Pulmonary aspiration in a long-term care setting: clinical and laboratory observations and an analysis of risk factors.

OBJECTIVE: To determine the incidence and risk factors associated with aspiration in a high risk group in a long-term care setting. DESIGN: A prospective study of demographic, nutritional, clinical, dental, and survival characteristics in 69 patients who suffered 98 aspirations events from May 1, 1990, to December 31, 1990. Demographic and nutritional data from 192 patients who did not aspirate were collected from September 1991 to December 1991. SETTING: A long-term care VA facility. PATIENTS: Long-term care residents, most of whom were neurologically debilitated. MEASUREMENTS: The incidence of aspiration was measured and the clinical and microbiological characteristics of aspiration-associated nosocomial pneumonia described. Mortality and demographic, clinical, and nutritional characteristics were compared between patients who aspirated and those who did not. MAIN RESULTS: Twenty-five percent of the study group aspirated during the 8-month observational period, and 56% of the aspiration events progressed to roentgenographically proven cases of nosocomial pneumonia. Six bacteremic episodes were documented, and results of sputum cultures were consistent with mixed Gram-positive and Gram-negative infections. During the study period, patients who aspirated were at three times the risk of dying compared with patients who did not aspirate. Three years later, only 17% of the original group of patients who aspirated were still alive compared with 60% of the patients who had not aspirated. Multivariate analysis identified tube feeding, presence of a hyperextended neck or contractions, malnutrition, and the use of benzodiazepines and anticholinergics as risk factors. CONCLUSIONS: Pulmonary aspiration is a common and serious event in neurologically impaired long-term care patients. Some risk factors are amenable to change.

A retrospective study of nosocomial pneumonia at a long-term care facility.

BACKGROUND: Results of a passive surveillance system (pneumonia confirmed by x-ray examination) suggested that in 1989 a total of 187 cases of nosocomial pneumonia had occurred at the Canandaigua Veterans Administration Medical Center among 250 long-term care patients. METHODS: A retrospective study was undertaken to validate cases and to enumerate risk factors. A chart review showed that 136 of 187 cases (72%) met predetermined criteria for nosocomial pneumonia. RESULTS: Three nursing units characterized as at high risk had a pneumonia rate of 1.90 per 1000 patient days, as compared with a rate of 0.70 cases per 1000 patient days on the two other units. There were no differences in age, mean white blood cell count, or clinical symptoms between high- and average-risk patients. Two thirds of all patients had a history of chronic aspiration. High-risk patients were more likely to be confined to bed, to have a debilitating neurologic disease, and to require tube feedings. Twenty percent of patients on high-risk units died of nosocomial pneumonia or with nosocomial pneumonia as a contributory factor. CONCLUSIONS: Facility-associated pneumonia is an important cause of morbidity and mortality in long-term care facilities.