INTRODUCTION

Nurses are taught early on that, in an emergency, focus should be placed on maintaining the patient’s ABCs: airway, breathing, and circulation. Yet, without the proper tools available, the patient’s airway may not be fully cleared, or there may be a delay in doing so. This puts the patient at risk for aspiration of foreign matter into the lungs and airway.

When aspiration occurs, various pulmonary complications can result. Two of the most significant are aspiration pneumonia and aspiration pneumonitis. Aspiration pneumonia develops when pathogenic microorganisms enter the lungs as a result of inhaling secretions from the mouth and upper airways. Aspiration pneumonitis occurs when the lungs are chemically injured from inhaling large amounts of gastric contents as a result of vomiting.i

Another type of pneumonia, called ventilator-associated pneumonia (VAP), is a common health­care-associated infection. It develops after a patient has been mechanically ventilated for 48 hours or longer. VAP has been shown to lead to longer ICU stays and higher hospital costs.ii

Recent studies have suggested, however, that aspiration prior to intubation may have a correlation with later diagnosis of VAP.ii-iv This paper will discuss the importance of portable emergency suction as a critical tool in preventing aspiration and its subsequent complications.


aspiration-pneumonia-introudction-1

 

WHAT DEFINES "IMPROVED PATIENT OUTCOMES?"

More and more, emphasis is being placed on using evidence-based practices in order to guide patient care. Simply put, this means applying the best available researched literature to clinical decision-making in order to improve care processes and patient outcomes.v

“Improved patient outcomes” can mean many different things depending on the type of illness or injury, healthcare provider goals, or patient goals. For the purpose of this paper, “improved patient outcomes” will refer to the avoidance of pneumonia, which of­ten results in a shorter hospital stay and decreased time receiving mechanical ventilation.

IMPROVED PATIENT OUTCOMES = Avoidance of Pneumonia

ASPIRATION AND PATIENT OUTCOMES

Certain patients are at higher risk of aspiration, including those with decreased level of consciousness, compromised airway protection, difficulty swallowing, gastroesophageal reflux, and frequent vomiting. Based on these characteristics, it is evident that many patients who are experiencing a medical emergency, such as cardiac arrest, have the potential to aspirate. In fact, several studies have been done to examine pre-hospital and emergency intubation of patients and have found an association between aspiration before or at the time of intubation and the subsequent development of pneumonia. In a retrospective study of trauma patients, data was reviewed from 197 adult patients who were intubated prior to admission to a Level I trauma center. Information from the peri-intubation period was provided, including vital signs, medications, use of bag-valve mask, and presence of foreign material in the airway.iii

Of the 197 patients, 32 (16.2%) developed pneumonia. These patients were noted to have vomit present in their airway at the time of intubation three times more often than those who did not develop pneumonia. The patients with pneumonia also had longer hospital stays and a greater incidence of reintubation.iii

PATIENTS

In this study, the patients’ pneumonia was classified as VAP. However, it was noted that diagnosis of aspiration pneumonia in trauma patients is hard to distinguish from VAP and that patients who aspirate prior to intubation may actually be misdiagnosed with VAP.iii

Similarly, Decelle et al. attempted to identify risk factors for the evelopment of VAP following emergent intubations. Patients who were intubated pre-hospital or while in the emergency room and were later admitted to the ICU were included in the study. Fifteen of the 75 patients (20%) who fit the criteria developed VAP. Analyzing various factors revealed that the observation of macroaspiration at the time of intubation was one of three independent variables associated with later diagnosis of VAP. Cardiac arrest and out-of-hospital intubation were the other two.iv

A study done by Fawcett et al. also supports this. Paramedics were asked to collect data regarding patient aspiration at the time of intubation. Eighty-nine of the 228 (39%) patients were noted to have aspirated, and 14 of those patients (16%) went on to develop pneumonia. However, only five of the 139 patients who didn’t aspirate (3.6%) later developed pneumonia, suggesting that aspiration prior to intubation resulted in an increased risk of pneumonia.v

197
PATIENTS
-
32 developed pneumonia
vomit present in their airway at time of intubation three times more often

 

aspiration-pneumonia-patients

 

89/228 Aspirated Prior to Intubation
Developed Pneumonia = 14

VS

139/228 Didn’t Aspirate Prior to Intubation
Developed Pneumonia = 5

 

 

HOW PORTABLE EMERGENCY SUCTION CAN HELP

Clearly, removing foreign material from the oropharynx before it can be aspirated into the lungs is vitally important in decreasing the incidence of pneumonia. In an emergency, priority must be given to clearing the airway, and this is for more than just the immediate need to remove secretions, allowing the vocal cords to be visualized for intubation. Suctioning should also be viewed as an important preventative measure to avoid pneumonia and other patient complications in the days that follow.

Most hospitals have in-wall suction available. However, a portable suction unit has many unique benefits. Should an emergency occur away from the bedside, this device can be brought quickly and easily to the patient’s side, at a time when seconds can make a difference. In the case of utility failure or failure of the in-wall system, a portable suction unit provides necessary back up. For small or rural hospitals without in-wall suction, portable units may provide the only means of performing this essential task.

Nurses should recognize the types of patients and situations where there is a high risk of aspiration. Whether it’s a patient arriving in the emergency room after a motor vehicle accident, a code in the ICU for sudden cardiac arrest, or an elderly patient on the floor who has difficulty swallowing, aspiration can occur in many different settings. Yet, being proactive and prepared with a portable suction device will provide the ability to remove secretions, vomit, or other obstructions without unnecessary delay.

