No VAP around here: How one hospital saw a 52% reduction

Memorial Hospital of South Bend | 368-bed hospital

Memorial Hospital of South Bend is a 368-bed hospital in South Bend, Ind., with a 36-bed NICU unit. The hospital’s VAP rates exceeded the national baseline (10 per 1,000 vent days) for two years in a row. Memorial Hospital set a goal to reduce the NICU VAP rate by 25% by the end of 2013.

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Striving to eliminate NICU VAPs

Tangible Impact

$95,753

Avoided NICU inpatient costs

65.8

Avoided NICU inpatient days

Memorial Hospital of South Bend used Quality Compass for data mining and reviewing NHSN surveillance definitions to establish a baseline for which the institution should try to meet. Next, the hospital established a VAP committee to analyze and instill policy change, and perform staff education on technique and new policies.

The committee evaluated existing practices in comparison to national best practices and developed recommendations for policy changes that included:

  • Move to Ballard suctioning system end caps
  • Respiratory therapists perform all circuit changes and education sessions on ambu bags
  • Implement a buddy system for disconnecting, kangaroo care, and turning heads
  • Create a VAP bundle drop-down in the EMR system

Quality Compass maximized the analytical capabilities and assisted with continuous monitoring. By the end of 2013, Memorial Hospital of South Bend experienced a 52% reduction in NICU VAP, resulting in a 4.99 rate.


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