JONA
Volume 48, Number 5, pp 285-291
Copyright B 2018 Wolters Kluwer Health, Inc. All rights reserved.
THE JOURNAL OF NURSING ADMINISTRATION
A Retrospective Study of NonYVentilator-
Associated Hospital Acquired Pneumonia
Incidence and Missed Opportunities
for Nursing Care
Mary Tesoro, DNS, RN-BC
Diane J. Peyser, PhD, RN, NEA-BC
Farley Villarente, MS, FNP, CNOR
OBJECTIVE: To determine nonYventilator-associated
hospital-acquired pneumonia (NV-HAP) incidence,
assess negative impacts on patient outcomes and cost,
and identify missed preventive nursing care opportunities.
BACKGROUND: NV-HAP is inadequately studied
and underreported. Missed nursing care opportunities,
particularly oral care, may aid NV-HAP prevention.
METHODS: This descriptive, observational, retro-
spective chart review identified adult NV-HAP cases
and associated demographic and hospital care data.
RESULTS: Two hundred five NV-HAP cases occurred
in 1 year at Montefiore Medical Center, equating to
an incidence of 0.47 per 1000 patient-days and an
estimated excess cost of $8.2 million. ICU transfer
Author Affiliations: Assistant Director of Nursing (Dr Tesoro),
Nursing Project Director for Magnet (Dr Peyser), Staff Nurse
(Mr Villarente), Montefiore Medical Center, The University Hospital
for Albert Einstein College of Medicine, Bronx, New York; Assistant
Professor of Nursing at Lehman College (Dr Tesoro), The City Uni-
versity of New York, Bronx.
The funding for this study was partially provided by Sage Prod-
ucts, LLC. Oversight for this study was provided by the National
Patient Safety Foundation. Medical writing and editorial support for
the initial draft of this article were provided by Dr Catherine Evans
(Medicalwriters.com, Zurich, Switzerland) and funded by Sage
Products. The institution had no obligation to order, purchase, or
recommend the ordering or purchasing of any item or service manu-
factured or distributed by Sage Products.
The authors declare no conflicts of interest.
Correspondence: Dr Tesoro, Montefiore Medical Center, 111 E
210th St, Bronx, NY 10467 (mtesoro@montefiore.org).
Supplemental digital content is available for this article. Direct
URL citations appear in the printed text and are provided in the
HTML and PDF versions of this article on the journal_s Web site
(www.jonajournal.com).
DOI: 10.1097/NNA.0000000000000614
JONA  Vol. 48, No. 5  May 2018
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
following pneumonia occurred in 15.6% of cases.
Care requirements from specialist nursing facilities
increased at discharge (26.8%), as compared with care
requirements on admission (17.6%). Complete nursing
care documentation was missing for most patients,
with oral care undocumented 60.5% of the time.
CONCLUSIONS: Preventable NV-HAP cases and
their negative impact on cost and patient outcomes
may decrease through improved basic nursing care.
Hospital-acquired infections (HAIs) are well-documented
challenges to patient safety that significantly increase
the cost of care.1-3 Hospital-acquired pneumonia (HAP),
which is composed of ventilator-associated pneumo-
nia (VAP) and nonYventilator-associated HAP (NV-
HAP), is 1 of the most prevalent subsets of HAIs in
the United States.1,4 Data support the assertion that
NV-HAP is an underreported condition with conse-
quences that include morbidity, prolonged hospital
stay, 30-day readmission to the hospital, and increased
risk of discharge to a skilled nursing facility (SNF) rather
than returning to home.5-10 Data suggest that there may
be no difference in mortality between patients with VAP
and those with NV-HAP,9 and others note that patients
with NV-HAP are more likely to die in the hospital
compared with patients without NV-HAP.10 Estimates
for excess cost due to HAP are as high as $40 000 per
HAP case,11 an expenditure that NV-HAP cases might
even exceed.9
Evidence-based care bundles for VAP prevention
have been well documented over the past decade and
include interventions such as early and frequent
285
mobilization, assessing the patient"s aspiration risk,
elevating the patient"s head of bed, and frequent oral
care.12-14 However, the link between basic oral care
and NV-HAP prevention has not been well studied
to date. To help reduce the incidence of NV-HAP
and other associated adverse events, an interprofes-
sional group at Sutter Medical Center in Sacramento,
California, began an NV-HAP prevention initiative
(Hospital-Acquired Pneumonia Prevention Initiative
[HAPPI]) in 2012. This nurse-led oral-care initiative
reduced NV-HAP incidence by nearly 40% and saved
the hospital $1.72 million over the course of 1 year.15
This initiative involved the implementation of a uni-
versal oral hygiene regimen to decrease oral bacterial
load and included significant staff education to sup-
port behavioral changes in nursing practice.15
Building on the success experienced in the HAPPI
initiative, a multicenter, nationwide, descriptive, ret-
rospective chart review (HAPPI-2) was designed to
determine the rate of occurrence of new NV-HAP
cases in hospitals across the United States during the
2014 calendar year. In addition, the documentation of
associated nursing care was also assessed. Single-site
data are presented from Montefiore Medical Center.
