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• Changes to Prevent Healthcare-Associated Infections
  Organizations must test and implement changes to existing processes in order to prevent healthcare-associated infections (HAIs).
• How-to Guide: Improving Hand Hygiene
  This How-to Guide is designed to help organizations reduce healthcare-associated infections, including infections due to antibiotic-resistant organisms, by improving hand hygiene practices and use of gloves among health care workers.
• How-to Guide: Prevent Catheter-Associated Urinary Tract Infection
  This How-to Guide describes key evidence-based care components for preventing catheter-associated urinary tract infections, describes how to implement these interventions, and recommends measures to gauge improvement.
• How-to Guide: Reduce MRSA Infection
  This How-to Guide describes key evidence-based care components for reducing methicillin-resistant Staphylococcus aureus (MRSA) infections, describes how to implement these interventions, and recommends measures to gauge improvement.

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• Administer Low-Dose Steroids by a Standard Policy
  Initiate low-dose steroids for septic shock in accordance with a standardized ICU policy
• Apply Vasopressors for Ongoing Hypotension
  Use of vasopressors in the presence of mean arterial pressures (MAP) less than 65 mm Hg is an essential practice to promote tissue perfusion and prevent worsening organ dysfunction.
• Blood Cultures Obtained Prior to Antibiotic Administration
  Checking blood cultures prior to antibiotic administration offers the best hope of identifying the causative organism for severe sepsis.
• Changes to Prevent Healthcare-Associated Infections
  Organizations must test and implement changes to existing processes in order to prevent healthcare-associated infections (HAIs).
• IHI Central Line Bundle: Chlorhexidine Skin Antisepsis
  Ensure chlorhexidine skin antisepsis to prevent contamination of central line sites and bloodstream infections.
• IHI Central Line Bundle: Daily Review of Line Necessity with Prompt Removal of Unnecessary Lines
  Ensure daily review of line necessity with prompt removal of unnecessary lines to prevent bloodstream infections.
• IHI Central Line Bundle: Hand Hygiene
  Ensure adequate hand hygiene to prevent contamination of central line sites and bloodstream infections.
• IHI Central Line Bundle: Maximal Barrier Precautions Upon Insertion
  Ensure application of maximal barrier precautions to prevent contamination of central line sites and bloodstream infections.
• IHI Central Line Bundle: Optimal Catheter Site Selection, with Avoidance of the Femoral Vein for Central Venous Access in Adult Patients
  Whenever possible, and not contraindicated, the femoral site should be avoided and the subclavian line site should be preferred over the jugular and femoral sites for non-tunneled catheters in adult patients to reduce the likelihood of infectious complications.
• IHI Ventilator Bundle: Daily "Sedation Vacations" and Assessment of Readiness to Extubate
  Using daily "sedation vacations" and assessing the patient’s readiness to extubate is an integral part of the Ventilator Bundle and has been correlated with reduction in the rate of ventilator-acquired pneumonia.
• IHI Ventilator Bundle: Daily Oral Care with Chlorhexidine
  Oral decontamination of mechanically ventilated adults using chlorhexidine is associated with a lower risk of ventilator-associated pneumonia. The recommended chlorhexidine solution strength is 0.12%.
• IHI Ventilator Bundle: Deep Venous Thrombosis Prophylaxis
  Applying deep venous thrombosis prophylaxis is an appropriate intervention in all patients who are sedentary, however the higher incidence of deep venous thrombosis in critical illness justifies greater vigilance.
• IHI Ventilator Bundle: Elevation of the Head of the Bed
  Elevation of the head of the bed is an integral part of the IHI Ventilator Bundle and has been correlated with reduction in the rate of ventilator-associated pneumonia.
• IHI Ventilator Bundle: Peptic Ulcer Disease Prophylaxis
  Applying peptic ulcer disease prophylaxis is an appropriate intervention in all patients who are sedentary, however the higher incidence of stress ulceration in critical illness justifies greater vigilance.
• Implement the IHI Central Line Bundle
  The IHI Central Line Bundle is a series of interventions that helps to decrease the incidence of catheter-related bloodstream infections.
• Implement the IHI Ventilator Bundle
  Reducing mortality due to ventilator-associated pneumonia requires an organized process that guarantees the early recognition of pneumonia along with the uniform and consistent application of the best evidence-based practices.
• Implement the Sepsis Management Bundle
  Reducing mortality due to severe sepsis requires an organized process that guarantees the early recognition of severe sepsis along with the uniform and consistent application of evidence-based practices
• Implement the Sepsis Resuscitation Bundle
  Reducing mortality due to severe sepsis requires an organized process that guarantees the early recognition of severe sepsis along with the uniform and consistent application of evidence-based practices
• Improve Time to Broad-Spectrum Antibiotics
  Once severe sepsis is identified, antibiotics must be started rapidly to treat the underlying infection
• Maintain Adequate Central Venous Oxygen Saturation
  In severely septic patients with lactate > 4 mmol/L (36 mg/dl) or in those with hypotension not responding to initial fluid resuscitation (septic shock) once central venous pressure has been maintained >= 8 mm Hg, central venous oxygen saturation should be maintained >= 70 percent.
• Maintain Adequate Central Venous Pressure
  The fluid resuscitation should be sufficient in severely septic patients with lactate > 4 mmol/L (36 mg/dl) or in those with hypotension not responding to initial fluid resuscitation (septic shock) to maintain CVP > 8 mm Hg
• Maintain Adequate Glycemic Control
  Maintain serum glucose levels less than 150 mg/dL in order to improve recovery in severe sepsis.
• Prevent Excessive Inspiratory Plateau Pressures
  Treat severely septic patients who require mechanical ventilation with a lung protective strategy that maintains plateau pressures < 30 cm H2O.
• Serum Lactate Measured
  Given the high risk for septic shock, all patients with elevated lactate greater than 4 mmol/L (36 mg/dl) enter the early goal-directed therapy portion of the Severe Sepsis Resuscitation Bundle, regardless of blood pressure.
• Treat Hypotension and/or Elevated Lactate with Fluids
  Patients with hypoperfusion or shock require a vigorous intravenous fluid challenge to expand effectively their circulating volume.

