Population  of  interest

All patients receiving mechanical ventilation.

Intent  (Expected  Outcomes)

  • Incidence of VAP is tracked in each ICU and for the system as a whole.
  • Mechanically ventilated patients receive VAP bundle.

Performance/Adherence  Metrics

  • Number and percentage of mechanically ventilated patients who develop VAP, tracked for each role 3 and 4 separately and overall for the system as a whole.
  • Number and percentage of patients who have daily sedation interruption and spontaneous breathing trial or contraindication documented.

DATA  SOURCES

  • Patient Record
  • Department of Defense Trauma Registry (DoDTR)

System Reporting & Frequency

The above constitutes the minimum criteria for PI monitoring of this CPG. System reporting will be performed annually; additional PI monitoring and system reporting may be performed as needed.

The system review and data analysis will be performed by the Joint Trauma System (JTS) Director, JTS Program Manager, and the JTS PI Branch.

Responsibilities

It is the trauma team leader’s responsibility to ensure familiarity, appropriate compliance and PI monitoring at the local level with this CPG.