Preventing Aspiration Pneumonia: A Relationship-Based Care ...



Preventing Aspiration Pneumonia: A Relationship-Based Care ProjectKami CuffDixie State UniversityPreventing Aspiration Pneumonia: A Relationship-Based Care ProjectNosocomial infections occur in five percent of hospitalized patients. That means that one in every twenty patients will be infected. Pneumonias are some of the most prevalent hospital acquired infections. Ventilator-associated pneumonia has an estimated mortality rate up to 50% and costs the hospital $40,000 per case. Next to ventilator-associated pneumonia, aspiration pneumonia is a major cause of illness and death in hospitalized patients and is related to significant increases in health care costs (Echevarria & Schwoebel, 2012). This paper will discuss aspiration pneumonia with its associated causes and risk factors, the project with its accompanying purpose and results, and how the project promotes relationship-based care (RBC).Plan and PurposeFor Dixie Regional Medical Center, the estimated amount of aspiration pneumonia cases in 2014 was 2.1%; below the national average, but still substantial enough to warrant change. For this purpose, a group of interdisciplinary healthcare workers was required to facilitate an alteration in procedure. This process would include creating a tool to collect and measure data, as well as implementing a specific protocol for treating aspiration pneumonia in patients presenting with it, while preventing it those with specific risk factors.Team The team members for this project were selected from various disciplines working in the Intensive Care Unit (ICU). Three intensive care physicians, a neurosurgeon, pharmacist, respiratory therapist, speech therapist, ICU manager, and three registered nurses of multiple experience levels comprised the team. Relationship management is an important aspect of relationship-based care, especially when it comes to interdisciplinary team projects. According to chapter three of Relationship-Based Care, trust, mutual respect, consistent and visible support, and open and honest communication are the four basic components of a successful healthcare team (Wright, 2004). These four characteristics were evident within each of our team members throughout the project. From the planning phase through implementation, each team member made positive contributions to the project. They showed appreciation for each idea presented, and did their best to represent the interest of their discipline within the aspiration prevention process. According to Kinnaird and Dingman (2004), as outcome accountability is positioned closer to the bedside, the more successful the plan for relationship-based care will be. The team is brought together for a common goal, and with mutual accountability has the ability to surpass their own expectations and those of their patients. ProjectAs the project began, the team worked together on a mission and aim statement. The mission was to describe our purpose, while the aim was more focused and specific to the particular goal we wished to achieve. After much deliberation we agreed on the following mission statement, “Develop, implement and monitor compliance to a standardized set of criteria/protocols for the prevention, diagnosis and treatment of aspiration pneumonia in the critically ill patient.” Our aim statement was more specific and measureable. According to Kelly and Tazbir (2014), goals should be specific, measureable, achievable, realistic, and timely. Our aim statement read, “We will reduce the overall occurrence of aspiration pneumonia from 2.1% in 2014 to less than 1.85% for 2015. This will be accomplished by identifying at risk patients for aspiration pneumonia and implementing an aspiration pneumonia protocol. We will decrease treatment variation by having a standardized therapeutic regimen for aspiration pneumonia.”ResearchOnce we established our mission and goal, we were ready to get to work. I researched aspiration pneumonia, risk factors, and successful aspiration pneumonia protocols that other hospitals have implemented. Through my research, I learned that aspiration is the unintentional intake of gastric or oropharyngeal contents into the lungs, which can lead to a variety of lung issues, depending on the type and amount of foreign material taken in. Aspiration pneumonia is the most common pulmonary syndrome (Ebihara, Ebihara, & Kohzuki, 2012).Aspiration pneumonia occurs when bacteria or other microorganisms residing in oral or gastric contents are diverted to the lungs through aspiration. As these organisms settle, they create an infection within the lung tissue. One or both lungs can be affected, but the right lower lobe is found to be the most common site for aspirated material (Pace & McCullough, 2010).Next to urinary tract infections, aspiration pneumonia is the most common infection, the leading reason for transfers to the hospital, and most common cause of death from infection among nursing home residents. Poor dentition, insufficient oral hygiene, and prevalence of neurologic disorders are major risk factors for this demographic (Pace & McCullough, 2010). Other aspiration risk factors in the elderly population are related to the aging process itself, subsequent illnesses, and daily medication administration. The combination of these issues have a devastating impact on respiratory tract defense systems. The