A lack of understanding of the burden and preventability of non-ventilator-associated hospital-acquired pneumonia contribute to hospitals’ limited attention to the infection.
Non-ventilator-associated hospital-acquired pneumonia (NV-HAP) is a common and deadly complication of hospitalization that could account for up to 1 in 14 hospital deaths, according to the results of a study published in JAMA Network Open.
As the most common health care-associated infection in the United States, hospital-acquired pneumonia is associated with high health care use, morbidity, and mortality. Despite most cases occurring in nonventilated patients, most hospitals only have surveillance and prevention programs for ventilator-associated pneumonia and not NV-HAP.
Limited understanding of the burden and preventability of NV-HAP, as well as difficulty defining and tracking NV-HAP contribute to hospitals’ limited attention to the infection.
To estimate the incidence, outcomes, population-attributable mortality, and variability of NV-HAP, investigators, conducted a retrospective cohort analysis of 284 hospitals using an electronic surveillance definition applied to detailed clinical data. The study included adult patients admitted to the HCA Healthcare hospitals between 2018 and 2020 and Veterans Health Administration hospital between 2015 and 2020.
Among the 284 included hospitals, approximately 1 in 200 admissions met electronic surveillance criteria for a possible NV-HAP event, of whom 22% died in-hospital. Another 8% were discharged to hospice, and just 38% were discharged directly home.
Investigators measured NV-HAP incidence, length-of-stay, and crude inpatient mortality.
There were 32,797 NV-HAP events (0.55 per 100 admissions [95% CI, 0.54-0.55] per 100 admissions and 0.96 per 1000 patient-days [95% CI, 0.95-0.97] per 1000 patient-days) among 6,022,185 hospitalizations (median [IQR] age, 66 [54-75] years; 1 829 475 [26.1%] female).
Investigators found that patients with NV-HAP had multiple comorbidities (median [IQR], 6 [4-7]), including cancer (5,467 [16.7%]), chronic lung disease (6439 [19.6%]), congestive heart failure (9680 [29.5%]), and neurologic conditions (8255 [25.2%]). Crude inpatient mortality was 22.4% (7361 of 32 797) for NV-HAP vs 1.9% (115 530 of 6 022 185) for all hospitalizations. Of these, 12,449 (8.0%) were discharged to hospice.
Median [IQR] length-of-stay was 16 (11-26) days vs 4 (3-6) days. Pneumonia was confirmed by bedside clinicians or reviewers in 202 of 250 patients (81%) on medical record review.
Ultimately, it was estimated that NV-HAP accounted for 7.3% (95% CI, 7.1%-7.5%) of all hospital deaths (total hospital population inpatient death risk of 1.87% with NV-HAP events included vs 1.73% with NV-HAP events excluded; risk ratio, 0.927; 95% CI, 0.925-0.929).
Most instances of NV-HAP affected patients defined as clinically vulnerable. The median age of patients with NV-HAP was aged 69. Most patients had multiple serious comorbidities, and one-quater of NV-HAP events involved patients in intensive care units. To account for confounding by patients’ baseline status and severity of illness, investigators incorporated a rich array of clinical parameters into the analysis. Even after accounting for these factors, outcomes experienced by patients with NV-HAP remained worse than those without NV-HAP.
High incidence and mortality rate associated with NV-HAP suggests it is an important hospital complication, warranting the development and testing of prevention programs, according to the study authors.
“While there has been substantial work to date on defining best practices to prevent ventilator-associated pneumonia, there is very little consensus on how best to prevent NV-HAP,” they wrote. “Potential strategies include enhanced oral care, mobilizing patients, minimizing the use of acid suppressants, and applying dysphagia precautions.”
These initiatives used diagnosis codes or manual medical record reviews to identify NV-HAP, a potential source of bias related to variability criteria and diagnosis codes between clinicians and hospitals.
Automated analyses of electronic clinical data may provide more consistent and efficient means to measure NV-HAP incidence and track the impact of prevention programs, the authors said.
Overall, the findings underscore the importance of developing and validating robust measurement tools to monitor NV-HAP incidence, identifying effective prevention strategies, and assessing the impact of prevention initiatives on hospital-level and patient outcomes, according to investigators.
Jones BE, Sarvet AL, Ying J, et al. Incidence and outcomes of non–ventilator-associated hospital-acquired pneumonia in 284 US hospitals using electronic surveillance criteria. JAMA Netw Open. 2023;6(5):e2314185.