Unsuspecting Bedfellows: Sepsis and Nonventilator Hospital-Acquired Pneumonia

Sepsis

(Adobe Stock FILE #: 110860650 By Zerbor)

Sepsis’s impact

Sepsis occurs when the immune system has an extreme and dangerous reaction to an infection, either bacterial, viral, or fungal. This reaction causes extensive inflammation throughout the body that can lead to tissue damage, organ failure, and even death. The quicker sepsis is identified and treated, the better the patient’s outcome. Sepsis is widely known as a major health care issue, causing over 250,000 deaths per year and costing over $40 billion in Medicare expenditures.^1,2 Presently, a laser focus is on sepsis identification, prevention, and treatment to lower the morbidity, mortality, and cost related to this deadly disease.

NV-HAP’s impact

In contrast, nonventilator hospital-acquired pneumonia (NV-HAP) has lesser notoriety. Still, it is a hospital complication with high morbidity (1 out of every 100 acute care patients will develop NV-HAP), mortality (15 to 30%), as well as cost.^3-8 It is defined as pneumonia that develops 48 hours or more after admission and is not present at admission. Pneumonia is the leading cause of death from health care-associated infections (HAI).^4,9

In a point prevalence study, pneumonia was the number one HAI, accounting for 25.8% of all HAIs. NV-HAP accounted for 65% of these pneumonia, whereas 35% were attributed to ventilator-associated pneumonia.¹⁰ There has been increased attention on NV-HAP and its prevention by many groups, including professional organizations, such as the CDC, Centers for Medicare and Medicaid Services (CMS), The Joint Commission, and others.³ A call to action was published in 2021, noting that no national policy or mandates currently flag NV-HAP as a priority condition for prevention, surveillance, and reporting. Even though NV-HAP is the no. 1 HAI, it is not part of the required national reporting for HAIs and is not included in CMS quality programs of pay for reporting or performance.³ There is an urgent need for increased awareness of NV-HAP and to focus on surveillance and prevention of this deadly HAI.

Sepsis and NV-HAP

How are sepsis and NV-HAP unsuspecting bedfellows? Studies have described sepsis occurring after the development of NV-HAP or as a complication of NV-HAP. Using the Healthcare Cost and Utilization Project database, Giuliano and Baker reported sepsis developing in 36.3% of NV-HAP cases with a mortality rate of 25%.¹¹ In a large Veterans Administration study of over 1.3 million admissions (2015-2020), approximately 9,000 patients developed NV-HAP (rate 0.6%), and of those, 20% developed sepsis following NV-HAP.¹² Studies such as these have stimulated researchers and clinicians to look at sepsis in relation to NV-HAP. Perhaps being proactive and focusing on preventing infections such as NV-HAP may also help decrease the burden of sepsis.

SEP-1 CMS Measure

In 2015, CMS started requiring acute care hospitals to report the Severe Sepsis/Septic Shock Management Bundle (SEP-1) as part of the Inpatient Quality Reporting (IQR) program. This was done to stimulate hospitals to evaluate their care for sepsis. SEP-1 is a complex, multistep process measure. It is an all-or-nothing measure, meaning if hospitals fail on bundle steps (blood tests, clinical evaluation, treatment), they fail the measure.¹³

Although the measure is evidence-based, there is some disagreement regarding its use by multiple national organizations.¹³ The SEP-1 criteria, as written, may cause overuse of broad-spectrum antibiotics, lactate measurements, and aggressive fluid resuscitation in patients with suspected sepsis in an attempt to meet the measure requirements versus focusing on more effective measures and comprehensive sepsis care (meeting the measure versus treating the patient).¹³

The CMS Care Compare website update (March 29, 2024) shows that the national average of hospitals meeting the SEP-1 measure is 60% (data from 7/1/2022 to 6/30/2022).¹⁴ Thus, there is still much work to be done by hospitals to improve the identification and treatment of sepsis. Effective Federal Fiscal Year 2026 (October 1, 2025), the SEP-1 measure will move to the Value-Based Purchasing Program (VBP) as one of the Safety domain measures to financially incentivize hospitals.¹⁵ The VBP Program is a performance-based incentive program where hospitals may increase or decrease part of their CMS fee-for-service Medicare payments depending upon how they perform compared to other hospitals on a set of measures.

