Hiding in Plain Sight: The Most Harmful and Costly Hospital-Acquired Infection

A patient lies in a hospital bed, connected to medical equipment, breathing through an oxygen mask while battling pneumonia

(Adobe Stock 92459913 by Darya)

Nonventilator hospital-acquired pneumonia (NV-HAP) is among the most deadly, harmful, and costly hospital-acquired infections (HAI).^1,2 In a 2023 study of 284 US hospitals, NV-HAP was attributed to 1 in 14 hospital deaths with an inpatient mortality of 22.4%.¹ NV-HAP is associated with significant morbidity and mortality, the incidence of sepsis, longer hospital stays, increased discharges to skilled nursing facilities and hospice, costs, and higher intensive care unity (ICU) utilization.^1,3

The CDC has recognized the harm from HAIs since the initiation 1965 of the Comprehensive Hospital Infections Project (CHIP).⁴ In response to this initiative, some hospitals voluntarily established infection control programs.⁴ This new focus on HAI prevention created a demand for healthcare professionals specializing in infection control. In addition, new professional specializations were formed along with HAI-focused professional organizations. In 1974, the CDC funded the Study on the Effectiveness of Nosocomial Infection Control (SENIC), scientifically comparing hospitals with and without infection control programs.⁵ The results were significant. Hospitals that actively pushed the prevention of HAIs reduced their incidence of HAIs and subsequent consequences.⁵ This study was a centennial game changer in HAI prevention. As a result of this study, in 1976, The Joint Commission required accreditation standards for all hospitals to house active HAI prevention programs.⁴ This accreditation springboard encouraged the emergence of several HAI prevention studies.

Studies focused on central line-associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections (CAUTIs), and surgical site infections (SSIs). As a result of research studies coming out on these HAIs, in 2008, the National Healthcare Safety Network (NHSN) and Centers for Medicare & Medicaid Services (CMS) hospital-acquired condition penalty payment system began to focus on reducing HAIs.⁶ The payment penalty system for HAIs included CLABSIs, CAUTIs, and SSIs.⁷ However, even today, missing from the penalty is a requirement to address the most prevalent of the HAIs—hospital-acquired pneumonia (HAP), specifically NV-HAP.⁸ Why was NV-HAP left off the list, and why does it remain hidden in plain sight today?

Hiding in Plain Sight

Only a handful of US hospitals understand the origins of NV-HAP in their hospitals, track its occurrence, or actively work to prevent it. Medical texts tend to describe the causality of pneumonia related to its most pathogenic culprits without an explanatory model of how those germs saturated the lung surfaces to incite an infection process. Unfortunately, the infectious source pathway for pneumonia and, therefore, opportunities for prevention are rarely mentioned in the literature. The suspicion that there was a symbiotic connection between the mouth and lung was reported in The Journal of Infectious Disease as early as 1906 and then in 1996, in the New England Journal of Medicine.^9,10 Despite these early realizations, little was known about the pathways and potential for prevention by effective oral hygiene. Studies done by Robert Dickson and Gary Huffnagle demonstrated that lungs harbor a small microflora in an interactive relationship with the oral flora.¹¹ This interaction is mediated by salivary flow and the microaspiration of oral biofilm into the pulmonary system.¹¹ Due to these studies, the “Island Habitat Model” emerged, promoting the key concept that there is a constant and important interchange in healthy humans between the oral and the lung’s microbiome.¹¹

When patients enter the hospital, a significant disruption to the lung-oral cavity homeostasis occurs, setting up a perfect storm for NV-HAP.¹² With therapeutic intention, patients undergo multiple disruptions to this delicate state, including multiple medications that suppress coughs, change oral pH, dry up salvia, and disrupt the microbial flora of the mouth—leading to the shift and dominance of health-harming bacteria.¹² In addition, patients have limited mobility, typically limited oral fluid intake, and experience a change in their diet, resulting in a changed oral flora. Studies have shown that the exact genetic allele that caused pneumonia may be sourced in this oral flora.¹³

Oral Microbiota as the Primary Prevention Target

The oral microbiota is a primary source for the development of pneumonia.¹⁴ Several studies demonstrated that respiratory pathogens are colonized on the teeth of hospitalized patients. During the first 48 hours of hospitalization, patients experienced an increased risk of pneumonia due to changes that occur in the oral microbiota.¹⁴ Maintaining a healthy oral microbiota through regular oral hygiene in the hospital can help reduce the risk factors of NV-HAP.¹⁴

Several studies over the last 2 decades indicate that evidence-based oral hygiene programs can reduce the incidence of NV-HAP by helping minimize the negative shift in the oral flora during hospitalization.¹⁴ Despite this evidence, hospitals are not tracking NV-HAP, and the opportunity for prevention—maintenance of a healthy oral microbiome—is too often overlooked as a part of hospitals’ HAI prevention programs.

