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Improvement Report
Eliminating Ventilator-Acquired Pneumonia
St. Vincent’s Hospital
Birmingham, Alabama, USA

Team

Sharon Simmons, CRNP, MSN, CNOR, Director of Clinical Excellence
William Leitner, MD, Vice President of Medical Affairs
Cindy Williams, RN, MBA, MSN, FACHE, Vice President of Patient Care Services
Frank Adkins, RN, MBA, Medical Outcomes Manager
Donna Manzella, RN, Manager, ICU
Becky McKinney, RN, Manager of Infection Control
Kay Como, RN, Charge Nurse ICU



Aim
Care and outcomes of the patients in ICU will be improved as evidenced by a reduction in the incidence of ventilator-acquired pneumonia by 50 percent, a reduction in length of stay by one day, and the reduction of average ventilator days by two days over the next calendar year.

Measures
  • Incidence of ventilator-acquired pneumonia utilizing NNIS criteria
  • Length of stay in ICU
  • Average number of ventilator days in ICU


Changes

The following changes were made in the ICU at St. Vincent’s Hospital in an effort to improve patient care and outcomes:

  • Implemented ventilator bundle in February 2004
  • Started multidisciplinary rounds and developed daily goal sheet in April 2004
  • Made daily goal sheet a permanent part of the electronic medical record in July 2004


Results
 
Summary of Results / Lessons Learned / Next Steps

As of September 10, 2004, we have not had a ventilator-acquired pneumonia in 255 days.  We attribute this to the implementation of ventilator bundles.

  • Utilizing ventilator bundles will decrease your ventilator-acquired pneumonia.
  • Consistent compliance to all pieces of the ventilator bundle is critical to your success.


Contact Information

Sharon Simmons
Director of Clinical Excellence
St. Vincent’s Hospital
ssimmon2@stv.org

 

[Storyboard presentation at IHI's National Forum, December 2004]