In this day and age, the general population assumes that when someone is hospitalized the risk for getting a new infection while in the hospital is minimal. However, in the United States the risk for gaining a hospital-associated infection has become a serious concern and a costly one at that. The Center for Disease Control and Prevention has reported that hospital-associated infections have cost an estimate of 35.7 to 45 billion dollars to United States hospital when 20% of these infections could have been preventable with the correct interventions. One of the most common hospital-associated infections has become hospital-acquired pneumonia. (Scott II, 2009) This type of pneumonia is easily preventable if healthcare workers would comply with a few simple interventions that should already be in place in their facility. While these interventions have been proven effective, full compliance is still lacking and in the end it is being left to up the health care staff to become aware of the results.
Pneumonia is an inflammatory response that results in an excess amount of fluid in the interstitial spaces, the alveoli, and the bronchioles. It is caused by the inhalation of organisms or irritants that move into the alveoli when the immune system is not strong enough to combat it. Once these organisms or irritants enter the lungs, they reach the alveoli where they begin to multiply. This multiplication of these organisms results in white blood cells traveling into the area subsequently causing local capillaries to become edematous, leaky, and to create exudate. The combination of this results in thickening of the alveolar wall due to fluid collection within and around the alveoli. Impaired gas exchange, which is the decrease in the amount of oxygen that is able to enter the lungs due to the fluid, also causes a decrease in the amount of oxygenated blood moving throughout the body. Pneumonia is usually first recognized by the signs and symptoms of shortness of breath, coughing, thick sputum, chest pain, fatigue, fever, and headache. Pneumonia can occur lobar meaning that it can occur in one segment or one entire lobe of the lung creating consolidation in that lobe. (Ignatavicius & Workman, pp. 647-649)
Currently, there are two categorizes that pneumonia can fall into depending on how it was acquired. These two categorizes are community-acquired pneumonia and hospital-acquired pneumonia. Community-acquired results from exposure in the community or the client’s normal environment. Hospital-acquired pneumonia occurs from exposure to pathogens during hospitalization. Hospital-acquired pneumonia has been shown to be more resistant to antibiotics than Community-acquired pneumonia which is why it has become such a rising issue along with all hospital-associated infections. (Ignatavicius ; Workman pp. 647) According to Kleinpell, Munro, and Giuliano (2008), “Hospital-associated infections have been identified as one of the most serious patient safety issues in health care” and there has been 2 million cases reported per year. These hospital-associated infections have been estimated as the cause for nearly 20,000 deaths per year. (Kleinpell et al., 2008)
Based on these facts, healthcare providers should be taking a more serious look at what they are doing to prevent these infections in the first place. Nurses especially should be looking closer at their plans of care for patients and considering every patient entering the hospital to be at risk for infection. Nurses should be contemplating more “risk for” nursing diagnoses, such as Risk for Infection related to exposure to hospital-acquired pathogens rather than just pushing it off to be the last priority. While often patients do come in with more serious needs that need to be addressed first, infection control should still be a priority. One of the top patient goals should always be for the patient to remain infection free during hospitalization. There are several simple interventions that can help all healthcare staff reach this goal.
Many of the interventions that are the best for infection control are already in place in most facilitates however, because pneumonia has been reported as the second most common hospital-associated infection, healthcare providers should be aware of what interventions have been shown to be some of the most effective for pneumonia prevention. One of the best interventions for pneumonia specifically is encouraging a patient to perform or assisting in adequate oral hygiene. Oral hygiene rationale has been linked to the removal of pathogens. Research has shown that “within 48 hours of admission to an ICU, patients have changes in the oral flora, which predominantly include gram-negative and other virulent organisms”.(Sedwick, Lance-Smith, Reeder, Nardi, 2012) This suggests that removal of the pathogens would be the best option to decrease the risk for possible infection. To fully evaluate the effectiveness of this intervention cultures would have to be taken; however, for the average nurse the effectiveness could be evaluated by noting decrease in oral plaque, no odor of the breath, assessing for moisture, bleeding, or lesions of the oral cavity. Another suggested intervention for prevention of pneumonia would be to elevate the head of the bed in order to reduce the risk of aspiration. Patients that are supine are more likely to aspiration food, fluid, or vomitus which could get into the lungs if aspirated. Raising the head of the bed decreases the possibility of aspiration thus decreasing the risk for infection and possible pneumonia (Ignatavicius ; Workman, pp 1237). This interventions effectiveness can be evaluated by simply monitoring the patient for aspiration. The most common intervention, not only for pneumonia prevention, but for all infection control is hand hygiene. Hand hygiene has been found to be an essential component in the reduction of hospital-acquired pneumonia according to Kleinpell et al. (2008). The use of alcohol hand rubs has been found to reduce transmission of pathogens from healthcare worker to patients as well as washing with antimicrobial soap and water. (Kleinpell et al., 2008). In the clinical setting, nurses can determine its effectiveness by noting a decrease in the amount of patients that become ill with a hospital-associated infection when hand hygiene is used. However, this intervention has a vast amount of research to support it that all healthcare workers should have access to and be aware of.
