September-October 2012 • Vol. 21/No. 5 303

Ilia M. Echevarria, MS, MSN, RN, CHES, CCRN, NEA-BC, is Administrative Director of CriticalCare and Inpatient Services, Virtua, Marlton NJ. She was Interim Director of Education,Pennsylvania Hospital, Philadelphia, PA, at the time this article was written.

Ann Schwoebel, MSN, CRNP, RNC-NIC, is Clinical Nurse Education Specialist, Intensive CareNursery, Pennsylvania Hospital, Philadelphia, PA.

Acknowledgment: The authors would like to acknowledge David O’Brien, MSN, RN, ClinicalNurse Education Specialist, Orthopedics, Pennsylvania Hospital, Philadelphia, PA.

Development of an InterventionModel for the Prevention of

Aspiration Pneumonia in High-RiskPatients on a Medical-Surgical Unit

Aspiration pneumonia is apulmonary infectious pro -cess that results from theinhalation of oropharyn-

geal or gastric contents into the lungs(Shigemitsu & Afshar, 2007). Pul -monary aspiration is a focal cause ofserious illness and death amongpatients in hospitals and nursinghomes, and is associated with signifi-cantly higher hospital costs (Marik,2011). Because this disease is pre-ventable, efforts to minimize itsoccurrence have surfaced in institu-tions across the United States. Therecommended preventive measuresare two-fold: identify high-riskpatients and implement evidence-based practices to prevent occur-rences. Another key element of theprocess is timing. The early identifi-cation of high-risk patients is a criti-cal element affecting patient out-come (Yokoe et al., 2008).

The purpose of this article is todescribe an intervention model forthe prevention of aspiration pneu-monia implemented at an urbanteaching hospital in the northeast-ern United States. This included thedevelopment, implementation, andevaluation of an assessment tool foridentifying medical-surgical inpa-tients at high risk for developingaspiration pneumonia, as well as anaspiration pneumonia preventionprotocol.

Background

Literature ReviewAspiration pneumonia, a pul-

monary infectious process, is associ-

ated with significantly higher mor-bidity and mortality rates, accompa-nied by high health care costs(Osborne, Gardner, Franklin, Tuohy,& Fisher, 2006). Mortality rates fromaspiration pneumonia range from20% to 65% (Eisenstadt, 2010).Pneumonia can be classified ascommunity-acquired or nosocomi-al. Community-acquired pneumo-nia develops in non-hospitalizedindividuals of all ages, and accountsfor 10% of aspiration pneumoniacases (Shigemitsu & Afshar, 2007).Nosocomial pneumonia, a healthcare-associated infection, developsin patients during their hospitaliza-tion frequently in intensive careunits, especially in patients intubat-ed for more than 48 hours.Incidence is approximately 20%with 10-15 cases per 1,000 days of

mechanical ventilation (Torres &Rello, 2010). When nosocomialpneumonia presents in mechanical-ly ventilated patients, it is known asventilator-associated pneumonia. It isassociated with 25%-50% mortalityand an estimated cost of more than$40,000 per episode (Deutsch,Hockey, Rosenblaum, & Gurman,2010). The Centers for DiseaseControl and Prevention (CDC, 2012)estimates health care-associatedinfections develop in approximately1 of every 20 hospitalized patients. Asa result, prevention of hospital-asso-ciated infections is a national priority(Yokoe et al., 2008).

Aspiration may manifest itself ascoughing and choking while eatingor drinking, as well as by drooling,gurgling sounds when speaking, orhoarseness. Silent aspiration, or aspi-

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Ilia M. EchevarriaAnn Schwoebel

Aspiration pneumonia is associated with significantly high morbidityand mortality rates, accompanied by high health care costs. As aresult, aspiration pneumonia preventive efforts are a national priori-ty. The development of an intervention model for the prevention ofaspiration pneumonia in high-risk medical-surgical inpatients at anurban teaching hospital is described. The intervention model consistsof the implementation and evaluation of a risk assessment tool anddevelopment of an aspiration pneumonia prevention protocol.

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ration without symptoms, also mayoccur and is even more difficult todetect (Eisenstadt, 2010; Marik,2011). Aspiration of substances, suchas food, tube-feeding formula, saliva,or vomitus, into the respiratory tractcan lead to aspiration pneumonia(Shigemitsu & Afshar, 2007).

