This online tutorial series "Quality Improvement: Tool Time" reinforces practical application of tools and competencies acquired during the live activity. Each Tool is a combination of faculty commentary on essentials in clinical practice, links to relevant scientific publications, and a printable handout that will serve as a reminder. Please select the topic:
  1. Ensuring Quality of Care 
  3. Optimizing Vancomycin for MRSA Infections
  5. Selecting Appropriate Therapy for ESBL- and KPC-Producers
  7. Dosing Strategies for MDR P. aeruginosa/A. baumannii Infections
  9. Adjusting Antimicrobial Regimens for Efficacy and Safety

Ensuring Quality of Care

Quality of Care and HAIs:
The Implications

Dr. David Burgess discusses
current healthcare environment

Today’s healthcare environment is characterized by an emphasis on improving patient quality of care and increasing transparency for hospital-acquired conditions. Institutions failing to abide by federal mandates will likely face financial consequences, notably non-reimbursement for conditions considered preventable. In 2009, the Centers for Medicare & Medicaid Services announced 8 hospital-acquired conditions that would no longer be reimbursed, and of these, 3 are infection-related. Other HAIs being considered for addition to this list include ventilator-associated pneumonia and C. difficile infections. A renewed focus on improving quality of care has placed emphasis on preventing HAIs.

Non-Payment for
Hospital-acquired Conditions
  1. Foreign object inadvertently left in patients after surgery
  2. Air embolism
  3. Transfusion with the wrong type of blood
  4. Severe pressure ulcers
  5. Catheter-associated UTI
  6. Vascular catheter-associated infection
  7. Surgical site infection following CABG
  8. Hospital-acquired injury due to external causes such as falls and other trauma
Using Bundled Approaches of Care to Prevent HAIs
Many studies involving the use of bundled approaches reveal that the vast majority of HAIs are preventable.[1-4]

CR-BSI: Keystone ICU Project


The Keystone ICU Project evaluated the effectiveness of a state-wide multidisciplinary program in reducing the incidence of catheter-related bloodstream infections (CR-BSIs).[1,2] This study involving 103 of the 108 ICUs in Michigan assessed the impact of implementing a bundled approach of care for all patients requiring a catheter. Following its implementation, the median rate of CR-BSIs significantly decreased from 2.7 to 0 per 1000 catheter-days (P>.002) within 3 months and remained at 0 per 1000 catheter-days during the 16–18-month sustainability period.

Keystone ICU Project Bundled Approach
  1. Hand-washing
  2. Full barrier precautions during CVC insertion
  3. Cleaning the skin with chlorhexidine
  4. Avoiding femoral site
  5. Removing unnecessary CVCs

VAP: Institute for
Healthcare Improvement


To reduce the incidence of ventilator-associated pneumonia (VAP) the Institute for Healthcare Improvement (IHI) in its “5 Million Lives Saved” program recommends a respiratory bundle be used for all patients requiring mechanical ventilation.

IHI’s Respiratory Bundle
  1. Elevation of the head of the bed
  2. Daily "sedation vacations" and assessment of readiness to extubate
  3. Peptic ulcer disease prophylaxis
  4. Deep venous thrombosis prophylaxis

VAP: University Hospital in France


In a report recently published in Critical Care Medicine, a French institution implemented a multifaceted program to improve adherence on 8 targeted measures aimed to reduce the incidence of VAP.[4] The program included a multidisciplinary task force, educational sessions, direct observations with performance feedback, technical improvements, and the use of reminders. Compliance for each of the targeted measures improved at the 1-, 6-, and 12-month periods while the prevalence of VAP decreased by 51%.

VAP Targeted Measures, France
  1. Hand hygiene adherence
  2. Glove-and-gown adherence
  3. Correct backrest elevation maintenance
  4. Correct tracheal tube cuff-pressure maintenance
  5. Use of an orogastric tube (rather than a nasogastric tube)
  6. Gastric overdistension avoidance
  7. Good oral hygiene
  8. Elimination of nonessential tracheal suction


  1. Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med. 2006;355:2725-2732.
  2. Pronovost PJ, Goeschel CA, Colantuoni E, et al. Sustaining reductions in catheter-related bloodstream infections in Michigan intensive care units: observational study. BMJ. 2010;340:c309.
  3. Weireter LJ Jr, Collins JN, Britt RC, Reed SF, Novosel TJ, Britt LD. Impact of a monitored program of care on incidence of ventilator-associated pneumonia: results of a longterm performance-improvement project. J Am Coll Surg. 2009;208:700-4; discussion 704-5.
  4. Bouadma L, Mourvillier B, Deiler V, et al. A multifaceted program to prevent ventilator-associated pneumonia: impact on compliance with preventive measures. Crit Care Med. 2010;38:789-796.

Suggested Reading
Vincent JL, Rello J, Marshall J, et al. International study of the prevalence and outcomes of infection in intensive care units. JAMA. 2009;302:2323-2329.
This one-day, prospective, point-prevalence study involved 1265 ICUs in 75 countries to provide an up-to-date international picture of the extent and patterns of infections in the ICU. On the day of the study, over 50% of 13,796 ICU patients were infected and 71% were receiving antimicrobials.

Roberts RR, Hota B, Ahmad I, et al. Hospital and societal costs of antimicrobial-resistant infections in a Chicago teaching hospital: implications for antibiotic stewardship. Clin Infect Dis. 2009;49:1175-1184.
This study was performed to measure the medical and societal cost attributable to antimicrobial-resistant infection (ARI). Of the 1391 high-risk hospitalized patients included in the study, 13.5% had an ARI. ARI presence resulted in significantly higher medical costs, LOS, and attributable mortality. Studies such as this can help support the clinical and economic benefits of prevention programs.

Wip C, Napolitano L. Bundles to prevent ventilator-associated pneumonia: how valuable are they? Curr Opin Infect Dis. 2009;22:159-166.
This review carefully evaluates the effectiveness of various components of care bundles in preventing ventilator-associated pneumonia. Though some components were shown to not directly impact the incidence of VAP (such as prophylaxis for peptic ulcer disease and deep vein thrombosis), several others were found to be effective and should be considered for inclusion in a modified or expanded VAP bundle.