QUERI – Quality Enhancement Research Initiative

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QUERI E-news
November 2019

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Preventing Hospital-Acquired Pneumonia through Improved Oral Hygiene

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.

Hospital-acquired pneumonia (HAP) 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.

[Oral bacteria form dental biofilm; for example, dental plaque is a poly-microbial biofilm that can cause human infections. Biofilm can be linked to respiratory infection, including pneumonia. See Brush Your Teeth to Prevent Pneumonia and Healthy Mouth, Healthy Body]

The Diffusion of Excellence Initiative helps identify and disseminate clinical and administrative best practices that empower top performers to apply their innovation ideas throughout the VA healthcare system. DoE’s flagship program – the VA Shark Tank Competition – offers VA employees the opportunity to share practices that address clinical and operational priorities to improve the Veteran care experience. The program has already impacted the lives of more than 100,000 Veterans at over 150 VA facilities across the country.

Project HAPPEN

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 (DoE) Initiative and operations partners, HAPPEN is spreading across the nation. The QUERI HAPPEN Partnered Evaluation Initiative will measure the successful adoption of HAPPEN and continually evaluate the quality of implementation at each facility—and its impact on clinical and financial outcomes. Investigators also will work to identify emerging trends and discover strategies to promote sustainment.

Collaboration

In addition to the DoE, this QUERI project brings together expertise from the VA Innovation Ecosystem, Office of Discovery, Education, and Affiliated Networks (Diffusion of Excellence), the Office of Nursing Services, the Office of Dentistry, and the Office of Rural Health (ORH).

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

Thus far, each facility that has implemented this practice [HAPPEN] has seen immediate reductions in pneumonia rates and associated healthcare costs.

  • Evaluating performance gaps and the quality of implementation across different sites;
  • 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.

Expected 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 reductions in pneumonia rates and associated healthcare costs.

For more information about this project, please contact Shannon Munro, PhD, APRN, BC, FNP at Shannon.Munro@va.gov .  You also may contact VAHAPPEN@va.gov .

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