Barriers and Solutions for NV-HAP Prevention: Diagnostic Barriers

One of the most significant barriers to NV-HAP prevention lies in the challenges with diagnosis. This diagnostic ambiguity is often due to difficulty obtaining direct cultures to establish infection. Therefore, pneumonia diagnosis relies on clinical symptoms and diagnostic procedures such as X-rays. Pneumonia symptoms mirror many other common conditions, such as congestive heart failure, and there can be challenges in X-ray interpretation. Due to this diagnostic dilemma and challenges in accuracy, pneumonia is often left off the HAI prevention strategies for hospitals.¹ Additionally, it is not included in the NHSN's required HAI prevention strategies.¹⁵

However, solutions for more accurate and reliable surveillance have emerged over the last few years. While reliance on administrative data such as ICD-10 codes can assist with surveillance, more accurate methods are now available to hospitals. Kaiser Permanente established an electronic surveillance system with real-time reproducible factors using a form of natural language processing identifiers in the electronic health record (EHR) to identify NV-HAP in their Northern California hospital system.¹⁶

In 2023, Barbara Jones, MD, MSCI, and her team partnered with Michael Klompas, MD, and his team to develop and evaluate an EHR surveillance system with multiple data detector points to identify cases of NV-HAP more accurately.¹ Their EHR detection system is free and available through JAMA Open Network.¹ Although in its infancy, multiple studies are underway to tap the potential of artificial intelligence to detect pneumonia. With excellent results, Becker et al. reported success using a deep learning algorithm to detect pneumonia in the emergency department.¹⁷ With these new resources, the rationale for not including pneumonia in active HAI prevention programs has been resolved.

With new diagnostic accuracy for pneumonia and more studies emerging demonstrating the effectiveness of regular oral hygiene in addressing risk factors of NV-HAP, why haven’t hospitals added NV-HAP to their quality metrics data boards?

Implementing NV-HAP Prevention Initiatives

Hospitals are complex systems with multiple competing demands, and with the lack of regulatory or accreditation mandates to address NV-HAP, establishing oral hygiene for prevention has been daunting. In a survey, it was found that up to 27% of hospitals do not supply basic oral care supplies, and even when available, they are often of such poor quality nurses are hesitant to use them.¹⁸

Even successful pneumonia prevention initiatives such as the I-COUGH program,¹⁹ Kaiser Permanente’s ROUTE initiative,¹⁶ and the Veteran’s Health Administration’s nationally recognized HAPPEN (The National Center for Healthcare Advancement and Partnerships Serves Veterans Through Partnership) program,²⁰ experienced challenges establishing a daily oral care routine. Perhaps because it sounds simple—brush your teeth—the typical efforts applied to a well-run and monitored quality improvement initiative are not always applied to launching oral hygiene initiatives.

However, there are solutions to these challenges. The American Dental Association-approved evidence-based oral care protocol for acute care hospitals provides frequency and supply recommendations for hospitals.²¹ Oral care and NV-HAP toolkits are available through the VHA’s National HAPPEN program and the CDC’s website.^20,22 To gain administrative support, grass root initiatives can lean on the calls for action from The Joint Commission’s patient safety issue #61, recognizing the harm from NV-HAP to patient safety, and the most recent compendium on pneumonia prevention from The Society for Healthcare Epidemiology of America (SHEA), Infectious Diseases Society of America (IDSA), and Association for Professionals in Infection Control and Epidemiology (APIC) that included NV-HAP for the first time.^23,24 When implementing NV-HAP prevention programs, it is important to educate staff on the causality of NV-HAP and the critical importance of source control (ie, daily oral hygiene).

Additionally, oral care manufacturer Stryker Sage offers a Non-vent Partnership Program to support hospitals’ grassroots efforts – helping to understand current practice and NV-HAP data. All-in-one oral care systems for independent and dependent aspiration-risk patients, like the ones Stryker Sage provides, are also available for hospitals to help address risk factors associated with NV-HAP. ^*

Pneumonia remains a leading killer and is responsible for significant patient harm in our hospitals.¹ Recent diagnostic advances and the availability of effective oral hygiene toolkits in hospitals have overcome long-standing barriers to addressing pneumonia prevention in hospitals. Despite NV-HAP’s absence from the NHSN’s hospital-acquired conditions list, many hospital systems across the US have started their own grassroots initiatives to keep their patients safe.

Financial support, assistance with writing this article, and editorial support provided by Stryker. The author received compensation from Stryker for this article.

Disclaimer: Results from case studies are not predictive of results in other cases. Results in other cases may vary.

*Please see product packaging for indications for use and warnings.

