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Consistent Oral Care Shows Potential in Decreasing Risk of Hospital-Acquired Pneumonia

July 12, 2021

Takeaway: This simple oral care initiative is being studied for its potential to reduce cases of hospital-acquired pneumonia, thereby improving the health and safety of the Veterans we proudly serve. HAPPEN is implemented in every VA Medical Center in the nation including medical surgical, intensive care, and long-term care units.

Non-ventilator associated hospital acquired pneumonia (NV-HAP) is the number one hospital-acquired infection in the United States, placing an estimated 35 million patients at risk annually. Further, patients who develop NV-HAP are 8 times more likely to die, require days in an intensive care unit, mechanical ventilation, and broad-spectrum antibiotics (Micek et al., 2016; Munro & Baker, 2018). Bacteria in the mouth multiply rapidly and may be aspirated into the lungs during sleep leading to pneumonia. When consistently delivered, oral care (e.g. tooth brushing) targets bacterial multiplication, thereby reducing the risk of NV-HAP.

HAPPEN (Hospital-Acquired Pneumonia Prevention by Engaging Nurses) was formally launched in October 2016 to provide better oral care for Veterans residing at the Salem VA Medical Center (VAMC) long-term care units. After successful pilots on the acute and long-term care units in all 7 hospitals in VISN 6 and the Houston VAMC, HAPPEN has spread to every VA Medical Center in the nation. The HAPPEN team ensures that bedside nurses assist Veterans with their oral hygiene at least twice daily. HAPPEN was chosen by the VA Diffusion of Excellence Initiative as a Gold Status promising practice and supported widespread implementation. HAPPEN was recognized as a Diffusion of Excellence Initiative best practice in the 2020 Gears of Government President’s Award for Innovation (Vega, et al., 2019).

Launched in 2015, VA’s Diffusion of Excellence initiative aligns organizational resources with early-stage to mid-stage promising practices and innovations to replicate, scale, and spread those with greatest potential for impact and positive outcomes throughout the VA healthcare system.

With the support of the Diffusion of Excellence Initiative and operations partners (see below), HAPPEN has spread across the nation. To date, more than 47,000 VA direct care staff have been trained to assist Veterans with their oral care. Although its core focus is improving care for hospitalized Veterans on acute care wards and residents in community living centers (long-term care), other participating units include pre-surgical areas, spinal cord injury, oncology, hospice and palliative care, inpatient mental health, and blind rehabilitation. A national oral care implementation toolkit and other resources provide step-by-step instructions and education for Veterans and VA staff.

QUERI supports the evaluation of HAPPEN implementation and outcomes including a return on investment and cost-savings. The partnership between QUERI and the Diffusion of Excellence focuses on implementing repeatable, scalable methods for measuring successful adoption of HAPPEN and evaluating the quality of implementation at each facility and its impact on clinical and financial outcomes, identifying emerging trends, and discovering strategies to promote sustainment.

The QUERI Partnered Evaluation Initiative Hospital Acquired Pneumonia Prevention by Engaging Nurses (HAPPEN) team is reviewing factors that influence the adoption and implementation of HAPPEN. Sites that do not meet HAPPEN benchmarks receive higher intensity support to enhance implementation and sustainment efforts by:

  • Providing consistent interactive and ongoing training, and assessing readiness and motivation for change;
  • Developing practical strategies to improve implementation and sustainment;
  • Encouraging interdisciplinary collaboration and subject matter expert involvement;
  • Monitoring oral care provision and documentation and tracking NV-HAP cases;
  • Facilitating follow up meetings.

The VHA Inpatient Evaluation Center (IPEC) released the new NV-HAP performance measure in March 2021 to track cases nationwide.


This simple initiative has reduced cases of hospital-acquired pneumonia, improving patient safety and quality of life. Facilities implementing HAPPEN have seen declines in hospital acquired pneumonia rates and associated healthcare costs.


VHA Innovation Ecosystem, Office of Discovery, Education, and Affiliated Networks (Diffusion of Excellence), VA’s Offices of Nursing Services (ONS), Dentistry, and Rural Health (ORH).


Lounsbury O, Munro S. Oral Care for non-ventilator associated hospital-acquired pneumonia prophylaxis: optimizing clinical outcomes and organizational effectiveness. Pennsylvania Patient Safety Authority Journal. December 2020;2(4):79-81.  

Munro S and Baker D. Reducing missed oral care opportunities to prevent non-ventilator associated hospital acquired pneumonia at the Department of Veterans AffairsApplied Nursing Research. December 2018;44:48-53.

Munro S, Baker D, Giuliano K, et al. Non-ventilator hospital-acquired pneumonia: A call to action: Recommendations from the National Organization to Prevent Hospital-Acquired Pneumonia (NOHAP) among nonventilated patients. Infection Control & Hospital Epidemiology. June 9, 2021:1-6.

Munro S, Haile-Mariam A, Greenwell C, et al. Implementation and dissemination of a Department of Veterans Affairs oral care initiative to prevent hospital-acquired pneumonia among non-ventilated patients. Nurses Administration Quarterly. Oct/Dec 2018;42(4):363-372.

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