Reducing the Incidence of Hospital Acquired Pneumonia (HAP)

According to recent research, Hospital-Acquired Pneumonia (HAP) is a contagion of the respiratory tract which is rated to affect about 1% of all inpatients as well as being the greatest risk of all known healthcare-associated infections easily leading to death. The infection is approximated to lengthen the period of hospital stay by up to an average of 8 days. The disorder is highly associated with ventilation mechanisms and could be referred to as the Ventilator- Associated Pneumonia (VAP). The mortality rate associated with complications of HAP can escalate to as high as 76% in the event when the pathogenic causals are multidrug resistant. HAP generally may account for over 30% of the ICU attentions with its highest prevalence in the early days of the ICU stay. 

Research agrees that the HAP incidence is brought about in by bacteria such as the Staphylococcus aureus and methicillin-resistant aureus which spread in the respiratory tract. The unfortunate side is that, though much is known in the prevention of the VAP, less is known concerning the prevention mechanisms of HAP and thus only ways to reduce the incidence are available (Passaro, 2016). The reduction of HAP can be accelerated through the attention to proper oral health and hygiene which is known to lower the susceptibility by an estimated 50% possibility (Quinn, et.al.,2014). Possible symptoms of a patient infected with HAP include; long term stay in health care facilities, intravenous therapy exceeding a month for a wound, intensive care hospitalization in a period exceeding 90 days, hemodialysis clinic for more than a month etc. Such risks associated with all cases of Hospital Acquired Pneumonia, high incidence of mortality and morbidity repercussions as well as the high cost of treatment which could also include the social costs are the key drivers towards search of ways of reducing the incidences of the complication. Therefore this paper entails topics of research which are aimed towards the reduction of the HAP incidence. 

The PICOT Question 

The questions were formulated according to the Patients, Intervention, Comparison, Outcome and Time (PICOT) format. In the reduction of the incidence of Hospital Acquired Pneumonia, how does oral care play an important role in reducing the incidence? How frequently should oral health be observed for patients who have dysphagia? And are there available protocols to aid in addressing oral care for aspiration risk patients? 

Search Strategy 

Information regarding this research study was acquired through electronic online search from relevant web resources covering scholarly work of several peer reviewed articles. The articles adopted were the most convincing with the richest content pertaining reduction or prevention of Hospital Acquired Pneumonia and specifically the role of oral health in handling the HAP complications. Meta-analysis, systematic reviews, e-book sources, clinical procedures, appraised studies, and individual searches were the main focus of the study. Important databases for the research materials included the following PubMed, Fraser health, CINAHL, Cochrane etc. All the materials embraced for this theoretical study were much trusted sources. 

Review of the Evidence 

In this section, three literary sources which evidenced the possibilities of tackling and managing the incidence of HAP were reviewed and the corresponding appraisal contribution of the particular sources was indicated. 

The first evidence is a narrative review conducted by Passaro et.al (2016) in the pursuit of investigating the standards towards prevention of HAP in non-ventilated adult patients. The paper searched the relevant literature of the years up to May 2015 using Medline guidelines of the Professional medical Associations as well as an intensive performance of preventive measures such as oral care, mobilization, bed position, hand hygiene and diagnosis and dysphagia treatment, viral infections, aspiration prevention and stress bleeding prophylaxis. The research still conducted a meta-analysis to probe the effect of overall improved levels of oral hygiene on the prevalence of HAP and its impression on the patients. Among other findings, the paper asserted that there was rational confirmation that oral care was highly related to reduction in HAP (Passaro, et.al, 2016). On the same platform, early mobilization interventions, swift diagnosis and multimodal programmes towards the prevention of nosocomial influenza also had a high positive impact on the reduction of HAP (Passaro, et.al, 2016). The research concluded that oral care was the most studied measure and the most commonly associated with a degree of decline in the prevalence of Hospital Acquired Pneumonia rate despite a wide range of interventions which are proposed. 