References

1. Jones B, Sarvet A, Ying J. Incidence and Outcomes of Non–Ventilator-Associated Hospital-Acquired Pneumonia in 284 US Hospitals Using Electronic Surveillance Criteria. JAMA. 2023;6(5):e2314185.
2. Baker D, Giuliano K, Desmarais M, et. al. Impact of hospital-acquired pneumonia on the Medicare program. ICHE. 2023;1-6.
3. Giuliano K, Baker D. Sepsis in the context of nonventilator hospital-acquired pneumonia. American Journal of Critical Care. 2020;29(1):9-14.
4. Control of Health-Care-Associated Infections, 1961-2011. CDC. https://www.cdc.gov/mmwr/preview/mmwrhtml/su6004a10.htm#:~:text=The. October 7, 2011. Accessed January 3, 2025.
5. Haley R, Quade D, Freeman H, et al. The Senic Project: Study on the Efficacy of Nosocomial Infection Control. American Journal of Epidemiology.
6. Hospital-Acquired Conditions. CMS.gov. https://www.cms.gov/medicare/payment/fee-for-service-providers/hospital-aquired-conditions-hac. Updated September 10, 2024. Accessed January 3, 2025.
7. Hospital-Acquired Condition Reduction Program. CMS.gov. https://www.cms.gov/medicare/quality/value-based-programs/hospital-acquired-conditions. Updated September 10, 2024. Accessed January 3, 2025.
8. Magill SS, O’Leary E, Janelle SJ, et al. Changes in Prevalence of Health Care–Associated Infections in U.S. Hospitals. New England Journal of Medicine. 2018;379(18):1732-1744.
9. Wadsworth A. The Division of Laboratories and Research of the New York State Department of Health; a short account of its history and present status. The Journal Of Infectious Disease 1906;3(5):774-797.
10. Waldemar g, Johanson MD, Peirce AK, Sanford JP. Changing pharyngeal bacterial flora of hospitalized patients. NEJM, 1969;281(21): 137-140.
11. Dickson R, Huffnagle G. The Lung Microbiome: New Principles for Respiratory Bacteriology in Health and Disease. PLoS Pathogens. 2015;11(7).
12. Kitsios GD, Morowitz MJ, Dickson RP, et al. Dysbiosis in the ICU: Microbiome science coming to the bedside. Journal of Critical Care. 2017;38:84-91.
13. Giuliano K, Penoyer D, Middleton A, Baker D. Original Research: Oral Care as Prevention for Nonventilator Hospital-Acquired Pneumonia: A Four-Unit Cluster Randomized Study. American Journal of Nursing. 2021;121(6):24-33.
14. Scannapieco F, Giuliano K, Baker D. Oral health status and the etiology and prevention of nonventilator hospital-associated pneumonia. Periodontology 2000. 2022;89:51–58.
15. HAI Checklists. CDC. https://www.cdc.gov/nhsn/hai-checklists/index.html. February 6, 2024. Accessed January 6, 2025.
16. Lacerna C, Patey D, Block L, et al. A successful program preventing nonventilator hospital-acquired pneumonia in a large hospital system. SHEA. 2020;41(5): 547-552.
17. Becker J, Decker J, Rommele C, et al. Artificial Intelligence-Based Detection of Pneumonia in Chest Radiographs. Diagnostics. 2022;12(1465).
18. Baker D, Giuliano K. Prevention practices for nonventilator hospital-acquired pneumonia: A survey of the Society for Healthcare Epidemiology of America (SHEA) Research Network (SRN). Infection Control & Hospital Epidemiology. 2022;43(3):379-380.
19. Cassidy M, Rosenkranz P, Macht R, et al. The I COUGH Multidisciplinary Perioperative Pulmonary Care Program: One Decade of Experience. The Joint Commission Journal on Quality and Patient Safety. 2020;46(5):241-249.
20. Hospital-Acquired Pneumonia Prevention by Engaging Nurses (HAPPEN) Implementation Guide. U.S. Department of Veterans Affairs. https://www.va.gov/nursing/docs/happen/HAPPEN-Guide-Non-VHA.pdf. Updated October 11, 2022. Accessed December 23, 2024.
21. Quinn B, et al. Non-ventilator health care-associated pneumonia (NV-HAP): Best practices for prevention of NV-HAP. American Journal of Infection Control. 2020;48(5):A23-A27.
22. Oral Health in Healthcare Settings to Prevent Pneumonia Toolkit. CDC. https://www.cdc.gov/healthcare-associated-infections/hcp/prevention-healthcare/oral-health-pneumonia-toolkit.html. March 27, 2024. Accessed January 14, 2025.
23. Quick Safety: Preventing non-ventilator hospital-acquired pneumonia. The Joint Commission. 2021; 61.
24. Klompas M, Branson R, Cawcutt K, et al. Strategies to prevent ventilator-associated pneumonia, ventilator-associated events, and nonventilator hospital-acquired pneumonia in acute-care hospitals: 2022 Update. ICHE. 2022;43(6):1-27.