ability to cough and swallow can diminish with age, leaving the patient unable to clear their airway. Impaired cough and swallow reflexes, is a leading cause of aspiration pneumonia in the elderly (Ebihara, Ebihara, & Kohzuki, 2012).Proper nutrition is an ongoing problem for the aging population. Older patients with dysphagia, or difficulty in swallowing, related to neurological disorders, are often fed through gastrostomy tubes for long-term nutrition. The prognosis of these patients is poor, due to the high prevalence of aspiration and subsequent aspiration pneumonia related to the regurgitation of gastric contents (Takatori et al., 2013). Patients with oral or nasogastric tubes, either for feeding or suction, are also at risk for aspiration. These tubes can cause disruption in the body’s normal swallowing mechanisms, causing an increase in oral secretions without a viable way to clear them. It is important to screen patients for proper swallowing ability to prevent aspiration. Screenings are usually done with a small amount of water. The person administering the screening watches for coughing, clearing of the throat, or voice changes that might denote liquid around the vocal chords (Steele, Sejdic, & Chau, 2013). PreventionAs with most illnesses or disorders, the best treatment, is prevention. Our team needed to create an aspiration prevention tool and protocol that was specific to the ICU. Using the expert knowledge of our interdisciplinary team, and utilizing the successful prevention plans of other hospitals, we created our own prevention/treatment algorithm. In addition, the physicians were able to update their aspiration pneumonia order set to include specific antibiotics that fight both gram negative and gram positive bacteria often found in patients with periodontal disease (Pace & McCullough, 2010). Risk Assessment ToolThe protocol begins with a risk screening that is to be implemented on admission. The admitting nurse would include an aspiration risk assessment and functional screening with the head to toe assessment and health history collection process. The risk assessment/screening tool allows the nurse to check boxes next to common aspiration risk factors in three categories: neurological, gastrointestinal, and respiratory. Neurologic risk factors included in the tool are decreased level of consciousness, diagnosis or history of stroke with residual, and neurodegenerative disease such as ALS or Parkinson’s. Under the gastrointestinal section, common risk factors are inability to perform oral hygiene, requires assistance with eating, and presence of a nasal, gastric, or feeding tube. Under the respiratory section there is an option to check if the patient has a tracheostomy. In case none of the risk factors apply, there is a box for this exclusion. If one or more of the risk factors are present, the nurse is directed to initiate the Aspiration Precaution Protocol, and complete the functional assessment.Functional ScreenThe functional assessment lists four criteria that, if one or more are present, the patient will remain on aspiration precautions, the physician must be contacted and a speech pathology consult needs to be requested. Food and water should be removed from the patient’s room and the patient is to have nothing by mouth until fully evaluated. The criteria are as follows: patient is unable to maintain a sustained level of alertness, slurred speech is present, difficulty chewing or sealing lips around cup, straw, or utensil, or patient fails the 90 ml swallow challenge given by RN. In order to pass the 90 ml swallow challenge the patient, must drink a full 90 ml of water without stopping or pausing. The patient cannot cough or choke during or immediately following the challenge. This results in a failed challenge (Leder, Suiter, Warner, & Kaplan, 2011). ProtocolThe aspiration pneumonia precaution protocol is included on the risk screening and assessment tool. Our protocol requires that a swallowing precaution sign be placed above the patient’s bed. This assures that all health care providers and family members are aware. It is essential for nurse to pass this information on in shift report, but the sign is there for back-up. The head of bed should be kept at 45 degrees or higher if not contraindicated. If the bed must remain flat, tube feedings must be discontinued until bed can be raised to a safe incline. When patient is eating or drinking, the head of bed must be at 90 degrees. Assistance with meals and close observation is required while eating. It is important to have a working suction canister and tubing ready at all times. Oral care is required each shift. Maintaining good oral hygiene will prevent microorganisms, normally found in the mouth, from relocating to the lungs and causing infection (Pace & McCullough, 2010). If the patient is to have nothing by mouth, it is imperative to place a NPO sign above the bed. This, as with the swallowing precautions sign, alerts all care personnel and family members that the patient is not allowed anything to eat or drink. Educating the patient and family about the importance of aspiration precautions is essential in the prevention of aspiration pneumonia. This should involve explanations and handouts to which the patient and family can refer back. Proper education and communication is at the core of relationship-based care. As nurses impart knowledge