While hand hygiene has been found to be the most effective interventions for infection control, the compliance to hand hygiene protocols seem to be lacking. Several research studies have found a need for better compliance, such as Chau, Thompson, Twinn, Lee, and Phang’s research study “An evaluation of hospital hand hygiene practice and glove use in Hong Kong”. Their study aimed “to identify omissions in hand hygiene practice and glove use among hospital workers in Hong Kong”(Chau et al., 2011) This study was a non-blinded observational study of hospital workers in four clinical areas in one acute hospital and two rehabilitation hospitals in Hong Kong. A non-probability quota sampling method was used in order to ensure that the entire population was represented. The researchers use an observational checklist to record the activities of the healthcare workers by checking a “yes” or “no” beside a behavior. The checklist included behaviors such as hand washing, antiseptic hand rub, wearing a mask, donning gloves, handling patient care equipment, linen and laundry, and routine cleaning. All data was gathered by registered nurses that had been trained to record data in a neutral and non-judgmental manner. Participation in the study was voluntary and all health care workers were aware that the study was taking place. The results of the study showed that only two-thirds of the healthcare workers washed their hands after each patient contact. Also out of that two-third, 78.5% of them failed to rub their hands together vigorously for 15 seconds and 70% of them used their own hand to turn off the water rather than a paper towel. The results of this study would suggest that hand hygiene needs to be worked on and taken more seriously in the health care environment to reduce the risk of patients contracting hospital-associated infections like hospital-acquired pneumonia. The hope of studies like this are to make health care workers more aware that the effectiveness of infection control that can only be seen when full compliance to procedures such as hand hygiene are shown as well. (Chau et al., 2011)
Some have assumed that student nurses are where the problem with compliance might lie and that the importance of hand hygiene is not stressed enough when in school. However another research study by Waltman, Schenk, Martin, and Walker called “Effects of Student Participation in Hand Hygiene Monitoring on Knowledge and Perception of infection Control Practices” acknowledges that in reality the teaching of hand hygiene has in fact had a positive effect on students and their compliance with hand hygiene protocol. The study reported that increasing awareness of the need for hand hygiene is key and that students should have it incorporated into their curriculum throughout their time in school. According to this study, “developing a strong appreciation of the importance of hand hygiene while still a student is an important first step for future nurses in clinical practice.” (Waltman et al., 2011) The problem is not that hand hygiene is not stress enough to nurses when they were in school but that may be more centrally located. The hospitals and health care facilities need to work on ways to ensure that hand hygiene compliance is increased in order reduce the occurrence of hospital-associated infections especially hospital-acquired pneumonia. This might mean holding people more accountable for the intervention and if their patient becomes ill due to a hospital-associated infection or possibly requiring hand hygiene classes throughout their time at the facility. (Waltman et al., 2011)
In conclusion, hospital-associated infections like pneumonia have become a serious issue within health care facilities. So serious that the Center of Disease Control and Prevention has reported that “one in every twenty hospitalized patients has an infection caused by receiving medical care”. (Center for Disease Control and Prevention, 2010) This statistic should be alarming to any health care worker, especially nurses, when there are known interventions that reduce the risk of infection. For hospital-acquired pneumonia simple things such as oral hygiene, hand hygiene, and raising the head of the bed lower a patient’s risk. Several research studies have been done not only to prove effectiveness but also to try to understand why these interventions are not being done. The most important thing for health care workers, aside from knowing the facts and interventions, is to be aware of the results of noncompliance and understand why it is important to follow through with them. By doing so, healthcare workers could potentially reduce the risk of gain a hospital-associated infection to almost nothing.