Reducing Non-Ventilator Hospital-Acquired Pneumonia (NV-HAP)

Authors

• Harvey F. Mason, MD, CPE, Thomas Jefferson UniversityFollow

Document Type

Presentation

Publication Date

7-16-2026

Comments

Presentation: 37:06

Abstract

Non-ventilator hospital-acquired pneumonia (NV-HAP) is a common, costly, and preventable patient-safety problem that has received far less surveillance and prevention attention than ventilator-associated pneumonia. Within Baptist Memorial Healthcare Corporation, baseline data from December 2023 through November 2024 documented 833 NV-HAP cases, 120 associated cases of sepsis or septic shock, 115 deaths, and $15.48 million in treatment cost, with average length of stay rising from 5.41 days to 19.72 days when NV-HAP developed. At two pilot hospitals, NEA Baptist, and Baptist Memorial Hospital–North Mississippi, recorded 114 cases during the baseline year. A five-element prevention bundle comprising oral hygiene, head-of-bed elevation, early mobilization, aspiration precautions, and respiratory therapy optimization, coupled with universal admission aspiration-risk screening, was implemented over ten months from March 2025 through January 2026. The implementation was evaluated with a controlled pre/post design using monthly statistical process control and Plan-Do-Study-Act cycles. The bundle was implemented in 600 high-risk patients. After adjusting for the difference in observation length, combined NV-HAP incidence fell approximately 30%, from 1.25 to 0.87 cases per 1,000 patient-days, with reductions of about 38% at North Mississippi and 25% at NEA Baptist. Bundle adherence rose from a baseline of 66% and 68% to 84% and 90% in the two hospitals, and screening within 24 hours rose from 76% and 80% to 95% and 98%, respectively. NV-HAP-associated sepsis and length of stay for affected patients also declined. The avoided cost was approximately $539,000 over the pilot or $647,000 annually if sustained. Staff reported no added workflow strain. Greater adherence tracked with greater reduction across the two sites, supporting the bundle as the driver of improvement. A reliably delivered prevention bundle meaningfully reduced NV-HAP and supports system-wide dissemination.

Recommended Citation

Language

English