Dysphagia, defined as impairmentof any part of the swallowingprocess, increases the risk of aspira-tion. Dysphagia and aspiration areassociated with the development ofaspiration pneumonia (Metheny etal., 2006). The ability to swallowsolid food and liquids depends onthe interplay of some 50 pairs ofmuscles in the head and neck. Whilesome changes in swallowing arerelated to aging, dysphagia often isassociated with or caused by neuro-logic impairment, which can inter-fere with the proper function ofthese muscle groups and in turninterfere with the closure of the lar-ynx when food or liquid reaches theback of the tongue (NationalInstitute of Neurological Disordersand Stroke [NINDS], 2010). Thesesubstances then can enter the tra-chea and lungs.

Older adults, especially those withneurologic conditions such as stroke,Parkinson’s disease, dementia, andmultiple sclerosis, are at risk for dys-phagia and aspiration (NINDS,2010). Patients who have decreasedalertness because of medications,medical conditions, or a combina-tion of these conditions may haveslowed gag and swallowing reflexesand therefore may be less able torespond to regurgitation and vomit-ing. Also, because chewing preparesfood for swallowing, the absence ofteeth or the presence of poorly fitteddentures increases the risk of aspira-tion. Poor oral hygiene promotes thegrowth of pathogenic organisms inthe mouth, thereby increasing therisk of aspiration pneumonia (Marik,2011; Pace & McCullough, 2010).

Reports of the prevalence of dys-phagia vary with study population,diagnosis, and treatment. Dysphagiain older adults is increasingly com-mon, with more than 10% of adultsover age 50 reporting some degree ofswallowing dysfunction (Andrews,Fraser, Heddle, Hebbard, & Checklin,

2008). In nursing homes, 50%-75%of residents have dysphagia; of thispopulation, half will aspirate andone-third will develop pneumonia(Eisenstadt, 2010). “Dysphagia isclinically present in 42% to 67% ofpatients within the first 3 days ofstroke, and the incidence of aspira-tion within the first 5 days rangesfrom 19.5% to 42%” (Trapl et al.,2007, p. 2948). As a result of thesestatistics, the early identification ofconditions and co-morbiditieswhich contribute to dysphagiabecame the main component in theauthors’ aspiration risk assessmenttool, and a point of interest for theprotocol.

Aspiration pneumonia representsa significant proportion of all pneu-monia cases. It is a common cause ofrespiratory illness and death in eldersand debilitated patients, and usuallyaffects older hospitalized adultpatients who have one or more majoraspiration risk factors (Altman, 2011;Paintal & Kuschner, 2007). Major riskfactors include increased age, stroke,altered mental status, poor oralhygiene, and gastroesophageal refluxdisease (Shigemitsu & Afshar, 2007).

In 1981, due to the high morbidi-ty and mortality associated withhealth care-associated pneumonia,the CDC published the first guide-lines for the prevention and controlof aspiration pneumonia. Sincerelease of the guidelines, several revi-sions and expansions have beenmade. The most recent revision pro-vides detailed recommendations forthe prevention of health care-associ-ated bacterial pneumonia (CDC,2004). Numerous acute care hospi-tals have adopted the guidelines inhope of eradicating or minimizingnosocomial pneumonia rates.

Early screening for the detection ofaspiration risk factors is a vital ele-ment for the prevention of pneumo-nia. Screening can occur via variousmethods, such as at the patient’s bed-side (simple preliminary exams or for-mal bedside swallowing assessments),under videofluoroscope, or throughfiberoptic endoscopic examination(Bours, Speyer, Lemmens, Limburg, &Wit, 2009). The type of screeningdepends on the patient’s individual-ized treatment plan. Screening for

dysphagia under videofluoroscopehas been considered the gold stan-dard for assessing swallowing ability(Bours et al., 2009). However, limita-tions or contraindications to thisinvasive procedure may necessitate aless-invasive bedside screeningapproach. In addition, waiting timesfor invasive procedures can be long,and patients can benefit from pre-vention strategies that are imple-mented far earlier.

Trapl and co-authors (2007) sug-gested most screening tools are com-plex and biased toward fluid swal-lowing. They developed a simple,stepped bedside screen, the GuggingSwallowing Screen (GUSS). TheGUSS allowed a graded rating withseparate evaluations for nonfluidand fluid nutrition, beginning withnonfluid textures. The GUSS aimedto decrease the risk of aspiration dur-ing the test to a minimum, whileallowing the severity of aspirationrisk to be assessed. The validity of theGUSS was established by fiberopticendoscope. It is deemed to be aquick, reliable method to identifypatients with stroke, dysphagia, andaspiration risk at the bedside.