Methods
Setting
The Montefiore Health System is an academic health-
care system consisting of 11 hospitals and specialty
care networks in New York. Data were gathered from
the adult inpatient facilities of Montefiore Medical
Center (Moses, Weiler, and Wakefield campusesV
approximately 1400 beds).
Ethics
Approval by the institutional review board of the
Montefiore Health System was obtained prior to study
initiation (IRB#2015-4972). Individual patient consent
was not required because no individual patients were
enrolled, no experimental procedures or medications
were used, and the research involved no more than
minimal risk. Deidentification of protected health infor-
mation followed the Safe Harbor Method.16 With the
exception of month of discharge, electronic health
record data were deidentified at the patient level and
reported as collated results. All research team mem-
bers declared any conflicts of interest and completed
required training on protection of human subjects.
Study Design
This descriptive, observational, retrospective chart re-
view was designed to determine NV-HAP incidence in
the 2014 calendar year. Documentation of associated
nursing care was also assessed. An independent panel
286
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
of clinical experts provided by the National Patient
Safety Foundation performed study oversight. Inclusion
criteria for cases were patient age 18 years or older,
hospital admission during the 2014 calendar year, and
hospital discharge following a diagnosis of pneumonia
not present on admission.
Diagnosis of NV-HAP
Diagnosis of pneumonia not present on admission to
the hospital was based on the Centers for Disease Con-
trol and Prevention (CDC) guidelines (2013) using a
modified format.8 Diagnosis of NV-HAP required
absence of mechanical ventilation for 48 hours be-
fore pneumonia diagnosis.
Data Collection and Chart Review
Chart review used a 2-step screening process. First,
the Clinical Looking Glass data mining program ex-
tracted patient data linked to International Classifi-
cation of Diseases, Ninth Revision (ICD-9) codes for
pneumonia diagnosis that were not present at hos-
pital admission (Table 1). Second, chart data were
reviewed to confirm that the CDC diagnostic cri-
teria for NV-HAP had been met. Data were electroni-
cally submitted to REDCap, a secure HIPAA-compliant
Web-based survey and database management applica-
tion designed and managed by the Sutter Institute for
Medical Research.17 Validation of case data included
the comparison of REDCap data collection sheets to
the REDCap database to identify missing data, to
validate whether the study criteria had been met, and
to correct data in REDCap where applicable. Data
sheets for cases not meeting the criteria were reviewed
for anomalies. Extracted information from medical re-
cords included demographic data, unit of hospital
admission, residential location preadmission and post-
discharge, unit of pneumonia acquisition, transfer to
an ICU due to pneumonia, readmission within 30 days
of discharge, and documented nursing care performed
24 hours before pneumonia diagnosis (frequency of
oral care, head-of-bed elevation to 30-40 degrees, out-
of-bed activity, incentive spirometry, and coughing and
deep breathing). For data on clinical hospital units,
general medical-surgical units were categorized sepa-
rately to medical-surgical units accommodating a
specific medical-surgical patient population (eg, ortho-
pedics, oncology, telemetry, and gynecology).
Training of Research Team
All team members participated in data collection train-
ing webinars provided by the principal investigators
of the multisite study. All 7 team members evaluated
1 chart to practice use of the CDC data collection tools.
Team members then separately evaluated 10 charts and
discussed any variation in interpretation of meeting
JONA  Vol. 48, No. 5  May 2018
 Table 1. ICD-9 Diagnostic Codes Used for Pneumonia Diagnosis

NV-HAP criteria. During data collection, team members statistical tests were applied to all parametric data.
collaborated to clarify any ambiguous criteria, for ex- NV-HAP incidence was calculated as follows:
ample, language used in radiologic findings for diag-
nosis of pneumonia. Team meetings were held Rate of NV HAP per 1000 patientdays
8 9
throughout the data collection process to assess progress > No: of NV HAPcase >
¼> : >
;  1000
and address any issues. One team member participated in Total no: of adult patientdays
a webinar for REDCap training and assumed responsi-
bility for all data entry into the REDCap software.

