Hospital-acquired complications (HAC) put a significant burden on the Australian healthcare system. Different sources suggest that the number of hospital-acquired complication cases occurring each year may be anywhere between 80,000 and 165,000 (Mitchell et al., 2017). However, as Mitchell et al. (2017) report based on the results of their meta-analysis, the scale of the problem might be even more serious as there is a lack of surveillance of HAC. HAC cases often result in the need for acute care, which is associated with significant challenges for healthcare workers. It is not a rarity to witness an emergency department struggling financially and not being able to cover all its needs regarding the key resources used in acute care intervention. Aside from that, health reform implementation often faces hurdles in the form of the lack of standardisation across the board and the discrepancy between guidelines and actual capacity of hospitals. This essay presents a case study that describes a patient suffering from hospital-acquired pneumonia and provides recommendations for current preventive care. It also draws a comparison between work practices in New South Wales and the Australian national standards and guidelines.
Overview of Hospital-Acquired Pneumonia
Pneumonia is caused by an infection that leads to the inflammation of air sacs in one or both lungs. The germs that spread pneumonia, be they viral or bacterial, are contagious. Pneumonia is the second most common HAC in Australia that is associated with a high mortality rate (the all-cause rate of 25-50%) (Australian Commission of Safety and Quality in Health Care, 2018; Hupp & Ferneini, 2015). According to the Australian Commission of Safety and Quality in Health Care (2018), each year Australian hospitals see as many as 17,584 cases of hospital-acquired pneumonia. The rate for this type of HAC is currently at 46.6 per 10,000 hospitalisations.
The condition causes considerable distress in patients as it is associated with a buildup of mucus (sometimes streaked with blood), difficulties breathing, chest pain, low energy and other symptoms. Aside from that, pneumonia prolongs the length of stay and increases costs of admission. Pneumonia is especially dangerous for elderly patients: the disease develops extremely fast and the overall prognosis is poor (Mitchell et al., 2017). For these reasons, it is critical to prevent hospital-acquired pneumonia in the first place and in the event of a patient developing the condition, prescribe adequate treatment.
Presented Case
For the sake of anonymity and confidentiality, from here on, the patient presented will be referred to as A. A. is a 67-year-old Caucasian man who was brought to the emergency unit by his family a few hours after a rapid onset of left-sided weakness and aphasia. The patient’s primary diagnosis was stroke; he was recommended urgent hospitalisation until significant improvements. The emergency department logged A.’s vital signs: blood pressure of 150/ 90 Hg in both arms, body temperature of 37.2C, respiratory rate of 16 breaths per minute and a heartbeat rate of 95 beats per min. A.’s teeth and gingiva showed no signs of disease; no gag reflex was detected. The medical staff noticed that the patient’s laryngeal cough reflex was weakened. On the Glasgow Coma Scale, A. scored four for eye movement (opens eyes spontaneously), four for verbal performance (confused, disoriented), and four for movement (withdrawal to painful stimuli). After the patient showed first signs of improvement, the medical staff encouraged him to walk with their support.
A.’s past medical history revealed some of the risk factors for pneumonia: he suffered from chronic obstructive pulmonary disease with chronic bronchitis. Besides, A. had been a lifelong smoker and suffered from diabetes. The hospital staff applied some preventive strategies such as hand hygiene to avert cross-contamination and appropriate disinfection or sterilisation of respiratory-therapy devices. However, two days after admission, A. started displaying concerning symptoms: the patient was sweating profusely and complained about the shortness of breath and the feeling of tightness in his chest. A. was coughing quite a lot, producing greenish mucus. After blood tests and chest X-ray, A. was diagnosed with hospital-acquired bacterial pneumonia and administered acute care. The patient was given antibiotics and nonsteroidal anti-inflammatory drugs (ibuprofen).
Core Acute Care Nursing Concepts
Hospital-acquired pneumonia treatment and prevention strategies are primarily based on the Adult Pneumonia Guideline (Community and Hospital-acquired) and Hospital-acquired Pneumonia & Ventilator-associated Pneumonia (Adults) Clinical Guideline provided by the Australian Commission of Safety and Quality in Health Care. When it comes to the nursing management of patients such as A., two core acute care concepts are applied – treatment and prevention. Treatment of hospital-acquired pneumonia typically takes seven days and requires the administration of antibiotics and ongoing monitoring of the patient. The length of treatment can be modified based on the dynamics of the progress. Mendoza and Patel (2016) highlight the importance of initiating antimicrobial treatment soon after the onset of hospital-acquired pneumonia. A delay in drug administration is associated with higher rates of mortality (Mendoza and Patel, 2016).