The second addition to the body of literary evidence is the work of Quinn et.al (2014) which studied on the non-ventilator HAP incidence in a given sample of convenience of the U.S hospitals to determine the impact of the reliably delivered basic oral nursing care in the reduction of the non-ventilator HAP. During this research, a quasi-experimental study was carried out using retrospective comparative outcomes to define the evidence of non-ventilator HAP and the effectiveness of enhanced basic oral nursing care in comparison to usual care in prevention of non-ventilator HAP after acquiring of the basic oral nursing care initiative (Quinn, et.al, 2014). The study adopted ICD-9 for pneumonia absence on admission and also completed an evidence-based gap analysis with a designed site-specific oral care initiative aimed at reduction of non-ventilator HAP (Quinn, et.al, 2014). The intervention process of the study was led by the influencer model. The findings recorded a decrease 0f 38.8% in the rate of HAP per100 days of stay after the initiation of the oral care protocols. A 37% reduction of the overall number of non-ventilator HAP cases was recorded within a period of 12-month intervention period which resulted in an estimated 8 lives saved (Quinn, et.al, 2014). The research concluded also that the inclusion of nursing staff in decision making pertaining the HAP condition also reduced the rate of patient diagnosis with the condition. 

Further research was done by Munro et.al (2018) to determine the effect of a two-times everyday oral care initiative on the incidence of non-ventilator HAP. The study was a single arm intervention which used both pre and post population statistics to conclude about the effectiveness of a universal and standardized oral care protocol versus the usual care in preventing the complication. The general findings were that the incidence rate decreased drastically with a huge estimated cost cut-off. The study concluded that hospitals recorded a struggle in the provision of an effective intensive oral health care and consequently oral care was encompassed by barriers such as; the perception that oral care is a routine optional individual activity, poor supplies of oral care by hospitals and the negligence to monitor the incidence of non-ventilator HAP (Munro, et.al., 2018). Consistent oral care is important in terms of quality life, well-being, veteran health and costs reduction. 

Theoretical/Conceptual framework 

This study acquires a Roy adaptation Model and Roger Change theory as the conceptual framework which is aimed in assisting to identify the main issues of concern in the reduction of the incidence of HAP through oral care. The Roy adaptation Model (RAM) has been highly instrumental in the nursing discipline (Naga & Al-Khasib, 2014). The RAM conceptual framework focuses on a holistic interconnected individuals and how they interact with the surroundings (Mintz-Binder, 2019). The model outlines the patient, nurse, health and the environment as well as the adaptation as the important concepts of this nursing theory. The Rogers adoption Curve Theory encompasses five key stages of awareness, interest, evaluation, implementation and adoption (Oguejiofo, 2018). Thus the RAM and the Rogers Adoption theory work together in an adaptive manner as the patient adjusts to new situations. 

The Roy adaptation model defines physiologic, self-concept, role function and interdependence as the modes of adaptation. The figure shown below outlines the conceptualization, research structure and selection of variables for this study using the Roy Adaptation Model. The Model illustrates human beings as psychosocial beings who can easily adapt to environmental stimuli. Nevertheless, challenges occur only if the individual’s adaptive system is quite unable to persevere and cope well with the changing stimuli in a positive behaviour that maintains the integrity of the system. Human health is a function of input stimuli and the individual adaptation level. In agreement with the propositions of the RAM and the exhaustive literature, psychosocial responses are interrelated and are hypothesized to include; oral health, social support, loneliness, and depressive symptoms (Chen, et.al., 2005). The model helps to explain the phenomenon, guides each phase of the study, and helps to identify all variables as well as locating outcome measures. 

A RAM-based Conceptual Framework 

Source: (AlKrisat & Dee, 2014) 

Since this study adopts oral care as the main way to reduce HAP incidence, the RAM model adopted measures by counting the remaining number of teeth in an individual, rated by the examiner for a Brief Oral Health State Examination (BOHSE), and then self-reported for Geriatric Oral Health Assessment Index (GOHAI). In this case then the number of natural teeth should be used as a proxy for oral care. 

The Rogers adaptation curve theory can be highly adopted for the quick and fast spread of the idea of minimizing the effects of Hospital-Acquired Pneumonia by oral care. The Rogers adoption curve helps to find the right group to adopt the right group to adopt the idea of oral care for the reduction of HAP incidence. 

Discussion /Implications for practice 

Researchers hypothesize that an enhanced protocol for oral care services will consequently result in a reduced incidence of the hospital acquired pneumonia. As this paper is committed to this research, there are however implications of the practice (Warren,et.al.,2019). The acute complications associated with HAP and high costs of prolonged stay demand a quick solution to navigate through the reduction of the problem altogether. However, studies show that improved oral hygiene in critical care reduces the incidence of HAP. The current oral care protocols, products as well as the practitioner practices on medical units do not consider the acuity and complexity affecting the patients (Mejia, et.al., 2018). The implications of the study include outcomes of improved oral health interventions to all the patients by reducing overall hospital bills, length of stay and patient mortality. 

