Brushing up on pneumonia prevention

One facility reduced rates of hospital-acquired pneumonia with simple oral hygiene.


Research suggests that providing oral care to patients on mechanical ventilation can reduce the incidence of pneumonia, but nonventilated patients often need help brushing their teeth as well, said Shannon Munro, PhD, APRN, FNP, a nurse-researcher at the Salem VA. “People don't realize that a lot of hospital-acquired pneumonia comes from germs in the mouth,” she said. “This is something nurses can assist with, and it's really simple.”

Expanding on the original initiative led by Dian Baker, PhD, APRN, PNP, and Barbara Quinn, MSN, RN, at Sutter Medical Center in Sacramento, Calif., Dr. Munro led the implementation of Project HAPPEN (Hospital-Acquired Pneumonia Prevention by Engaging Nurses) in 2016 at the Salem VA. Eight VA hospitals are now involved. Preliminary research shows that 70% of patients in the hospital nationwide do not receive oral hygiene, “But many patients can brush their teeth themselves. They just need a little gentle encouragement and being given the supplies,” said Dr. Munro. “You can brush your teeth from your hospital bed; you don't have to be able to walk to the bathroom sink and do it yourself.”

How it works

The first units to roll out the project were part of the hospital's 50-bed community living center, which cares for many elderly patients with dementia and other health issues and had the highest rates of pneumonia, she said. Nurses began assessing and documenting patients' oral care as a standardized operating procedure. Veterans able to brush their own teeth received supplies and gentle encouragement, while nurses completed oral care for those who needed assistance. A suction toothbrush was used for patients at high-risk for aspiration.


In the first year after implementation, the pilot units at the community living center had a 92% reduction in the incidence rate of nonventilator-associated hospital-acquired pneumonia, which decreased from 105 to 8.3 cases per 1,000 patient-days, according to results published in September 2018 in Applied Nursing Research. Project leaders estimate that, as of September 2018, the effort had prevented 136 cases of nonventilator-associated hospital-acquired pneumonia, saved $5.46 million, and saved 24 veterans' lives. “We expect to save over $207 million a year if this project was implemented in all VAs that have inpatient units,” Dr. Munro said.

The VA selected the initiative as a best practice in 2016 and provided initial funding and implementation support to expand it to additional hospitals. With these funds, the Salem VA and other hospitals could upgrade to higher-quality oral-care supplies approved by the American Dental Association and develop patient education materials and two public service announcements. “We've been able to roll out to an additional seven VA hospitals, and no one has had to hire additional nursing staff to accommodate this because most patients are able to do it themselves,” Dr. Munro said.


Getting the nurses on board wasn't quite like pulling teeth, but there were some mixed reactions. The biggest challenge was the common perception among nurses that oral care is a low priority, according to Dr. Munro. “Overcoming that belief takes a little time, to get nursing staff and nursing assistants on board with realizing that there's such a huge potential to save patients' lives by getting those germs off the teeth so they don't aspirate them into their lungs,” she said.

While the community living center nurses responded to the project with enthusiasm, some of the nurses in other units and hospitals anticipated that it would take a lot of extra time. However, Dr. Munro said “It takes less than two minutes per patient if you are organized and you have all your supplies there.” Within the VA, dental staff are available to help train nurses and address issues such as resistant patients or those with mouth pain. Dental staff support is a strength of the VA and more of a challenge to obtain in other hospitals, she noted.

Lessons learned

Involving nursing staff throughout the entire process was essential. “You can't just go in and teach them and think that you're done. You have to have that feedback loop so that they know that what they're doing is making a difference,” said Dr. Munro. Tracking pneumonia cases, estimating the patient lives and money saved, and updating staff with monthly totals helped make oral care a high priority, she said.

Next steps

The plan is to roll out the project to even more VA medical centers, with the larger goal of nationwide implementation, she said. “Our plan is to deploy to another 40 VA hospitals next year,” Dr. Munro said. “There are 115 VAs across the U.S. that have inpatient units, so if we hit 40, then we'll be nationwide in probably two years.”