​With the exception of VAP, there is very little data and evidence regarding HAP. The grade of the evidence in many cases is low due to methodology, questions about generalizability from other settings or patient populations and other issues. In some instances, evidence may be upgraded based on low cost and feasibility of the intervention. The following suggestions are therefore evidence-informed practices.

Routine Precautions – All patients

Routine Practices and Additional Precautions for Preventing the Transmission of Infection in Healthcare Settings (Public Health Agency of Canada, 2012).

Healthcare-Associated Pneumonia

(Tablan et al., 2003; Davis, 2012)^;

1. Staff education and involvement in infection prevention.
2. Infection and microbiologic surveillance with data on local drug resistant pathogens.
3. Appropriate cleaning, sterilization or disinfection and maintenance of equipment, devices and environment.
4. Vaccinate staff and high risk patients (i.e. Flu shots).
5. Deep breathing exercises and ambulation.
6. Isolate infected patients as indicated.
7. Rapid screening with isolation as indicated.
8. Limit symptomatic staff and visitors.
9. Maintain intact, moist, and healthy oral lining and mucosa.
10. †Monitoring and early removal of invasive devices.
11. ^†Anti-microbial stewardship program.
12. ‡Swallow screens.
13. ^‡Lung expansion/mobilize.
14. ^‡Adequate nutrition.
15. ^‡Serum glucose in target range.
16. See prevention strategies for Aspiration Pneumonia.

Ventilator-Associated Pneumonia

(Safer Healthcare Now! 2012)

1. Elevation of the head of the bed to 45° when possible, otherwise attempt to maintain the head of the bed greater than 30° should be considered.
2. Daily evaluation of readiness for extubation.
3. The utilization of endotracheal tubes with subglottic secretion drainage.
4. Oral care and decontamination with Chlorhexidine.
5. Initiation of safe enteral nutrition within 24-48h of ICU admission.

^†[1]   Rotstein et al. 2008

‡   Quinn et al. 2014

Conduct Clinical and System Reviews (see details below)

Given the broad range of potential causes of this clinical group, in addition to recommendations listed above, we recommend conducting clinical and system reviews to identify latent causes and determine appropriate recommendations.

Clinical and System Reviews, Incident Analyses

Occurrences of harm are often complex with many contributing factors. Organizations need to:

1. Measure and monitor the types and frequency of these occurrences.
2. Use appropriate analytical methods to understand the contributing factors.
3. Identify and implement solutions or interventions that are designed to prevent recurrence and reduce risk of harm.
4. Have mechanisms in place to mitigate consequences of harm when it occurs.

To develop a more in-depth understanding of the care delivered to patients, chart audits, incident analyses and prospective analyses can be helpful in identifying quality improvement opportunities. Links to key resources for analysis methods are included in Resources for Conducting Incident and/or Prospective Analyses section of the Introduction to the Hospital Harm Improvement Resource.

Chart audits are recommended as a means to develop a more in-depth understanding of the care delivered to patients identified by the HHI. Chart audits help identify quality improvement opportunities.

Useful resources for conducting clinical and system reviews:

• Chart Audit Review Process (see Introduction to the Improvement Resource)
• Canadian Incident Analysis Framework
• CPSI Patient Safety and Incident Management Toolkit
• Institute for the Safe Medication Practices Canadian Failure Mode and Effects Analysis Framework
• Institute for Healthcare Improvement Failure Mode and Effects Analysis Tool