The second core concept used in the management of patients such as A. is prevention. In medicine, prevention encompasses strategies undertaken to decrease the chances of a patient getting a disease or condition. When it comes to hospital-acquired pneumonia, preventive care can make a significant difference in the quality of patient outcomes. Rothberg et al. (2014) conclude that hospital-associated pneumonia is more lethal than the community-acquired type, which is why it is imperative to avert such cases rather than handling the consequences of neglect and poor treatment.
Strengths and Weakness of the Nursing Management Provided
The first notable element of preventive care administered by the hospital staff is the patient’s assessment for risk factors. The Australian Commission of Safety and Quality in Health Care (2018) discusses in detail which host factors put patients at a greater risk of developing hospital-acquired pneumonia. A.’s medical history was thoroughly investigated, and the medical staff was able to discover that the patient had had a long story of living with chronic obstructive pulmonary disease (COPD) and chronic bronchitis. A.’s nurses pointed out the fact that the patient’s increasing age might be making him especially fragile, and his diabetes must have contributed to his overall poor condition. Besides, from the conversation with A.’s family and A. himself, the medical team learned about his smoking habit that must have also made him more prone to developing lung infections.
Apart from the initial assessment and identification of A. as a vulnerable patient, the medical staff administered two important interventions: hand hygiene to avert cross-contamination and appropriate disinfection or sterilisation of respiratory-therapy devices. Passaro, Harbarth and Landelle (2016) have found that hand hygiene was an effective measure against hospital-acquired complications of all kinds, especially pneumonia. The access to bedside antiseptic hand rubs and increased pneumonia awareness among medical staff resulted in a reduction in the nosocomial infection prevalence (from 16.9 to 9.9%). Sterilisation of respiratory-therapy devices to protect A. from contracting pneumonia was also a recognised evidence-based practice. Guzmán-Herrador et al. (2016) discovered that the use of a nasogastric tube was one of the strongest contributing factors to hospital-acquired pneumonia. In summation, the medical staff showed awareness of the threat and took some reasonable measures to decrease the chances of the patient suffering from a HAC.
However, the medical staff failed to provide the patient with a wider range of preventive interventions that could have increased his chances to avoid HACs. Firstly, A. could have benefitted from allied health interventions such as chest physiotherapy. Besides, A. was not monitored for issues that could enable early identification of pneumonia. Namely, the Australian Commission of Safety and Quality in Health Care (2018) recommends paying attention to vulnerable patients’ respiratory rate and monitor them for signs of sepsis. The latter may include but are not limited to high temperature, increased heart rate and elevated blood pressure. Other symptoms that might be indicative of bacterial pneumonia in its early stages are white cell count, C reactive protein and arterial blood gases (Australian Commission of Safety and Quality in Health Care, 2018). All in all, pneumonia prevention with regard to A.’s case left a lot to be desired.
It should be noted that even the current treatment strategy might be suboptimal under certain circumstances. Mendoza and Patel (2016) write that on the one hand, antimicrobial treatment of pneumonia of both kinds (community- and hospital-acquired) is the standard. On the other hand, these days, patients often have histories of excessive use or even abuse of antibiotics, which results in antibiotic resistance. This risk should be taken into account when treating A.
Best Practice Guidelines
Because pneumonia poses a significant risk not only to patients’ quality of life but also to their general survivability, several different governing bodies have published their recommendations regarding treatment and prevention of this condition. The Clinical Excellence Commission (CEC) (n.d.) addresses hospital-acquired infections on the whole. The commission pays special attention to the surveillance of the disease at various levels, which should result in precise and reliable statistics regarding disease prevalence and management. This idea is not found in the Adult Pneumonia Guideline (Community and Hospital-acquired) published by the governing body of New South Wales (NSW Health, 2012).
Nor is this recommendation echoed in the Hospital-Acquired Complications Information kit by the Australian Commission of Safety and Quality in Health Care (2018) or the document by the Government of South Australia (2018). This implies that while the CEC fulfills its function as a surveillance body, lower-level facilities are not encouraged to gather data, which could be helpful in understanding trends in their own limited context. The workplace does not have strict procedures regarding data collection, which is consistent with the latter two documents.
The US Centers for Disease Control and Prevention (CDC) (2003) provide recommendations similar to those found in the Australian documents mentioned above. However, the CDC puts forward a suggestion regarding the replacement of nasogastric tubes with oro-tracheal tubes to prevent pneumonia. The Australian guidelines as well as the guidelines published by the Clinical Excellence Commission contain this idea. The workplace does not use oro-tracheal tubes in lieu of nasogastric tubes, instead, it sterilises the latter – a practice that is promoted by all the mentioned governing bodies.