Conclusion 

Non-ventilator Hospital Acquired Pneumonia is now a prevalent cause of fatality and death in hospitals whereby the condition approximately accounts for a significant portion of the Hospital Associated Infections (HAI) (Passaro et al., 2016). The research also point to the most dominant causal factors of the condition as well as its prevalence. The studies reveal that oral care and hygiene significantly reduces the incidence of HAP together with preventing fatality as a result of HAP. Given the deductions drawn by the research findings it is safe to conclude that commitment to thorough oral hygiene is important for both health facilities and patients to ensure that the incidence of the condition and its impact are restrained. 

Evidence Table 

Evidence Citation	Design	Sample	Findings	Appraisal Rating
Pássaro, L., Harbarth, S., & Landelle, C. (2016). Prevention of hospital-acquired pneumonia in non-ventilated adult patients: a narrative review. Antimicrobial Resistance & Infection Control , 5 (1). doi:10.1186/s13756-016-0150-3	Narrative Review	Comprehensive search for oral hygiene and other parameters  .	Reasonable evidence available that oral care is associated with a reduction in HAP.	Level V/A
Quinn, B.,Baker, D. L., Cohen, S., Stewart, J. L., Lima, C. A., & Parise, C. (2013). Basic Nursing Care to Prevent Nonventilator Hospital-Acquired Pneumonia. Journal of Nursing Scholarship , 46 (1), 11-19. doi:10.1111/jnu.12050	Descriptive Quasi-experimental study	Intervention by use of Influencer model	Substantial amount of unreported NV-HAP.  The rate of NV-HAP per 100 patient days decreased from 0.49 to 0.3 (38.8%)  The avoidance  of NV-HAP cases resulted in an estimated 8 lives saved, $1.72 million cost avoided, and 500 extra hospital days averted.	Level V/A
Munro, S., & Baker, D. (2018). Reducing missed oral care opportunities to prevent non-ventilator associated hospital acquired pneumonia at the Department of Veterans Affairs. Applied Nursing Research , 44 , 48-53. doi:10.1016/j.apnr.2018.09.004	Single Arm Intervention Study	14,396 patient days (2002-2012) that determined the pre-intervention  levels	The pilot incidence rate on the geriatric units decreased from 105 to 8.3 cases per 1,000 patient days (by  92%) in the first year.  The intervention yielded an estimated cost avoidance of $2.84 million and 13 lives saved  in 19 months post-implementation.	Level V/A

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Mintz-Binder, R. (2019). The connection between nursing theory and practice. Nursing made Incredibly Easy, 17(1), 6-9. 

Munro, S., & Baker, D. (2018). Reducing missed oral care opportunities to prevent non-ventilator associated hospital acquired pneumonia at the Department of Veterans Affairs. Applied Nursing Research , 44 , 48-53. doi:10.1016/j.apnr.2018.09.004 

Naga, B.S., & Al-Khasib, E.A. (2014). Roy Adaptation Model: Application of Theoretical Framework 

Oguejiofo, N. (2018). Rogers change theory. Retrieved from www.bizfluent.com 

Pássaro, L., Harbarth, S., & Landelle, C. (2016). Prevention of hospital-acquired pneumonia in non-ventilated adult patients: a narrative review. Antimicrobial Resistance & Infection Control , 5 (1). doi:10.1186/s13756-016-0150-3 

Quinn, B., Baker, D. L., Cohen, S., Stewart, J. L., Lima, C. A., & Parise, C. (2013). Basic Nursing Care to Prevent Nonventilator Hospital-Acquired Pneumonia. Journal of Nursing Scholarship , 46 (1), 11-19. doi:10.1111/jnu.12050 

Rapsomaniki, N. (2019). Introduction and analysis of the S.I.V. epidemiological model, a variation of the classic S.I.R. model. doi:10.1063/1.5091434 

Tesoro, M., Peyser, D. J., & Villarente, F. (2018). A Retrospective Study of Non–Ventilator-Associated Hospital Acquired Pneumonia Incidence and Missed Opportunities for Nursing Care. JONA: The Journal of Nursing Administration , 48 (5), 285-291. doi:10.1097/nna.0000000000000614 

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Warren, C., Medei, M. K., Wood, B., & Schutte, D. (2019). A Nurse-Driven Oral Care Protocol to Reduce Hospital-Acquired Pneumonia. AJN, American Journal of Nursing , 119 (2), 44-51. doi:10.1097/01.naj.0000553204.21342.01