HAP: In the ‘too difficult box’?

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User:KGH at Wikimedia Commons

I’ve had an enjoyable time at ICPIC. Sessions (abstracts here) have been great, speakers excellent, meeting well-organised but one session rattled my cage. Point prevalence surveys (PPS) and their value was an interesting session, however at the end of it I was wondering whether this was ‘Surveillance in action’ or ‘Surveillance inaction’.

Repeated PPS across Europe show that a significant proportion of hospital-onset HCAI are pneumonia. In fact, data from the England PPS in 2011 showed that the greatest proportion were pneumonia, with a small subset being device-associated (ventilator in this case) and this is unlikely to be different when the 2016 data are published. The German results presented in the session showed a similar picture although they were not divided into HAP and VAP, however unless things are going disastrously wrong in German ITUs the burden will be in HAP. Repeated PPS show no change (or even an increase in the proportion that are pneumonia). The cost of this must be huge, even if low cost/case. Among the recommendations from the 2011 PPS in England (the great majority of which have not seen much action either) was a recommendation that there should be a “development of learning tools for the prevention of healthcare-associated pneumonia” however none have been forthcoming.

The guidance for HAP prevention seems to be a grand total of zero internationally. A systematic review found only two RCT papers that could be evaluated, both in stroke patients. The authors were able to propose no interventions, looked for funding to take things further however none was forthcoming. A further review in 2016 by Stephan Harbarth and colleagues became a narrative review because of the paucity of evidence, although some interventions were suggested, based primarily on the sound principles of common sense.

We use much energy on device or intervention-related infections such as CAUTI, SSI, CLABSI and VAP, but what about the non-intervention related HCAIs? In my (totally evidence-free) opinion, HAP results precisely from non-intervention. It is nursing actions that may be implicated and is this why IPC (predominantly medical-led) does not seem to be as interested? There are some non-RCTs that suggest that mobility and oral care seem to be able to influence the incidence of pneumonia. HAP is of course likely to be linked to lung expansion and micro/macro aspiration of oral flora into the lungs. What happened to mobility of the elderly in hospitals I wonder? It is quicker and easier to move a patient with poor mobility to the toilet or bathroom on a chair than to walk with them yet an early mobility bundle was shown to be effective. No-one walks to the dining table in a ward any more, yet in stroke patients even simple passive exercise by trained relatives has been shown to reduce HAP. Another very practical study that used a package of simple measures including providing toothbrushes of a reasonable quality so that bristles didn’t fall out in patient’s mouths was another non-RCT with an effect on VAP. There is even a recent paper suggesting that leaving dentures in overnight is a significant risk factor for pneumonia.

Many countries undertake or participate in PPS every X years to look at what the direction of travel is. HAP is only studied in this way and as far as I am aware, very little is done in terms of surveillance apart from this. Yes, I know that this would be difficult, and I am not arguing for that. It is however surely time that some funding was found to undertake a study that would demonstrate a potential effect of a simple bundle consisting of two interventions (mobility and teeth cleaning) that looks suspiciously like what would be considered to be good nursing care. Perhaps the connections between these and pneumonia are not being made. Do staff realise the impact of these simple interventions? Perhaps not as they are likely to be carried out by care assistants as opposed to trained nurses and would education of this group be of benefit? The prize, if successful, is huge as many antibiotics are prescribed for HAP, increasing other risks such as Clostridium difficile infections. It has to be time to move from surveillance inaction to surveillance in action, otherwise what’s the point?

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4 thoughts on “HAP: In the ‘too difficult box’?

  1. Well put together piece Martin and spot on as usual.
    It makes huge sense to find and implement a bundle that would impact on something which causes such a high proportion of infection and as you said the treatment of which may lead to other infection such as CDT and MDRO colonization.

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  2. That is a lot of information to reflect on. Good basic nursing care does make a difference in infection prevention – how can we articulate that without making it a bundle?

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    • I don’t think a mimimum mobility bundle (walking around the bed, walking back from the toillet, passive limb movements if bedbound etc.,) and cleaning teeth twice a day (with toothpaste) would be too difficult as a bundle of two interventions. The evidence is that if people implement bundles (and measure that they are actually doing it) then interventions are successful.

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  3. Martin, I couldn’t agree more about surveillance inaction. Why do we stand and watch HCWs not cleaning their hands? Surely we need to intervene when we are doing audits rather than simply noting down a missed opportunity and non compliance. How is that helpful?

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