ABSTRACT
BACKGROUND & PROBLEMS: Ventilator-associated pneumonia (VAP) is a common healthcare-associated infection in the intensive care unit. The average VAP rate was .128% in our unit during 2011. Therefore, we designed a project to identify relevant problems, including: inadequate knowledge about VAP care, incorrect techniques for sputum suction, patient head elevation < 30~45 degrees, ventilator humidifier installed with water equipment designed without water-resistant barriers, failure to change the resuscitator and small-volume nebulizer regularly, and possible cross-contamination between respiratory-care devices. PURPOSE: We targeted a VAP rate decrease from the current .128% to less than .1%. RESOLUTION: The improvement measures implemented included team resource management (TRM) with VAP education, promotion, a written reminder regarding sputum accumulation sites, instruction to elevate the head of patients to an appropriate height, introduction of an auto-stop water adding system, and regular changes of related devices at assigned positions. RESULTS: The VAP rate decreased from .128% to .065%. CONCLUSIONS: The risk identification and associated TRM project improved teamwork and the quality of care in the ICU.