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• Central Line Bundle Compliance
  The compliance measure is an assessment of how well the team is adhering to the entire Central Line Bundle, not just parts of the bundle.
• Central Line Catheter-Related Bloodstream Infection (CR-BSI) Rate per 1,000 Central-Line Days
  The catheter-related bloodstream infection rate is defined as the number of central line catheter-related blood stream infections per 1,000 central line days.
• Central Venous Oxygen Saturation Goal
  A measure of compliance with the Sepsis Resuscitation Bundle element. In the event of persistent hypotension despite fluid resuscitation (septic shock) and/or lactate 4 mmol/L (36 mg/dl), achieve central venous oxygen saturation (ScvO2) of 70 percent.
• Central Venous Pressure Goal
  A measure of compliance with the Sepsis Resuscitation Bundle element. In the event of persistent hypotension despite fluid resuscitation (septic shock) and/or lactate 4 mmol/L (36 mg/dl), achieve central venous pressure (CVP) of 8 mm Hg.
• Evaluation of Glycemic Control
  Measure of control of glucose which can reduce a patient's risk for infections and mortality.
• Glycemic Control Goal
  Current literature suggests appropriate glycemic control in the ICU reduces morbidity and overall mortality in the critically ill.
• Incidence of Severe Hypoglycemic Episodes
  The aim is to achieve glucose control less than 180 mg/dl in 100 percent of critically ill patients without increased incidence of severe hypoglycemia
• Inspiratory Plateau Pressure Goal
  A measure of compliance with Sepsis Management Bundle element. Inspiratory plateau pressures maintained 30 cm H2O for mechanically ventilated patients.
• Low-Dose Steroid Administration
  A measure of compliance with the Sepsis Management Bundle element. Low-dose steroids administered for septic shock in accordance with a standardized ICU policy.
• Measures to Prevent Healthcare-Associated Infections
  It is important to track three types of measures when you are working to reduce healthcare-associated infections (HAIs).
• Measures: Prevent Central Line Infection
  Care teams should measure each of the evidence-based interventions recommended by the How-to Guide: Prevent Central Line Infection.
• Mortality Due to Severe Sepsis and Septic Shock
  A measure of mortality due to severe sepsis and septic shock.
• Reliability: Sepsis Management Bundle
  A measure of compliance with all elements of the Sepsis Management Bundle.
• Reliability: Sepsis Resuscitation Bundle
  A measure of compliance with all elements of the Sepsis Resuscitation Bundle.
• Timing of Antibiotics
  A measure of compliance with the Sepsis Resuscitation Bundle element. Median time in minutes to broad-spectrum antibiotic(s) administration from time of presentation.
• Timing of Blood Cultures
  A measure of compliance with the Sepsis Resuscitation Bundle element. Blood cultures collected before broad-spectrum antibiotic administration.
• Ventilator Bundle Compliance
  Compliance with the Ventilator Bundle is defined as the percentage of intensive care patients on mechanical ventilation for whom all four of the elements of the Ventilator Bundle are documented on daily goals sheets and/or elsewhere in the medical record.
• Ventilator-Associated Pneumonia (VAP) Rate per 1,000 Ventilator Days
  Ventilator-associated pneumonia (VAP) is defined as pneumonia in a patient intubated and ventilated at the time of or within 48 hours before the onset of the event. (There is no minimum period of time that the ventilator must be in place in order for the pneumonia to be considered ventilator-associated.) The VAP rate is defined as the number of ventilator-associated pneumonias per 1,000 ventilator days

