Postoperative pneumonia continues to create a burden on healthcare systems, often leading to increases in morbidity, length of hospital stay, and costs. Postoperative pneumonia is the third most common complication among surgical patients and is the third most common infectious complication after urinary tract and wound infections. Despite the availability of effective antibiotics, published research indicates that mortality rates associated with hospital-acquired pneumonia due to gram-negative infection are between 25% and 50%. The overall prognosis for patients experiencing postoperative pneumonia is poor, due in part to comorbidities.
“Postoperative pneumonia is the third most common complication among surgical patients and is the third most common infectious complication after urinary tract and wound infections.”
According to the Institute for Healthcare Improvement, a facility that performed 10,000 non-cardiac operations per year would be expected to have about 150 cases of postoperative pneumonia. In the ICU, this complication can translate into additional healthcare costs of as much as $40,000 per patient; the estimated mortality rate ranges from 20% to 70%. Throughout the country, pneumonia-prevention programs have been successfully implemented in ICU settings. However, there are currently no such programs in place for patients in surgical wards.
An Effective Pilot Program
In the April 2010 Journal of the American College of Surgeons, my colleagues and I reported a study in which we tested a pilot pneumonia-prevention program to assess its effect on reducing the incidence of postoperative pneumonia in a hospital surgical ward. The pilot prevention program was designed and implemented based on an extensive literature review of risk reduction interventions. In the program, physicians and ward staff received education on preventing pneumonia. Other components of the program included:
Cough and deep-breathing exercises with incentive spirometer.
Twice daily oral hygiene with chlorhexidine swabs.
Ambulation with good pain control.
Head-of-bed elevation to at least 30° and sitting up for all meals.
Quarterly staff meetings were also initiated to discuss the results of and compliance with the program. Pneumonia bundle documentation and computerized pneumonia-prevention order sets in the physician order entry system were also key components in the program.
After the intervention, we calculated the incidence of postoperative pneumonia using the prospectively collected National Surgical Quality Improvement Project database, which captured data on approximately half of inpatient admissions. According to findings, our pilot pneumonia-prevention program significantly reduced postoperative pneumonia in a hospital surgical ward. There was a significant decrease in ward pneumonia incidence from 0.78% in the pre-intervention group, as compared with 0.18% in the post-intervention group. This represented an 81% decrease in the incidence of postoperative pneumonia from 2006 to 2008. Pneumonia was diagnosed in the surgical ward in 13 of 1,668 inpatient admissions before the pilot program was initiated. After program initiation, only three of 1,651 inpatient admissions with pneumonia were diagnosed in the ward.
Potential for Universal Implementation
In light of our findings, there is hope that this pilot program can be used in more institutions throughout the United States. If expanded to other VA or private hospitals, this program could help improve patient care and lower morbidity, mortality, and overall healthcare costs. It’s also a low-cost, high-impact program that is simple to implement. The interventions were not costly, but did require ongoing communication and cooperation between physicians and nursing leadership to achieve compliance with the measures. The hope is that with more research we can optimize the potential of the pilot program and disseminate it to more hospital surgical wards in an effort to decrease inpatient postoperative pneumonias and reduce the burden of these problems in the future.
Readings & Resources (click to view)
Wren SM, Martin M, Yoon JK, Bech F. Postoperative pneumonia-prevention program for the inpatient surgical ward. J Am Coll Surg. 2010;210:491-495. Abstract available at: http://www.sciencedirect.com/science.html.
Arozullah AM, Khuri SF, Henderson WG, et al. Development and validation of a multifactorial risk index for predicting postoperative pneumonia after major noncardiac surgery. Ann Intern Med. 2001;135:847-857.
Warren DK, Shukla SJ, Olsen MA, et al. Outcome and attributable cost of ventilator-associated pneumonia among intensive care unit patients in a suburban medical center. Crit Care Med. 2003;31:1312-1317.
Babcock HM, Zack JE, Garrison T, et al. An educational intervention to reduce ventilator-associated pneumonia in an integrated health system: a comparison of effects. Chest. 2004;125:2224-2231.
Hall JC, Tarala RA, Tapper J, Hall JL. Prevention of respiratory complications after abdominal surgery: a randomized clinical trial. BMJ. 1996;312:148-153.