Pneumonia is a common nosocomial infection that accounts for approximately 2.7% to 3.4% of complications among surgical patients. Nosocomial pneumonia has been linked to high morbidity, mortality, and costs, and is among the complications used to assess readmission rates for hospital profiling and reimbursement. “In recent years, greater attention has been given to improving the quality of patient care, with an emphasis on infection control,” says Sherry M. Wren MD, FACS. “This has spurred the development of several guidelines for nosocomial pneumonia prevention.”

Throughout the United States, some hospitals have developed multidisciplinary quality improvement (QI) programs that aim to reduce postoperative risk for pneumonia. Most of these programs have been initiated in critical care and ICU settings, but few have explored their effect in surgical wards. To address this research gap, Dr. Wren and colleagues at the VA Palo Alto Health Care System developed a pneumonia prevention QI program for surgical ward-acquired pneumonia prevention strategies that consist of several important steps (Table 1). The study group published long-term results of the program in JAMA Surgery.

“We focused our research entirely on patients hospitalized on the surgical ward to evaluate the long-term effectiveness of our program,” Dr. Wren says. “It’s important to see if we can achieve sustained reductions in postoperative pneumonia in the surgical ward and to assess how effective it has been to adopt of our pneumonia prevention program.” The study revealed results of the program over a 5-year period since the intervention was implemented.

Profound Results

According to findings, between 2008 and 2012, there were just 18 cases of postoperative pneumonia among the more than 4,000 at-risk patients who were hospitalized on the surgical ward and included in prospectively tracked data from the VA Surgical Quality Improvement Program (VA-SQIP) sample, which captures approximately 50% of inpatients after surgical procedures. This yielded a case rate of 0.44%, which represented a 43.6% decrease from our pre-intervention rate, according to Dr. Wren. The pneumonia rates in all years assessed in the study were lower than pre-intervention rates between 2008 and 2012 (Table 2).

The researchers also compared overall pneumonia rates of their pneumonia prevention program with that of the American College of Surgeons’ National Surgical Quality Improvement Program (ACS-NSQIP). The overall pneumonia rate in ACS-NSQIP was 2.56%, which was 582% higher than the post-intervention rate seen at the surgical ward in the study by Dr. Wren and colleagues. If a 43.6% decrease in pneumonia rates occurred at ACS-NSQIP hospitals during the same 5-year period—as was the case for the QI program used by the VA Palo Alto Health Care System—there would be approximately 6,118 prevented pneumonia cases and a cost savings of more than $280 million.

“By introducing our program and making concerted efforts to maintain compliance with it, we have achieved substantial and sustained decreases in pneumonia rates,” Dr. Wren says. There was only one case of pneumonia in 2012 among more than 750 postoperative patients in the VA-SQIP sample hospitalized in the VA Palo Alto surgical ward, indicating that the goal of zero cases of pneumonia may be achievable. “Other hospitals throughout the U.S. are implementing similar QI initiatives to reduce postoperative pneumonia rates,” adds Dr. Wren. “Our results demonstrate that pneumonia among surgical patients can be prevented by adhering to bundles of infection prevention measures.”

Commitment Is Key

In recent years, there has been a renewed focus on patient safety, and recent healthcare legislation and Medicare reimbursement policies are aiming to decrease morbidity and healthcare expenditures. To meet these goals, considerable effort is needed across institutions to reduce the occurrence of postoperative pneumonia and hospital readmissions that are secondary to a diagnosis of pneumonia. “Adopting QI programs similar to ours can considerably reduce postoperative pneumonia rates,” says Dr. Wren. “The key is to commit to the program. This means using electronic medical record systems to facilitate and standardize the application of elements used in our program. All members the multidisciplinary care team must also be committed to following the QI protocols.”

Looking Ahead

According to Dr. Wren, no single specific element of the QI program that her study team initiated was critically important to achieving improvements in postoperative pneumonia rates. “Instead, it’s likely that the sum of its parts is what made our program successful,” she says. “It’s important for clinicians to recognize the importance of using each element of our QI program to reduce the burden of postoperative pneumonia. As these elements become more automatic, we can giving physicians more time to deal with other important medical issues in surgical patients.”


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