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Nursing News HighlightsNurses Leading Innovation

How an Innovative Nurse-Led Program is Reducing Pneumonia Across the VA

VA nurse researcher Shannon Munro, PhD, APRN, BC, FNP, discovered an easy and inexpensive solution to reduce cases of hospital-acquired pneumonia in her hospital: encouraging patients to brush their teeth. Munro explains the science behind the nurse-led innovative program, HAPPEN.

According to the Centers for Disease Control and Prevention, pneumonia is the number one hospital-acquired infection in America, with the largest cause of pneumonia stemming from bacteria originating from the patient’s own mouth.[1] After learning about the correlation between poor oral care and hospital-acquired pneumonia, Shannon Munro, PhD, APRN, BC, FNP, nurse researcher at the Department of Veterans Affairs Medical Center in Salem, Virginia recognized the need to bring a program focused on consistent oral care to the Veterans Affairs (VA) healthcare system.

Munro serves as the National Implementation Lead for HAPPEN (Hospital-Acquired Pneumonia Prevention by Engaging Nurses), a collaborative program that utilizes hospital nurses, nursing assistants, physicians, dental professionals, speech and language pathologists and infection control experts to encourage patients to brush their teeth twice a day. This simple and inexpensive solution has had a remarkable effect on the number of pneumonia cases among non-ventilated patients in VA hospitals.

“By utilizing our multidisciplinary workforce and electronic medical record data, we were able to identify a simple, inexpensive solution that doesn’t require a large investment in staff time and can make a measurable impact,” explained Munro. “We’re getting our veterans and staff interested in the importance of brushing teeth.”

Munro was first introduced to the research behind oral care and pneumonia when she attended a conference where her colleague Dian Baker, PhD, RN, nurse researcher at California State University in Sacramento, presented her work in preventing infections by providing consistent oral care during hospitalization.[2]

“By introducing this evidence-based practice to the VA health system, we have expanded the reach of the pneumonia prevention initiative to 41 VA hospitals so far” Munro said.

Buildup of plaque and biofilm on a patient’s teeth acts as a magnet for bacteria, which can travel down the throat and into the lungs, resulting in pneumonia. Hospital-acquired pneumonia is a significant risk for patients, especially those who are elderly. At best, patients who develop hospital-acquired pneumonia expect a longer length of stay of about two weeks, but at worst, cases of hospital-acquired pneumonia have a mortality rate of 19% or more.[3],[4]

“The patient population we have are at higher risk for pneumonia,” explained Munro. “This is usually because of age, but also can be a result of additional health conditions.”

HAPPEN was first tested in 2016 at the Salem VA Medical Center in the Community Living Center (CLC), which offers long-term care to veterans, most of whom are elderly and have multiple chronic health conditions. Munro studied the patient data in her hospital and found that they were averaging four cases of hospital-acquired pneumonia every month on the pilot CLC units, but once HAPPEN was implemented, that number dropped dramatically.[5],[6],[7]

Nurses are now required to document the oral care provided to patients in the electronic medical record. Munro estimates that by the simple act of assisting veterans with their oral care at the pilot sites has prevented 236 cases of hospital-acquired pneumonia and saved at least 42 veteran lives. [8] And since a single case of pneumonia can cost a healthcare system an estimated $40,000, Munro predicts the program has reduced VA hospital costs by $9.4 million at the initial pilot sites. [9]

“Consistent oral care, which means brushing your teeth and also cleaning one’s dentures, can help save your life,” said Munro. “We’re spending an average of $3-5 on oral care supplies and less than five extra minutes per patient, creating tremendous outcomes for patients without a significant investment in time or money.”

For years, hospitals have focused on tackling pneumonia cases contracted through ventilators, but cases of pneumonia can also be found in patients who are breathing on their own, younger patients and patients on all types of hospital units. Munro and her colleagues know the common reason- a lack of oral care.

“The number of patients who don’t receive oral care when staying in a hospital in the United States is high; some studies have shown that 70% of hospitalized patients do not receive assistance with their oral hygiene[10],” said Munro. “Oral care has dropped to a low priority and we need to elevate it back up.”

Due to the efforts of the HAPPEN team, oral care is regarded with greater urgency throughout her hospital network. To date, HAPPEN is active in over 41 hospitals across 120 medical surgical, pre-surgical, intensive care, inpatient mental health, and long-term care units in the VA. Other healthcare systems outside the VA have reached out to Drs. Munro and Baker eager to start similar programs as well.