Statistical Analyses Rate of NVHAP per 100 patients

8 9
Statistical analyses were performed using SPSS 22 > No: of NVHAP case >
¼: > >
;  100
(IBM-SPSS Inc, Armonk, New York). Descriptive Total no: of adult discharges

JONA  Vol. 48, No. 5  May 2018 287

Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

Results
Incidence of NV-HAP
For the 2014 calendar year, 837 cases of pneumo-
nia not present on admission were recorded for the
Moses, Weiler, and Wakefield campuses of Montefiore
Medical Center. Of these cases, 49 were not reviewed
(47 patients were G18 years of age, and 2 had missing
records), leaving 788 eligible cases of HAP for review.
Of these 788 HAP cases, 205 (26%) were classified as
NV-HAP meeting modified CDC guidelines, corre-
sponding to an NV-HAP incidence rate of 0.47 per
1000 patient-days and 0.27 NV-HAP cases per 100
patients.
Demographics of Patients With NV-HAP
The majority of patients with NV-HAP (189/205
[92.2%]) were younger than 89 years. The mean age
of these patients was 64 years (n = 189). For patients
89 years or older (n = 16), specific age was not cap-
tured (as per the Safe Harbor Method of patient dei-
dentification).16 The breakdown of male and females
was balanced, with 50.2% (103/205) being female. The
most frequent patient race was African American (34.1%
of patients) followed by Hispanic/Latino (29.8%), white
(23.9%), Bother[ (6.3%), and Asian American (1.5%).
Description of NV-HAP Cases
Most patients with NV-HAP (60.5% [124/205]) were
admitted to the hospital from a medical service, fol-
lowed by 22.9% (47/205) of patients being admitted
from a surgical service. One patient (0.5%) was ad-
mitted from a psychiatric service (Supplementary
Digital Content 1, http://links.lww.com/JONA/A620,
which details unit of admission to the hospital for
patients later acquiring NV-HAP). Most patients
(69.8% [143/205]) acquired NV-HAP in a general
medical-surgical unit, followed by 12.2% (25/205) in
an ICU (Supplementary Digital Content 2, http://links.
lww.com/JONA/A621, which details the hospital units
where NV-HAP was identified). Of patients who
acquired NV-HAP outside an ICU, 15.6% (32/205) were
transferred to the ICU as a direct result of pneumonia. The
mean length of stay (LOS) in the hospital for patients with
NV-HAP was 24 days (range, 3-157 days) with 24.9%
(51/205) of patients with NV-HAP being readmitted
within 30 days of discharge. The in-hospital mortality
rate of NV-HAP patients was 19% (39/205).
Comparison of Patient Residential Location Before
Hospital Admission and at Discharge
Figure 1 compares the proportions of patients with
NV-HAP who were admitted from, and discharged to,
SNFs and home. Most patients (77.6% [159/205]) were
admitted to the hospital from home, whereas fewer
288
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
Figure 1. Proportions of patients residing in SNFs and home
before hospital admission and at discharge. Additional loca-
tions before admission were acute care (5 patients), residen-
tial care (3 patients), and acute rehabilitation (1 patient). One
patient was homeless. At discharge, 39 were deceased, and
additional locations were acute rehabilitation (14 patients),
hospice/comfort care (5 patients), and residential care (1 patient).
One patient left hospital against medical advice.
than half of patients (43.9% [90/205]) were discharged
to home after their hospital stay. Thirty-six patients
(17.6%) were admitted from an SNF, whereas 26.8%
(55/205) entered an SNF when discharged from hospital,
representing a 9.2% increase in the number of patients
requiring SNF-level care after hospital discharge.
Documented Nursing Care
Table 2 describes the documentation of nursing inter-
ventions in the 24 hours prior to pneumonia diagno-
sis. Slightly more than half of patients were found to
have their head of bed elevated (52.2% [107/205]),
and one-third of patients had out-of-bed activity
(32.2% [66/205]), whereas a small number of pa-
tients were noted to use incentive spirometry (20.0%
[41/205]) and to carry out coughing and deep breathing
exercises (16.6% [34/205]). Regarding oral care, fewer
than half of the patients had any oral care (49.5% [81/
205]) documented (Figure 2).