and explain unfamiliar information they are fulfilling their role as a guide and teacher, which is key in creating a therapeutic relationship with patients and their families (Koloroutis, 2004).ImplementationAs the protocol was implemented, my job was to make sure that every patient on the floor, no matter when they were admitted, were assessed and screened for aspiration risk. Once the current patients were assessed, the assessment tool would then be included in the admissions packet. We were able to implement the new protocol on October 1st. At that time, we had fourteen patients on the floor. Of the fourteen patients twelve had risk factors, eight had one or more indicators in the functional screening, and seven were referred to the physician for a speech and swallow consultation. All twelve patients were set up on the aspiration precaution protocol. Outcomes MeasurementAs the assessment tool was audited through October and most of November, the results were very educational. Through November 20th, 183 patients were assessed. Of the total patients assessed, 79 patients were put on the protocol, 48 patients obtained a speech and swallow consult, and 39 patients did not require intervention. According to Kinnaird and Dingman (2004), when measuring outcomes the data collected must be valid and reliable. For data to be valid it must measure that which it was anticipated to measure. Reliability refers to the consistency of a tool of measurement. So far our tool has generated valid and reliable data. EvaluationWe will continue to utilize our prevention tool through September of 2015. At that time we will be able to tally the data and find out if our goal of reducing the number of aspiration pneumonia cases by 0.25% was reached. Once we have processed the data we will be able to evaluate our tool, make adjustments as necessary, and implement additional interventions. “Effective data gathering, reliable findings, and the application of those findings to everyday practice are all essential for successful implementation and maintenance of RBC” (Kinnaird & Dingman, 2004, p. 238). Even though we will not have definitive numbers until September of 2015, it is evident that the protocol, when followed, is effective in preventing aspiration in at risk patients. ConclusionThis paper has discussed how a well-organized interdisciplinary team can come together with a collective aim and mission to devise a tool to help prevent aspiration in the critically ill patient. In addition, this paper has explained how relationship management within healthcare teams and the elements of mutual respect, trust, visible and consistent support, and open and honest communication are important components of relationship-based care. The paper further explained that good communication while teaching patients helps to build therapeutic relationships. This project also incorporated the RBC factor of outcomes measurement, including the evaluation of interventions through valid and reliable data collection. In conclusion, aspiration pneumonia is a common and devastating illness, with poor outcomes in the elderly. It is associated with high mortality and increasing hospital costs, but with the efforts of interdisciplinary teams focused on RBC and united under a common goal, prevention of aspiration pneumonia becomes a reality.ReferencesEbihara, S., Ebihara, T., & Kohzuki, M. (2012, February). Effect of aging on cough and swallowing reflexes: Implications for preventing aspiration pneumonia. Lung, 190(1), 29-33. , L. M., & Schwoebel, A. (2012, September-October). Development of an intervention model for the prevention of aspiration pneumonia in high-risk patients on a medical-surgical unit. MEDSURG NURSING, 21, 303-308. Retrieved from , P., & Tazbir, J. (2014). Essentials of nursing leadership & management (3rd ed.). Clifton Park, NY: Delmar, Cengage Learning.Kinnaird, L., & Dingman, S. (2004). Outcomes measurement. In M. Koloroutis (Ed.), Relationship-based care: A model for transforming practice (pp. 215-248). Minneapolis, MN: Creative Health Care Management.Koloroutis, M. (2004). Professional nursing practice. In M. Koloroutis (Ed.), Relationship-based care: A model for transforming practice. Minneapolis, MN: Creative Health Care Management.Leder, S. B., Suiter, D. M., Warner, H. L., & Kaplan, L. J. (2011, May). Initiating safe oral feeding in critically ill intensive care and step-down unit patients based on passing a 3-ounce (90 milliliters) water swallow challenge. Journal of Trauma, 70, 1203-1207. , C. C., & McCullough, G. H. (2010, September). The association between oral microorganisms and aspiration pneumonia in the institutionalized elderly: Review and recommendations. Dysphagia, 25, 307-322. , C. M., Sejdic, E., & Chau, T. (2013). Noninvasive detection of thin-liquid aspiration using dual-axis swallowing accelerometry. Dysphagia, 28, 105-112. , K., Yoshida, R., Horai, A., Satake, S., Ose, T., Kitajima, N., ... Kinoshita, Y. (2013, October). Therapeutic effects of mosapride citrate and lansoprazole for prevention of aspiration pneumonia in patients receiving gastrostomy feeding. Journal of Gastroenterology, 48, 1105-1110. , D. (2004). Teamwork. In M. Koloroutis (Ed.), Relationship-based care: A model for transforming practice (pp. 91-116). Minneapolis, MN: Creative Health Care Management. ................
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