Striving for excellence in ventilator bundle compliance through continuous quality improvement initiative in the intensive care unit of a tertiary care hospital in India

Abstract

Background: Ventilator-associated pneumonia (VAP) is a significant nosocomial infection in intensive care units (ICUs). Ventilator bundle (VB) implementation has been shown to decrease the incidence of VAP. This study presents a 1-year quality improvement (QI) project conducted in the ICU of a tertiary care hospital with the goal of increasing VB compliance to greater than 90% and evaluating its impact on VAP incidence and ICU length of stay.

Methods: A series of Plan-Do-Study-Act (PDSA) cycles, including educational boot camps, checklist implementation, and simulation-based training, was implemented. Emphasis on standardization and documentation for each VB component further improved compliance. Data were compared using a chi-square test, unpaired t-test, or Mann-Whitney U-Test, as appropriate. A P-value <0.05 was considered statistically significant.

Results: The initial observed compliance was 40.7%, with a significant difference between knowledge and implementation. The compliance increased to 90% after the second PDSA cycle. In the third PDSA cycle, uniformity and standardization of all components of VAP were ensured. After increasing the VB compliance at greater than 90%, there was a significant decline in the incidence of VAP, from 62.4/1,000 ventilatory days to 25.7/1,000 ventilatory days, with a 2.34 times risk reduction in the VAP rate (P= 0.004).

Conclusions: The study highlights the effectiveness of a structured QI approach in enhancing VB compliance and reducing VAP incidence. There is a need for continued education, protocol standardization, and continuous monitoring to ensure the sustainability of this implementation.

Keywords: checklist; intensive care unit; nosocomial infection; quality improvement; ventilator-associated pneumonia.

Figure 1.

The root causes and associated sub-causes contributing to challenges in the effective implementation of the ventilator bundle protocol. VAP: ventilator associated pneumonia; APACHE: Acute Physiology and Chronic Health Evaluation.

Figure 2.

Key driver diagram for increasing ventilator bundle compliance. VAP: ventilator associated pneumonia; ICU: intensive care unit; DVT: deep venous thrombosis; SBT: Spontaneous Breathing Trials.

Figure 3.

Placard of ventilator bundle.

Figure 4.

Gantt chart for the quality improvement project. VAP: ventilator associated pneumonia; IRB: institutional review board; PDSA: Plan-Do-Study-Act; VB: ventilator bundle.

Figure 5.

Flowchart depicting inclusion of patients in the study. COPD: chronic obstructive pulmonary disease; ICU: intensive care unit.