Financial Impact
Based on an excess cost estimate of $40 000 per NV-
HAP case,11 the 205 NV-HAP cases presented here
equate to a potential excess healthcare expenditure
of $8.2 million for Montefiore in the 2014 calendar
year. To promote standardization in NV-HAP cost
analysis, cost in this study was calculated using the
American Thoracic Society 2005 estimates,11 the
same cost estimates used in the original research.15
Discussion
Ensuring quality nursing care and patient safety is a major
challenge in today"s healthcare system. Data support
JONA  Vol. 48, No. 5  May 2018
 Table 2. Documentation of Nursing Interventions in the 24 Hours Before Pneumonia Diagnosis for
Patients With NV-HAP
that missed nursing care is associated with adverse
events18,19 and in this case may have relevance for
NV-HAP prevention. Data collected at this research
site revealed an incidence of NV-HAP of 0.47 per
1000 patient-days with 32 transfers to the ICU, a
mean hospital LOS of 24 days, and a 9.2% increase
in SNF-level care requirements compared with before
admission, as well as an in-hospital mortality rate of
19%, a 30-day readmission rate of 24.9%, and an
excess cost of $8.2 million. NV-HAP incidence rates
at this site are consistent with the other sites in the
HAPPI-2 study that found rates of 0.12 to 2.28 per
1000 patient-days.20
The CDC recommends a focus on modifiable risk
factors for the prevention of HAIs.8 NonYventilator-
associated HAP incidence may be reduced with imple-
mentation of fundamental nursing care procedures.
This study identified a lack in documentation of
implemented nursing care (oral care, elevation of
head of bed, out-of-bed activity, incentive spirome-
try, and coughing and deep breathing) 24 hours prior
to an NV-HAP diagnosis for many patients included
in this study (Figure 2, Table 2). Incentive spirometry,
coughing and deep breathing, head-of-bed elevation,
and out-of-bed activities may help to increase lung
volume, mobilize secretions, and prevent atelecta-
sis.21-23 Unfortunately, studies have identified that
these and other nursing care activities are often missed
or not documented.19,24 Oral care is standard prac-
tice to prevent VAP while patients are ventilated;
however, for medical/surgical units, oral care has long
been considered a comfort measure in caring for pa-
tients.25 This may be one of the reasons that oral care
is consistently found to be missing from patient care.
In the pilot study preceding this chart review,
Quinn et al15 concluded that decreasing the oral bac-
terial load is the most modifiable factor for NV-HAP
JONA  Vol. 48, No. 5  May 2018
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
prevention and implemented a universal oral care nurs-
ing protocol designed for NV-HAP prevention.15,26
Guidelines recommend oral care for patients 65 years
or older every morning and evening and, as neces-
sary, and recommend that patients in acute care or
long-term care or home settings receive oral hygiene
at least once every 8 hours.27,28 However, practices
vary among hospitals, and although these recom-
mendations can be generalized to other populations,
there is currently no standard for frequency of oral
care for nonventilated patients. The protocol used by
Quinn et al15 involved more frequent oral care than is
currently recommendedV4 times a day for all adult
nonventilated patients and every 6 hours for patients
being tube fed or not eating.15
Similar to its role in VAP prevention, it is likely
that oral care serves an important role in NV-HAP
prevention and may also improve overall patient sat-
isfaction.29 Chipps et al29 assessed the difference in
patient satisfaction between 2 groups of postY
mechanically ventilated patients. One group received
Figure 2. Frequency of documented oral healthcare in the
24 hours before pneumonia diagnosis for patients with
NV-HAP.
289
a systematic, evidence-based oral care regimen, whereas
the other group received standard care. Overall, the
patients who received the systematic oral care were
more satisfied with their protocol compared with
patients in the standard care group.
Results from the retrospective chart review at our
site revealed that 60.5% of patients with NV-HAP
had no documented oral healthcare, and only 3.9% of
patients (8/205) received documented oral care at least
4 times a day (Figure 2). This lack of documented oral
healthcare demonstrates a clear missed opportunity
of nursing care in potentially preventing NV-HAP.
Reasons for the omission of documented nursing
care may be related to workload, communication
errors, and/or staff training.15,19 Barriers to the pro-
vision of oral care include lack of time and staffing
resources, which may lead to delegation of oral care
to untrained personnel.25 In addition, oral care may
be omitted or undocumented through low recogni-
tion of its value and low prioritization relative to other
care activities and through the assumption that pa-
tients can perform oral care independently.25,30
Limitations
The observational, retrospective study design of this
descriptive chart review limits the conclusions that
can be drawn. In addition, as several research team
members performed data extraction, human variabil-
ity in application of diagnostic guidelines is possible.
Our data also depended on reliable documentation
of nursing care procedures, a limitation of all studies
of similar nature. In some instances, care may have
been provided but not documented. It is also possible
that some care may have been documented but not
provided. This limitation emphasizes the importance
of thorough and accurate documentation in health-
care settings to identify opportunities for quality
improvement, design relevant care improvement
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