Cichero, Heaton, and Bassett(2009) developed another approachto screen patients with dysphagia orthose at risk of aspiration on admis-sion to an acute hospital. Theprospective, quasi-experimental trialwas conducted to investigate the uti-lization of a tool that consisted of atwo-phase question screen, a waterswallow test, and a swallowing man-agement plan. Results suggested thedsyphagia screening tool is a quick,robust tool for triaging individualswith dysphagia.

While the procedures described inthese studies allow identification ofmany risk factors associated with anaspiration risk, common risk factorssuch as dysphagia can be identifiedearly through proper screeningmethods. This early identificationfurther leads to the implementationof preventive measures to reduceoccurrences. It thus was the drivingforce for this program.

Organizing FrameworkThe Quality Health Outcomes

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Development of an Intervention Model for the Prevention of Aspiration Pneumonia in High-Risk Patients on a Medical-Surgical Unit

Model (QHOM) served as the organ-izing framework for the interventionmodel to be described in this article(Mitchell, Ferketich, & Jennings,1998). The model is ideal for thisproject because it provides a frame-work for studying the quality ofhealth care and describes relation-ships among interventions, patientcharacteristics, health care systemcharacteristics, and patient out-comes. The early identification ofpatients at high risk for developingaspiration pneumonia can lead toimplementation of an aspirationprotocol. Placement of the protocolallows execution of appropriateinterventions to minimize potentialfor developing an aspiration occur-rence. This process should lead toimproved patient and hospital out-comes.

Needs AssessmentIdentification of a need for an

intervention model became evidentafter the third quarter 2007, whenthe number of pneumonia cases inthe medical-surgical settings in -creased from none in the previoustwo quarters to three cases in thepreceding two quarters. In 2007,three pneumonia cases were docu-mented, compared to 10 cases forcalendar year 2008. This representeda 70% increase in total annual cases

(see Figure 1). Data indicated anincrease in aspiration occurrences inthe medical-surgical setting. Theseoccurrences further led to longerhospital stays, as patients were intu-bated routinely and transferred tothe intensive care unit. Infectionsoccurred randomly in multiple med-ical surgical units.

Program Plan

PlanningA sub-committee was formed

under the auspices of the hospital’sexisting Ventilator-Associated Pneu -monia Committee. The AspirationPrecaution Committee was com-prised of an interdisciplinary groupwhich included representatives fromnursing, pharmacy, infection preven-tion, medicine, nutrition, perform-ance improvement, and speech thera-py. Staff from Nursing Educationserved as team leaders.

The primary responsibility of thecommittee was to develop an assess-ment tool which would promote theeasy identification of non-ventilatedpatients at high risk for aspiration,and to develop an interventionmodel to facilitate utilization of thetool. As a result, the Aspiration Pneu -monia Risk Assessment Screen ingTool and Aspiration PrecautionProtocol (see Figures 2 & 4) were

crafted. These tools, which weredeveloped after an extensive litera-ture review, were major componentsof the intervention model. Whilethe purpose of the assessment toolwas to identify patients at risk foraspiration, the resulting protocol wasdesigned to promote the implemen-tation of strategies to reduce identi-fied risks. During development, thetool was revised and reformatted sev-eral times due to feedback receivedfrom the committee members beforeits pilot implementation.

Model ImplementationAfter the committee finalized the

three-phase intervention model, thetool was piloted on a neurosurgery/orthopedic medical-surgical unit.The choice of this unit for the pilotwas based on the unit’s high-riskpatient population. The interven-tion model commenced in first quar-ter 2009 and was piloted over 4months (see Figure 3). Imple -mentation of the model occurredover three phases. Phase One consist-ed of one-on-one training for properfeeding methods provided by a hos-pital-based speech therapist. Allpatient-care technicians (nursingassistants) on the trial unit, and anumber of adults from the hospital’svolunteer program, attended thetraining. Participants were trainedon proper feeding and positioning

FIGURE 1. Pneumonia Infections in the Medical Surgical Settings: Pre-Intervention

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01st Qtr-07 2nd Qtr-07 3rd Qtr-07 4th Qtr-07 1st Qtr-08 2nd Qtr-08 3rd Qtr-08 4th Qtr-08 1st Qtr-09

0

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4

3 3

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Trial beginsIndentified need

Planning committee in place

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techniques, and identification ofpatients who demonstrated signs ofdysphagia and/or aspiration. Thistraining, aligned with the AspirationPrecaution Protocol, suggests apatient who is placed on the proto-col be assisted and monitored close-ly during meals.

