QUERI – Quality Enhancement Research Initiative

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Hospital Acquired Pneumonia Prevention by Engaging Nurses

Salem, VA


Project HappenHospital-acquired pneumonia is one of the leading hospital-acquired infections in U.S. hospitals (Magill, 2014). Further, non-ventilator associated hospital-acquired pneumonia (NV-HAP) occurs more often than ventilator associated pneumonia with similar mortality, extended length of hospital stay, and increased costs (Davis, 2012). Given the association between oral biofilm and the development of pneumonia, VA investigators utilized interdisciplinary partnerships (e.g., dental, nursing, and medicine) to assess the effectiveness of a standardized oral care protocol on the prevention of NV-HAP among hospitalized Veterans. When consistently delivered, oral care targets bacterial multiplication, thus reducing the risk of NV-HAP.

A national VA oral care dissemination and implementation toolkit – Hospital Acquired Pneumonia Prevention by Engaging Nurses (HAPPEN) – was developed to ensure staff have the resources needed for success. Findings from the eight pilot sites demonstrated the effectiveness of the oral care intervention preventing an expected 256 cases with a cost avoidance estimate of $10.2M and 46 lives saved (July 2019).  

With the support of the Diffusion of Excellence Initiative and operations partners, HAPPEN is spreading across the nation. The QUERI Hospital Acquired Pneumonia Prevention by Engaging Nurses (HAPPEN) Partnered Evaluation Initiative will implement repeatable, scalable methods for measuring the successful adoption of HAPPEN and continually evaluate the quality of implementation at each facility and its impact on clinical and financial outcomes, identify emerging trends, and discover strategies to promote sustainment.


The partnership between QUERI and the Diffusion of Excellence also will determine if expansion to additional sites is associated with reductions in NV-HAP by:

  • Evaluating performance gaps and the quality of implementation;
  • Exploring healthcare provider, patient, and organizational barriers, challenges, and facilitators that predict reduced NV-HAP rates;
  • Determining the effect of implementing NV-HAP case tracking and consistent inpatient oral care on the incidence of NV-HAP and other health outcomes during the phased nationwide roll-out (stepped wedge design); and
  • Calculating the return on investment of HAPPEN.

Anticipated Impacts

HAPPEN is expected to reduce the risk of NV-HAP and improve Veterans’ quality of life and health; it also will modernize systems/processes with a focus on preventive care and improve access and timeliness of service through reductions in length of stay. Thus far, each facility that has implemented this practice has seen immediate drops in pneumonia rates and associated healthcare costs.

Corresponding Principal Investigator: Shannon Munro, PhD, APRN, BC, FNP
  Contact Project HAPPEN at VAHAPPEN@va.gov .

Operations Partners: VA Innovation Ecosystem, Office of Discovery, Education, and Affiliated Networks (Diffusion of Excellence), the VHA Office of Nursing Services, the VHA Office of Dentistry, and the VHA Office of Rural Health (ORH).