Per ACLS guidelines, portable and installed suction units should be available as needed during resuscitations. Suction tubing should be large-bore and free from kinks, and collection bottles should be resistant to breaking. Both semi-rigid and flexible suction catheters, as well as sterile water, should be accessible. Vacuum strength should be adjustable for children and intubated patients.vi

Just as important as having the proper portable emergency suction device available is ensuring that it is in working order. Units should be routinely inspected for proper charge/ working batteries; appropriate vacuum level; free, undamaged tubing and canister; and correct assembly. Inspections should be documented. Though complications tend to be infrequent, as an important tool in airway management, these devices must be well maintained.vii

 

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S-SCORT III portable suction for ems

 

FROM VOLUME-BASED TO VALUE-BASED CARE

Recent healthcare reform is changing the practice of medicine. Rather than focusing on the quantity of patients seen and procedures that are performed, emphasis is being placed on improving the quality and outcomes of patient care per dollars spent.viii

More effort is going into prevention, wellness, and health maintenance. Additionally, reimbursement under a value-based care model generally occurs in the form of bundled payments, meaning hospitals and healthcare providers receive a single payment for all services provided for treating a medical condition. This strategy aims to make providers accountable for the quality and cost of their services.ix

Taking it a step further, initiatives such as the Hospital Value-Based Purchasing Program reward hospitals with incentive payments for providing high-quality care to Medicare patients. Hospital performance is judged along various domains, including Clinical Process, Patient Experience, Outcomes, Efficiency, and Safety. Scores are given for achievement and improvement across these domains. Incentive payments will then be provided to hospitals based on their scores. Two other initiatives, the Hospital-Acquired Condition Reduction Program and the Hospital Readmissions Reduction Program, penalize hospitals with reductions in their Medicare payments for high rates of healthcare-associated infections and 30-day readmissions.x

Nursing care plays an important role in this. By implementing evidence-based practices, nurses have a direct impact on the prevention of healthcare-associated infections and improved patient outcomes.

The occurrence of pneumonia, for example, is one of the performance measures used in order to determine Medicare payments. When nurses take the steps to avoid patient aspiration, such as suctioning the airway, they are decreasing the likelihood of their patients developing pneumonia. This has positive implications for the patient, as well as the hospital.

 

CONCLUSION

Nurses should always strive to improve the quality of care that they provide to their patients, and with the change to value-based care, this is more important than ever. The availability and appropriate use of portable emergency suction will result in fewer occurrences of aspiration and complications like pneumonia that can result.5

i Hu, X., Lee, J. S., Pianosi, P. T., & Ryu, J. H. (2015). Aspiration-Related Pulmonary Syndromes. Chest, 147(3), 815- 823. Retrieved April 3, 2016, from http://www.sciencedirect.com/science/article/pii/S001236921539680X

ii Koenig, S. M., & Truwit, J. D. (2006). Ventilator-Associated Pneumonia: Diagnosis, Treatment, and Prevention. Clinical Microbiology Reviews, 19(4), 637-657. Retrieved April 4, 2016, from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1592694/ 

iii Evans, H. L., Warner, K., Bulger, E. M., Sharar, S. R., Maier, R. V., Cuschieri, J. (2011). Pre-Hospital Intubation Factors and Pneumonia in Trauma Patients. Surgical Infections, 12(5), 339-344. Retrieved April 4, 2016, from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3607967/

iv Fawcett, V. J., Warner, K. J., Cuschieri, J., Copass, M., Grabinsky, A., Kwok, H., Evans, H. L. (2015). Pre-Hospital Aspiration Is Associated with Increased Pulmonary Complications. Surgical Infections, 16(2), 159-164. Retrieved April 4, 2016, from http://www.ncbi.nlm.nih.gov/pubmed/24896218

vi Neumar, R. W., Otto, C. W., Link, M. S., Kronick, S. L., Shuster, M., Callaway, C. W., Morrison, L. J. (2010). Part 8: Adult Advanced Cardiovascular Life Support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation, 122(18_suppl_3). Retrieved April 4, 2016, from http://circ.ahajournals.org/content/122/18_suppl_3/S729.long

vii Risavi, B. L., Sabotchick, K. J., & Heile, C. J. (2013). Portable Suction Unit Failure in a Rural EMS System. Prehospital and Disaster Medicine Prehosp. Disaster Med., 28(04), 388-390. doi:10.1017/s1049023x13000393

viii Porter, M. E. (2009). A Strategy for Health Care Reform — Toward a Value-Based System. New England Journal of Medicine N Engl J Med, 361(2), 109-112. doi:10.1056/nejmp0904131

ix Hospital Value-Based Purchasing Program Fact Sheet. (n.d.). Retrieved April 7, 2016, from http://www.cms.gov/ Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Hospital_VBPurchasing_Fact_ Sheet_ICN907664.pdf

x Yakusheva, O., PhD, Lindrooth, R. C., PhD, Weiner, J., MPH, Spetz, J., PhD, FAAN, & Pauly, M. V., PhD. (2015, November). How Nursing Affects Medicare’s Outcome-based Hospital Payments. Retrieved April 7, 2016, from http:// ldi.upenn.edu/brief/how-nursing-affects-medicare’s-outcome-based-hospital-payments