Prevention Bundle Significantly Reduced Rates of Non-Ventilator HAP

A prevention bundle composed of 7 interventions for patients at high-risk for non-ventilator hospital-acquired pneumonia (HAP) was effective in significantly reducing HAP rates.

A prevention bundle comprising 7 interventions (aggressive mobilization, upright posture for meals, swallowing evaluation before feeding, sedation restriction, elevated head of bed, oral care, and feeding tube care) for patients at high risk for non-ventilator hospital-acquired pneumonia (HAP) was effective in significantly reducing HAP rates, mortality, and broad-spectrum antibiotic use in the Kaiser Permanente Northern California (KPNC) hospitals, according to research presented at IDWeek 2019, held from October 2 to October 6, 2019 in Washington, DC.

In 2008, a mortality review conducted in KPNC hospitals showed that inpatient mortality among patients with HAP was 21% vs 2% among patients without HAP. Most cases of HAP were acquired in units other than intensive care units. In order to reduce the incidence of HAP, researchers developed and implemented the ROUTE (Respiratory care/Reduced sedation, Oral care, Up, Tube care, Education) prevention bundle composed of the 7 interventions mentioned above.

A natural language extraction program identified new and persisting imaging findings, providing specificity. None of the other surveillance factors added specificity (fever, change in sputum characteristics, leukocytosis). Surgery, altered mental status, sedation, albumin <3 g/dl, and tube feedings were identified factors that predicted an increased risk for pneumonia.

Region-wide implementation was started in late 2012 and the project was fully implemented in 2015. Metrics were reported by 1000 admissions and 100,000 members served, to address a rapidly growing population.

Between 2012 and 2018, HAP decreased from 5.92 to 1.79 per 1000 admissions and 24.57 to 6.49 per 100,000 members. HAP case mortality remained stable (18%-19%) while overall HAP mortality decreased from 1.05 to 0.34 per 1000 admissions (4.37 to 1.24/100,000 members).

Carbapenem, quinolone, aminoglycoside, and vancomycin use all decreased significantly. Benzodiazepine use decreased from 10.4% of all inpatient days in 2014 to 8.8% of inpatient days in 2016.

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The ROUTE prevention bundle significantly reduced HAP rates, mortality, and broad-spectrum antibiotic use, “despite the absence of clinical practice guidelines or strong supportive literature for guidance,” noted the researchers. “This supports the need to examine practices to improve care despite absent literature and even more so supports a need to study these difficult nebulous areas of care,” they concluded.


Naik S, Lucerne C, Kevorkova Y, et al. Significant reduction of non-ventilator hospital acquired pneumonia (HAP) with a prevention bundle and clinical and leadership feedback in a large integrated healthcare system. Presented at: IDWeek 2019; October 2-6, 2019; Washington, DC, MD. Poster 1181.