Phase Two included educationabout the program objectives, back-ground and overview of the pro-gram, and proper utilization of thenew Risk Assessment Screening Tooland Aspiration Protocol. Educationwas provided by the clinical nurseeducator to all unit professional staff.With the intent of expanding theprogram after the trial completion,education was expanded to includeall medical-surgical registered nursesand patient care technicians. PhaseThree of the intervention modelinvolved the development and revi-sion of patient education material

for distribution to patients and fam-ilies during program implementa-tion.

During the trial period, allpatients received an aspiration riskassessment on admission to the unit.If a patient was identified as at high

risk, as noted by the indicators onthe Risk Assessment Screening Tool,the nurse would initiate theAspiration Precaution Protocol andcomplete the second part of thescreening tool (the FunctionalAssessment) (see Figure 2). The

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FIGURE 2.Aspiration Pneumonia Risk Assessment Tool

NEUROLOGIC:■ Decreased level of consiousness■ Diagnosis of history of stroke with residual■ Neurodegenerative disease (ALS, Parkinson’s)

GASTROINTESTINAL■ Unable to perform oral hygiene■ Full assist with meals (requires help eating)■ Presence of a nasal, gastric, or feeding tube

RESPIRATORY■ Tracheostomy

■ NONE OF THE ABOVE APPLY Initials: ______

Risk Assessment: Check all that apply

■ Difficulty maintaining sustained level of alertness■ Shortness of breath or oxygen desaturation dur-

ing or after oral intake■ Difficulty chewing or sealing lips around cup,

straw, or utensil■ Gagging or coughing during oral intake■ Voice changes/wet sounding voice during oral

intake

■ NONE OF THE ABOVE APPLY Initials: ______

Functional Assessment: Check all that apply

If ONE or more indicators are checked: ➣ Initiate Aspiration

Precaution Protocol➣ Complete Functional

Assessment

If ONE or more indicators are checked: ➣ Maintain Aspiration

Precautions Protocol➣ Remove all foods and liquids➣ Initiate NPO status➣ Consult Speech Pathology

Date: _______ Initials: _______

FIGURE 3.Pneumonia Infections on the Trial Medical-Surgical Unit

After Intervention

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01st Qtr-09 2nd Qtr-09 3rd Qtr-09 4th Qtr-09 1st Qtr-10

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Functional Assessment provided amore in-depth evaluation of anyidentified risk factors. If a patientdemonstrated one or more criteriaon the Functional Assessment (e.g.,pockets food while eating), the nursewould maintain the AspirationPrecaution Protocol and initiate anNPO status (nothing by mouth) anda speech pathologist consultation.

EvaluationA formative evaluation of the

intervention model was performedduring the trial period. Nursing staffwas asked to provide feedbackregarding ease, usability, and accura-cy of the newly developed RiskAssessment Tool in addition to othercomponents of the interventionmodel. Verbal feedback was providedto the clinical nurse educator inmeetings and through interviews. Aspart of the evaluation period, weeklyaudits were performed to determineadherence to the model. Data col-lected included compliance inregards to use of tool, and appropri-ate utilization of the tool.

Early audits indicated a high per-centage of patient placements on theAspiration Precaution Protocol. Dur -ing the first 2 months, while only 31patients met diagnostic criteria forplacement on Aspiration Precau -

tions, 49 patients were placed onprecautions. During the evaluation,the need for an ongoing assessmentin addition to the admission screen-ing was identified. Patients who werenot deemed at high risk upon admis-sion to the unit potentially coulddevelop new risk factors based ontheir diagnosis (e.g., postoperativestatus). To capture this patient popu-lation, staff conducted daily surveil-lance to determine ongoing risks foraspiration. This information wasrelayed to the charge nurse and doc-umented on a daily log.

DiscussionUtilization of the QHOM as the

organizing framework during themodel’s implementation allowed forprocess restructuring. Nurses wereable to identify the significance ofhaving all model componentsaddressed and implemented. Forexample, allowing nurses to providefeedback regarding the RiskAssessment Tool led to a vital revi-sion of the tool. When performingthe risk assessment, nurses identifiedthe need to have a concrete way ofdocumenting implementation of theAspiration Precaution Protocol onpatients who met the criteria, and if

warranted, that a speech pathologyconsult was placed. The nursing staffsuggested initialing the form wheninitiating the Aspiration PrecautionProtocol and a speech pathologyconsultation.

The main challenge of the inter-vention model has been achievingconsistency and compliance withfeeding assistance for patients placedon the Aspiration PrecautionProtocol. This is primarily due to lackof personnel resources. As part of theAspiration Precaution Protocol,patients are required to have assis-tance with all meals and be moni-tored closely. Because team leadersknew this component would provechallenging due to issues associatedwith staffing and high patient-nurseratios, part of the intervention modelconsisted of utilization of the hospi-tal’s volunteers to assist with thisprocess. Unfortunately, the numberof patients needing assistance mayexceed personnel available to help.

