Nursing Home-Acquired Pneumonia (NHAP)

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Nursing Home-Acquired Pneumonia (NHAP)

• NHAP is defined as pneumonia occurring in a
  resident of a long-term care facility
• Second leading cause of infection and a
  significant cause of morbidity and mortality
  among residents of long-term care facilities
• More closely resembles community-acquired
  pneumonia (CAP) than hospital-acquired pneumonia
  (HAP)
• NHAP is a common diagnosis applied at admission
  but is the definitive diagnosis in only 33 of
  residents
• RAR - 2015

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DIAGNOSISClinical diagnosis

• Chest x-ray... New, persistent infiltrate- best
• indicator. NHAP often mimics congestive
  heart failure,
• pulmonary embolism, bronchogenic
  malignancies,
• COPD, and others. Non-infectious infiltrates
  frequently
• misdiagnosed as NHP
• Symptoms and physical findings of infection
• Fever, frequently 102 and above -may be low
  or absent Cough
• Rales over involved lung segments, signs of
  consolidation, or pleural effusion
• Shortness of breath, pulse above 100,
  respirations above 25. oxygen saturation 94
• Acute change in cognitive or functional
  status

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Laboratory findings

• Leukocytosis Not helpful because results are
  nonspecific. Left shift due to stress to the
  individual may also occur with MI, pulmonary
  embolism, dehydrations, any stress
• Blood cultures usually positive if causative
  agent is Streptococcus Pneumoniae or Haemophilus
  influenza
• Sputum culture may be useful if specimen reflects
  lower respiratory flora
• Definitive microbiologic method specimen
  collected by bronchoscopy, or transtracheal
  aspirate

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Most common pathogens

• Streptococcus pneumoniae
• Haemophilus influenza
• Gram-negative rods
• Moxcella
• Note Antibiogram will provide information
• specific to the organization
• Role of viruses as cause of NHAP is unclear

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Treatment goal

• Reduce morbidity and mortality, and
• eradicate infection
• Clinicians generally approach treatment of NHAP
  and Community-acquired pneumonia (CAP) with
  similar antibiotic coverage
• Initiation of empiric therapy critical in the
  medical management of NHAP
• Select agents that have appropriate spectrum,
  minimal resistance profiles and are
  cost-effective

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Management of Pneumonia with a Clinical Pathway,
LTCF
Loeb M JAMA 2006
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Aspiration Pneumonia

• Aspiration pneumonia results microbioligically
  from aspirated/inhalation of anaerobic
  oropharyngeal flora or gastric contents into one
  or more lung segments or lobes. May also occur if
  distant focus of infection disseminates to the
  lungs. Small volume aspirate that produce no
  overt changes common often not discovered until
  condition progresses to pneumonia
• Preventing aspiration reduces the risk of the
• resident acquiring aspiration pneumonia
• Major sources of aspiration
• Dysphagia
• Mouth/oral cavity
• Medications especially to treat Gastric
  regurgitation/Gasto-esophygeal reflux disease
  (GERD)

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Dysphagia

• DIAGNOSIS
• Symptoms, by observation
• Sudden appearance of respiratory symptoms -
  coughing associated with eating or drinking
• Increased respirations
• Delerium
• Regurgitation of gastric contents
• Voice changes after swallowing
• Confirmatory tests, such as
• Modified barium swallow
• Video fluoroscopy (a swallowing study)
• Fiberoptic endoscopy
• Evaluation by qualified O.T. or speech and
  language pathologist

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Dysphagia, Prevention Strategies

• Scant literature available that provides
  evidence-based
• interventions. Basic care appears to be the most
• effective preventive measure
• Optimize nutritional status - Suggest developing
  facility meal/feeding program or guidelines -
  include caregiver education, encourage food and
  fluid, positioning, e.g. upright feeding
  position, adaptive eating equipment, utilize
  assisted-eating techniques, careful, appropriate
  decisions regarding non-oral feeding
• and
• Encourage sedentary residents to ambulate -
  stand,
• walk, or propel their wheelchairs

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References

• Norma A. Metheny. Preventing Aspiration in Older
  Adults with Dysphagia. From the Hartland Group
  for Geriatric Nursing, 2012
• John Liantonio et al. Preventing Aspiration
  Pneumonia by Addressing Three Key Risk Factors
  Dysphagia, Poor Oral Hygiene, and Medication Use.
  www.annalsoflongtermcare.com Volume 22 Issue 10
  Oct 2014

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Prevent aspiration via ORAL CARE

• Resident hygiene is recognized as an important
  aspect of nursing care but mouth care is often a
  stressful and neglected procedure.
• Evidence increasingly recognizes that aspiration
  of oral secretions and their bacteria are
  important factors in pneumonia.
• In multiple studies study (first in 2002), oral
  care has been shown to reduce NHAP, reinforcing
  that adequate oral care is a modifiable risk
  factor.

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Preventing NHAP, cont. ORAL CARE

• GOAL Develop and implement a
• comprehensive oral hygiene program
• for all residents.
• 1. Oral health assessment and
• individualized program
• 2. Daily oral care - real teeth, dentures,
• edentuous. Manual brushing and rinse
• 3. Preventive care by dental professionals

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Oral Care, continued

• EDUCATION
• Healthcare worker
• Basic information
• Organizations protocol
• Resident/family
• COMMUNICATION TECHNIQUES during care

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References

• Mary E. McNally et al. Action Planning for Daily
  Mouth Care in Long-Term Care The Brushing Up on
  Mouth Care Project. Research Article. 2012
• Implementing a Geriatric Oral health Aid Model in
  a Long Term Care Facility. University of KY,
  2012. (slide set)
• Vincent Quagliarello et al. Pilot Testing of
  intervention Protocols to Prevent Pneumonia among
  Nursing Home Residents. 2009 NIH Public Access

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Preventing NHAP, cont. Medications

• Minimize use of medications that block acid
  secretion and promote bacterial overgrowth.
• Offer between meal snacks for residents with
  GERD, or GI-conditions that limit bulk food
  intake
• Treat GI symptoms that may hinder absorption of
  nutrients.
• Avoid NPO restriction whenever possible
• Elevate head of bed at all times (30-45 degrees)

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Prevention strategy VACCINATION

• Residents
• Two separate vaccine directed at preventing
  pneumonia
• Pneumoccocal conjugate vaccine (PCV13,
  Prevnar-13) and
• Pneumococcal polysaccharide vaccine
  (PPSV23,
• Pneumovax 23)
• Influenza - annual
• Healthcare personnel (HP)
• Influenza - annual
• Note Specifics to be presented Day 3

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Performance Measures Process and Outcome

• PROCESS examples
• 1. Vaccination Assess population
• a. Influenza residents and HPs
• b. Pneumococcal residents
• c. Or Prevnar-13 prn
• 2. Oral care
• a. Assess availability of supplies
• b. Assess adherence to protocol
• OUTCOME examples
• Incidence pneumonia, influenza/influenza-like
  illness
• Targeted - before and after prevention strategies
  implemented

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Additional References

• Raghavendran K et al. Periodontics 2000,
  200744164-177, Nursing home-associated
  pneumonia, hospital-acquired pneumonia and
  ventilator-associated pneumonia the contribution
  of dental biofilms and periodontal inflammation
• Cunha B, Bronze M. Nursing Home Acquired
  Pneumonia. Nursing Home Acquired Pneumonia.
  httpemedicine.medscape.com/article/234916-overvie
  w
• Multiple references and resources are cited with
  links and ordering information in the MARR 2008
  Long-Term Care Toolkit 2998. Steps 1,2
  currently in revision