Both New South Wales and the Australian Commission of Safety and Quality in Health Care prioritise risk assessment for further preventive measures. However, the Australian Commission of Safety and Quality in Health Care (2018) pays more attention to listing all possible risk factors and grouping them into various categories such as host and environmental factors. Besides, the Australian Commission of Safety and Quality in Health Care (2018) is more elaborate in its classification of risks into modifiable and non-modifiable, which can be easily translated into prevention strategies. As seen from the present case, the workplace puts an emphasis on risk assessment. However, in A.’s case, the medical staff focused on host factors (smoking, diabetes, age and others) rather than environmental factors (A.’s potential exposure to other patients).
All the guidelines analyzed in this section contain similar recommendations regarding patient treatment. They adhere to antimicrobial treatment as a standard for addressing hospital-acquired pneumonia. The length of treatment cited as the ideal is the same in both New South Wales and statewide documents: from five to seven days. However, the statewide guidelines make it a point to advise treatment length reduction where possible. The rationale behind reduction is the need to decrease patients’ chances of developing antimicrobial reduction. This is consistent with the research by Mendoza and Patel (2016) that provides a caution regarding the use of antimicrobial medication for hospital-acquired pneumonia treatment. The workplace shows commitment to both the regional and statewide guidelines by prescribing A. a seven-day antimicrobial treatment. However, the workplace does not pay regard to reducing the exposure to antibiotics.
Areas for Improvement
The analysis of the case of A. and various recommendations regarding hospital-acquired pneumonia treatment has shown that the workplace needs to concentrate on several growth areas for further HAC rate reduction. The barriers to the administration of evidence-based prevention and treatment strategies fall into three categories: nurses’ limited knowledge and expertise, unfavorable work conditions and incompetent human resource management (Atashi et al., 2018). The first category encompasses a range of smaller issues: professional attitude, lack of specialised knowledge and the lack of motivation, engagement and accountability. As the analysis of relevant guidelines has shown, they do not contain any discrepancies that could appear confusing to medical staff. Hence, the primary cause might lie in healthcare workers’ lack of personal initiative in studying legal texts and seeking ways to implement them. They might not be aware of the wide range of practices targeted at hospital-acquired pneumonia prevention, which is why they have only implemented a few of them.
The second category of barriers is the inadequate hospital environment. While the workplace has shown a high standard for hand hygiene and sterilisation of medical equipment, it was not able to provide A. with chest physiotherapy. Besides, vaccinations have not been widely available or even considered for patients such as A. These two facts imply that as it is right now, the workplace might not be conducive to effective strategy implementation. Lastly, some of the issues might stem from poor human resource management. The workplace is typically overwhelmed with patients, many of which suffer from severe conditions. Heavy workload and staff shortage mean the practical impossibility of paying attention to every single patient. Besides, human resource management at the workplace appears not to prioritise staff training that could propel the implementation of statewide guidelines.
Recommended Changes and Their Implementation
Inadequate hospital environment and poor human resources management would require a profound restructuring of the facility. Since hospital-acquired complications stem from a multitude of factors, addressing them might take recruiting a multidisciplinary team (MDT). The primary advantage of having an MDT at a facility is the complementary nature of each person’s expertise. Due to a variety of skills and knowledge, every member can provide a fresh perspective on a patient’s course of treatment. For instance, in the case of A., the medical staff did dismiss some of the critical factors. Had it been an MDT collaborating on A.’s case, there might have been better suggestions regarding pneumonia prevention. The effectiveness of having an MDT is grounded in hard evidence. For instance, Aoki et al. (2016) show that the presence of a multidisciplinary swallowing team decreases pneumonia onset in acute stroke patients. Such a team can identify the symptoms of dysphagia early on and take measures to protect a patient.
Another meaningful response to the problem described in the previous section is patient and caregiver education, which will address the deficient knowledge of both parties. For nurses, it can take the form of formal (organised sessions) and informal training (workplace mentorship). The focus should be on improving healthcare workers’ accountability and motivation to be proactive as opposed to being reactive and handling consequences. As for patients, they should be educated on host factors for developing hospital-acquired complications. For instance, A. could work on smoking cessation that would, in turn, serve as a relief for his COPD and bronchitis and make him less vulnerable to pneumonia. Hospital-acquired complications require a group effort of all stakeholders and scientific evidence to serve as a basis for bedside interventions.
Reference List
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The Clinical Excellence Commission n.d., Hospital acquired complications.
The Government of South Australia 2018, Hospital-acquired pneumonia & ventilator-associated pneumonia (adults) clinical guideline.