Intervention reduced postoperative pneumonia rates in VA surgical ward

A postoperative pneumonia prevention program introduced in 2007 for patients on the surgical ward of a California Veterans Affairs hospital was successful in lowering the incidence of the infection, according to recent study results.

Nosocomial pneumonia accounts for 15% of all hospital-acquired infections, and it is associated with high morbidity, mortality and health care costs, the researchers wrote in JAMA Surgery.

Hadiza S. Kazaure, MD, of the department of general surgery at Stanford University School of Medicine, and colleagues reported on the long-term results of a standardized postoperative pneumonia prevention program at the VA Palo Alto Health Care System for at-risk patients who were not on a mechanical ventilator. The program included ongoing education for surgical ward staff on pneumonia prevention, coughing and deep-breathing exercises with incentive spirometer, head-of-bed elevation of at least 30 degrees, sitting up for every meal, twice-daily oral hygiene with chlorhexidine and ambulation.

Rates of pneumonia were compared with those captured in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). The researchers also evaluated the cost-effectiveness of the intervention.

Between 2008 and 2012, 18 cases of postoperative pneumonia were documented among 4,099 at-risk patients — a case rate of 0.44%. This is a 43.6% decrease from the hospital’s pre-intervention rate of 0.78% (P=.01). Pneumonia rates were lower in all years compared with the pre-intervention rate, ranging from 0.13% in 2012 to 0.68% in 2011. The overall pneumonia rate in the ACS-NSQIP was 2.56%, or 14,033 cases among 547,571 at-risk patients, which is 582% higher than the rate in the hospital’s surgical ward following the launch of its prevention program.

According to the researchers, a similar reduction in postoperative pneumonia cases at ACS-NSQIP hospitals would result in more than $280 million in cost savings. This calculation is based on a national average of $46,400 in health care costs associated with postoperative pneumonia and a benchmark of a 43.6% decrease in the pneumonia rate achieved at the VA facility over the span of 5 years.

The researchers noted certain limitations of the study, including the lack of adjustment for case mix, a primarily male patient population at the VA, and that the intervention was performed at a single medical center and therefore the results may not be generalizable to other hospitals.

“Despite the limitations listed earlier, our study supports the concept that successful and sustained reduction of pneumonia among postoperative patients requires multiple performance measures and unrelenting standardized quality improvement efforts,” they wrote.

In a related editorial, Catherine E. Lewis, MD, of the department of surgery at Geffen School of Medicine, University of California, Los Angeles, said that although the results are encouraging, they should be viewed with caution.

“The [pre-intervention] rate of pneumonia was 0.78% in the Veterans Affairs Palo Alto Health Care System and 2.56% in the ACS-NSQIP — a difference of 328% that is already of statistical significance,” she wrote. “This remarkably low rate of pneumonia calls into question the adequacy of detection and reporting of pneumonia on their ward and also makes their findings of a significant difference between their [post-intervention] and ACS-NSQIP rate of somewhat less consequence.”

However, Lewis added that the researchers should be “commended for the development and implementation of a quality improvement measure aimed at decreasing the rate of postoperative pneumonia…”

For more information:

Hadiza SK. JAMA Surg. 2014;doi:10.1001/jamasurg.2014.1216.

Lewis CE. JAMA Surg. 2014;doi:10.1001/jamasurg.2014.1249.

Disclosure: The researchers report no relevant financial disclosures.