-rating
10. Giuliano KK, Baker D, Quinn B. The epidemiology of nonventilator hospital-acquired pneumonia in the United States. Am J Infect Control. Published online October 16, 2017. doi:10.1016/j.ajic.2017.09.005
11. Medicare Inpatient Hospitals – by Provider and Service – Havasu Regional Medical Center. CMS. Published 2022. Accessed September 4, 2024. https://data.cms.gov/provider-summary-by-type-of-service/medicare-inpatient-hospitals/medicare-inpatient-hospitals-by-provider-and-service/data?query=%7B%22filters%22%3A%7B%22rootConjunction%22%3A%22And%22%2C%22value%22%3A%22AND%22%7D%2C%22list%22%3A%5B%5D%7D%2C%22keywords%22%3A%22havasu%22%2C%22offset%22%3A0%2C%22limit%22%3A10%2C%22sort%22%3A%7B%22sortBy%22%3Anull%2C%22sortOrder%22%3Anull%7D%2C%22columns%22%3A%5B%5D%7D
12. Quinn B, Baker D, Cohen S, Stewart J, Lima C, Parise C. Basic nursing care to prevent nonventilator hospital-acquired pneumonia. J Nurs Scholarsh. 2014;46(1):11-19. doi:10.1111/jnu.12050
13. Giuliano K, Penoyer D, Middleton A, Baker D. Original research: Oral care as prevention for nonventilator hospital-acquired pneumonia. Am J Nurs. Published online June 2021. doi:10.1097/01.NAJ.0000753468.99321.93
14. Baker D, Giuliano K. Prevention practices for nonventilator hospital-acquired pneumonia: A survey of the Society for Healthcare Epidemiology of America (SHEA) Research Network. Infect Control Hosp Epidemiol. Published online October 4, 2021. Accessed September 4, 2024. doi:10.1017/ice.2021.427
15. Coury E, Dietz S. Implementation and evaluation of an oral care bundle for reduction of non-ventilator hospital-acquired pneumonia in a multi-unit community hospital. Poster presented at SHEA Spring Conference; April 12-14, 2022.