Looking at NV-HAP and Sepsis together

In summary, there is an important relationship between NV-HAP and sepsis. Hospitals can be more efficient and effective in improving patient outcomes by looking at these conditions and complications in tandem versus in isolation. Focusing on preventing NV-HAP through comprehensive oral care and mobility may help decrease the burden of sepsis.¹⁶

References:

1. Rhee C, Dantes R, Epstein L, et al. CDC Prevention Epicenter Program. Incidence and Trends of Sepsis in US Hospitals Using Clinical vs Claims Data, 2009-2014. JAMA. 2017 Oct 3;318(13):1241-1249. doi: 10.1001/jama.2017.13836
2. Buchman TG, Simpson SQ, Sciarretta KL, et al. Sepsis Among Medicare Beneficiaries: 1. The Burdens of Sepsis, 2012-2018. Crit Care Med. 2020 Mar;48(3):276-288. doi: 10.1097/CCM.0000000000004224.
3. Munro SC, Baker D, Giuliano KK, et al. Nonventilator hospital-acquired pneumonia: A call to action. Infect Control Hosp Epidemiol. 2021 Aug;42(8):991-996. doi: 10.1017/ice.2021.239
4. Lyons P, Kollef M. Prevention of hospital-acquired pneumonia. Current Opinion in Critical Care 24(5):370-378, October 2018. doi: 10.1097/MCC
5. Davis J, Finley E. A second breadth: hospital-acquired pneumonia in Pennsylvania, nonventilated versus ventilated patients. Pennsylvania Patient Safety Advisory. 2018;15(3):48-59
6. Micek ST, Chew B, Hampton N, Kollef MH. A Case-Control Study Assessing the Impact of Nonventilated Hospital-Acquired Pneumonia on Patient Outcomes. Chest. 2016 Nov;150(5):1008-1014. doi: 10.1016/j.chest.2016.04.009
7. Giuliano KK, Baker D, Quinn B. The epidemiology of nonventilator hospital-acquired pneumonia in the United States. Am J Infect Control. 2018 Mar;46(3):322-327. doi: 10.1016/j.ajic.2017.09.005
8. See I, Chang J, Gualand N et al. Clinical correlates of surveillance events detected by the National Healthcare Safety Network pneumonia and lower respiratory tract definitions–Pennsylvania, 2011-2012. Infection Control & Hospital Epidemiology. 2016;37(7):818-824
9. Kalil AC, Metersky ML, Klompas M, et al. Management of Adults with Hospital-acquired and Ventilator-associated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Clin Infect Dis. 2016 Sep 1;63(5):e61-e111. doi: 10.1093/cid/ciw353
10. Magill SS, O'Leary E, Janelle SJ, et al. Emerging Infections Program Hospital Prevalence Survey Team. Changes in Prevalence of Health Care-Associated Infections in U.S. Hospitals. N Engl J Med. 2018 Nov 1;379(18):1732-1744. doi: 10.1056/NEJMoa1801550. PMID: 30380384; PMCID: PMC7978499
11. Giuliano KK, Baker D. Sepsis in the Context of Nonventilator Hospital-Acquired Pneumonia. Am J Crit Care. 2020 Jan 1;29(1):9-14. doi: 10.4037/ajcc2020402. PMID: 31968079
12. Carey E, Chen HP, Baker D, et al. The Association Between Non-ventilator Associated Hospital Acquired Pneumonia and Patient Outcomes Among U.S. Veterans. Am J Infect Control. 2022; 50(12):1339-1345. doi: 10.1016/j.ajic.2022.02.023
13. Rhee C, Strich JR, Chiotos K, et al. Improving Sepsis Outcomes in the Era of Pay-for-Performance and Electronic Quality Measures: A Joint IDSA/ACEP/PIDS/SHEA/SHM/SIDP Position Paper. Clin Infect Dis. 2024 Mar 20;78(3):505-513. doi: 10.1093/cid/ciad447. PMID: 37831591
14. Centers for Medicare and Medicaid Care Compare website. Accessed April 24, 2024. https://www.medicare.gov/care-compare/details/hospital/420082?city=Aiken&state=SC&zipcode=29801
15. Centers for Medicare and Medicaid. FY 2024 Inpatient Prospective Payment System (IPPS) Final Rule. Accessed April 20, 2024. FY 2024 IPPS Final Rule Home Page | CMS.
16. Quinn B, Baker DL, Cohen S, et al. Basic nursing care to prevent nonventilator hospital-acquired pneumonia. J Nurs Scholarsh. 2014, 46(1):11-9. doi: 10.1111/jnu.12050. PMID: 24119253