Munro notes that the support from multiple disciplines across the VA was crucial to the adoption and spread of HAPPEN. Not only did her team work in tandem with the VA’s nursing workforce and dental professionals, but also with VA speech and language pathologists to help patients at risk for aspiration, respiratory therapists to assist with oral care after breathing treatments, executive leadership to guarantee support across the network and even the food services departments to institute reminders for patients to brush their teeth.

Above all, Munro knew for the program to be successful, she had to get VA nurses on board. And as the largest nursing workforce in the nation with over 80,000 nurses[11], she knew it would be no small feat. She is proud that nurses have led the effort to adopt this practice and recognizes success wouldn’t be possible without the many nurse champions across the VA network serving in a leadership capacity for the program.

“Our nurses are really excited about HAPPEN and are taking ownership in helping it succeed,” said Munro. “It’s wonderful that multiple teams have had a role in developing our program, but we knew we needed nurses and nursing assistants to lead and support it because they are the ones delivering the care.”

The success of HAPPEN in the VA health system has inspired Munro and her team to set aggressive goals for expansion, as well as supporting more quality improvement projects within the VA.

“We would love this program to be implemented in 80% of VA hospitals. It seems like a lofty goal, but I’m confident we’ll get there because we have the manpower and the support of our leadership, which is paramount to success,” said Munro.

In addition to serving as the National HAPPEN Implementation Lead, Munro also supports the VA’s Diffusion of Excellence Initiative, which is a “Shark Tank” style initiative launched in 2015 to engage and support employees in bringing forward their innovative ideas to improve clinical and administrative practices throughout the VA health system. Recent competition finalists have proposed solutions to improve medical-surgical nursing, healthcare quality and safety, the veteran experience and suicide prevention.

“It’s been wonderful to pull nurses into life-saving and cost-saving projects,” said Munro. “It’s a great way for VA nurses to collaborate with colleagues across the network to improve our health system, and the value of their participation has been tremendous.”

Munro hopes the success of HAPPEN and the Diffusion of Excellence Initiative will encourage nurses across the country to share their innovative ideas with leadership at their healthcare system.

“After seeing the great health outcomes HAPPEN has been able to create, our nurses feel more empowered than ever before to pursue innovative ideas,” said Munro. “I would encourage nurses with innovative ideas to be persistent. If you know it’s the right thing to do for your patients, keep trying to solve the problem and approach it from different directions. And don’t forget your input is crucial to the success of any healthcare program.”

(A team of nurses showcasing HAPPEN at a VA hospital in Asheville, North Carolina)

EDITOR'S NOTE: The patient featured in the above header image is an actor. Learn more about HAPPEN at the VA here.

[1] Lagnado, L. (2018, February 17). In Hospitals, Pneumonia Is a Lethal Enemy. Retrieved from
[2] Quinn, B., Baker, D., Munro-Cohen, S., Stewart, J., Lima, C., Parise, C. (2014). Basic nursing care to prevent non-ventilator hospital acquired pneumonia. Journal of Nursing Scholarship 46(1): 11-19
[3] Munro, S., Baker, D. (2018). Reducing missed oral care opportunities to prevent non-ventilator associated hospital acquired pneumonia at the Department of Veterans Affairs. Applied Nursing Research 44, 48-53. Doi: 10.1016/j.apnr.2018.09.004
[4] Munro S, Baker D. (July 2019). Integrating oral healthcare into patient management to prevent hospital-acquired pneumonia- A team approach. Michigan Dental Association Journal, 48-57.
[5] Munro S, Baker D. (July 2019). Integrating oral healthcare into patient management to prevent hospital-acquired pneumonia- A team approach. Michigan Dental Association Journal, 48-57.
[6] Munro S, Haile-Mariam A, Greenwell C, Demirci S, Farooqi O, Vasudeva S. (2018). Implementation and dissemination of a Department of Veterans Affairs oral care initiative to prevent hospital acquired pneumonia among non-ventilated patients. Nursing Administration Quarterly 42(4), 363-372. Doi: 10.1097/NAQ.0000000000000308
[7] Munro, S., Baker, D. (2018). Reducing missed oral care opportunities to prevent non-ventilator associated hospital acquired pneumonia at the Department of Veterans Affairs. Applied Nursing Research 44, 48-53. Doi: 10.1016/j.apnr.2018.09.004
[8] Office of Research & Development. (2018). Oral hygiene to fight pneumonia. Retrieved from
[9] Office of Research & Development. (2018). Oral hygiene to fight pneumonia. Retrieved from
[10] Durkin, M. (2018, December 15). Brushing up on pneumonia prevention. Retrieved from
[11] Workforce/Learning. (2014, January 2). Office of Nursing Services (ONS). Retrieved from

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