Strategies To Reduce the Incidence of Pneumonia in a Pediatric Long Term Care Population

Abstract

ISSUE: A pediatric long-term care organization includes a number of residents with limited mobility due to cerebral palsy with spastic quadriplegia, or encephalopathy. Pneumonia is a leading cause of morbidity and mortality in this population. The hospital's infection control statistics indicated a steady increase in incidence of healthcare-associated pneumonia throughout 2003: 1.34 episodes per 1,000 patient days in the First Quarter to 2.65 episodes per 1,000 patient days in the Fourth Quarter. PROJECT: A study was undertaken to determine compliance with current pneumonia prevention measures, and to implement additional measures which may reduce pneumonia risk for these patients. Pneumonia in these patients is caused by host susceptibility, microbial colonization of the oropharynx or stomach, increased risk of aspiration or reflux. Standard prevention strategies include use of influenza and pneumococcal immunization, and aspiration precautions. The 2003 healthcare-associated pneumonia cases were reviewed: 38 episodes of pneumonia occurred in 23 long-term care residents. Eleven residents had two or more episodes of pneumonia. Residents with multiple episodes of pneumonia were selected for further monitoring. Review of immunization records for these residents showed annual influenza and pneumococcal immunization rates over 90%. Audits of compliance with aspiration precautions ranged from 91% to 100%. "The Vest" is an airway clearance system that uses high-frequency chest wall oscillation to mobilize respiratory secretions, which can then be cleared by coughing or suctioning. Several clinical trials have demonstrated efficacy of "The Vest" in decreasing the incidence of pneumonia in pediatric patients with diagnoses similar to this population. In 2004, Vest Therapy was initiated in three patients at each of two long-term care facilities. The rate of healthcare-associated pneumonia for patients while on Vest Therapy was compared to pneumonia rates in these same patients for the year prior to Vest Therapy. RESULTS: Audits of compliance with standard pneumonia prevention measures indicated overall compliance rates above 90%. The healthcare-associated pneumonia rate for the first cohort of three patients on Vest Therapy decreased from 8.2 episodes per 1,000 patient days to 0.9 episodes per 1,000 patient days. A cohort of three patients at a second facility has shown a decrease in the pneumonia rate from 4.6 episodes per 1,000 days to 1.8 per 1,000 patient days. LESSONS LEARNED: The addition of a new modality for secretion mobilization proved effective in reducing the number of episodes of pneumonia in this population. Studies are continuing to determine if these measures are effective in sustaining the reduction in infection over a longer time period. Priliminary data from this study was presented in a poster session at a Pediatric Nursing conference held September 2005 in Philadelphia, PA.