In spite of these challenges, thedevelopment of this interventionmodel proved to be successful onvarious levels. The multidisciplinarycollaboration and the formativeevaluation, which allowed for feed-back during the trial, were two keysto its success. Since implementationof the model on the trial unit, nocases of non-ventilator-related aspi-ration pneumonia have occurred. Asa result of these outcomes, themodel was extended to all medical-surgical areas. Other positive out-comes of this project includeincreased awareness of aspirationrisk factors among nurses andpatient care technicians, increasedpatient and family education regard-ing the pulmonary infectiousprocess, and improved collaborationamong disciplines.

Implications for PracticeWith vast supporting evidence

that sustains the detrimental effectsof aspiration pneumonia to both thepatient and the health care organiza-tion, efforts to prevent occurrencesare warranted. For this project, anevidenced-based screening tool andcare protocol were developed toidentify patients at high risk for aspi-

Development of an Intervention Model for the Prevention of Aspiration Pneumonia in High-Risk Patients on a Medical-Surgical Unit

FIGURE 4.Aspiration Precaution Protocol

■ Aspiration Precaution Protocol Implemented: RN Signature: ___________________________________ Date: ___________

• “Aspiration Precautions” should be documented on the patient’s Kardex/reportsheet and communicated during hand-off communication.

• Place “SWALLOWING PRECAUTIONS” sign above the patient’s bed.

• Maintain HOB at 45 degrees or higher at all times, unless otherwise contraindi-cated. (If patient’s head of bed is flat, maintain tube feedings off.)

• Maintain HOB at 90 degrees when eating or drinking. If eating, patient must beassisted with all meals and observed closely during meals.

• Maintain operating suction readily available.

• Provide oral care each shift.

• If NPO, place NPO sign over bed.

• Provide patient and/or family with education regarding aspiration precautions,and educational hand-outs.

• If patient suspected to have aspirated, notify physician immediately and initiatespeech pathology consult.

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ration and implement appropriatepreventative interventions. The deci-sion to focus efforts on screening wasmade as a direct result of supportingevidence that suggested early detec-tion of aspiration risk factors as avital element in the prevention ofaspiration pneumonia.

Protocols, clinical pathways, andscreening tools are examples ofprocesses which have improvedstandardization for the identifica-tion, assessment, and treatment ofhospitalized patients with dysphagia(Altman, 2011). An example of ahighly recognized successful screen-ing tool which has been utilizedwidely in nursing is the Morse FallsScale (Harrington et al., 2010). Thistool allows for the rapid assessmentof a patient’s likelihood of falling,and offers prevention strategies tar-geted to the risk identified. Manyother recognized treatment flow-charts are utilized to support bestpractice standards by providing evi-denced-based interventions in themanagement and/or prevention ofpatient disease. Health care leadersneed to focus efforts on preventivemeasures as a necessity of effectivepractice.

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Andrews, J.M., Fraser, R.J., Heddle, R,Hebbard, G., & Checklin, H. (2008). Isesophageal dysphagia in the extremeelderly (>80 years) different to dysphagiayounger adults? A clinical motility audit.Diseases of the Esophagus, 21, 656-659.

Bours, G., Speyer, R., Lemmens, J., Limburg,M., & Wit, R. (2009). Bedside screeningtests vs. videofluroscopy or fiberopticendoscopic evaluation of swallowing todetect dysphagia in patients with neuro-logical disorders: Systemic review.Journal of Advanced Nursing, 65, 477-493.

Centers for Disease Control and Prevention(CDC). (2004). Guidelines for the preven-tion of health-care-associated pneumo-nia. Retrieved from http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5303a1.htm

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Osborne S., Gardner, G., Franklin, S., Tuohy,E., & Fisher, A. (2006). Using a moni-tored tip sip test to assess risk of aspira-tion in postoperative patients. AORNJournal, 83(4), 908-927.

Pace, C., & McCullough, GH. (2010). Theassociation between oral microorgan-isms and aspiration pneumonia in theinstitutionalized elderly: Review and rec-ommendations. Dysphagia, 25, 307-322.

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Yokoe, D., Mermel, L., Anderson, D., Arias, K.,Burstin, H., Calfee, D., & Classen, D.(2008). A compendium of strategies toprevent healthcare-associated infectionsin acute care hospitals. Infection Controland Hospital Epidemiology, 29, S12-S21.

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