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• Sepsis Resuscitation Checklist
  
  This checklist is used when a patient presents with severe sepsis or septic shock to provide a quick picture of the immediate goals of treatment, with a prioritized list of interventions to be completed within the first hour and within the first six hours of sepsis resuscitation.
• Ventilator Bundle Checklist
  
  This checklist helps track compliance with implementing each element of the IHI Ventilator Bundle.
• How-to Guide: Prevent Central Line-Associated Bloodstream Infection
  
  This How-to Guide describes key evidence-based care components of the IHI Central Line Bundle which has been linked to prevention of central line-associated bloodstream infections, describes how to implement these interventions, and recommends measures to gauge improvement.
• How-to Guide: Prevent Ventilator-Associated Pneumonia
  
  This How-to Guide describes key evidence-based care components of the IHI Ventilator Bundle which has been linked to prevention of ventilator-associated pneumonia.
• How-to Guide: Prevent Catheter-Associated Urinary Tract Infection
  
  This How-to Guide describes key evidence-based care components for preventing catheter-associated urinary tract infections, describes how to implement these interventions, and recommends measures to gauge improvement.
• CDC Guideline for Prevention and Control of Catheter-Associated Urinary Tract Infections (2009)
  
  This 2009 guideline updates and expands the original Centers for Disease Control and Prevention (CDC) Guideline for Prevention of Catheter-Associated Urinary Tract Infections (CAUTI) published in 1981.
• Mechanical Ventilation Liberation Protocol
  
  This Respiratory Therapist-driven protocol provides assessment criteria for readiness to implement a Spontaneous Breathing Trial.
• Sedation Interruption Protocol
  
  This nurse-driven algorithm provides inclusion and exclusion criteria for implementing appropriate daily sedation interruption for patients on continuous sedation.
• Scrub the Hub: Example Posters
  
  These example posters are used to remind staff to scrub the hub of a central line prior to accessing the line to instill medications or draw blood, in an effort to reduce potential central line-associate bloodstream infections.
• Sepsis Definitions
  
  Detailed definitions of and parameters for "severe sepsis" (including general and inflammatory variables) and severe sepsis (including organ dysfunction, tissue perfusion, and hemodynamic variables).
• Sepsis Measures
  
  This tool is a listing of all the measures related to the Sepsis Bundle with their associated specifications.
• Medical-Surgical Intensive Care Unit Daily Sedation Vacation Protocol
  
  This protocol is used by staff in medical-surgical intensive care units to remove patients from continuous IV drip sedation as soon as is medically feasible
• Evaluation for Severe Sepsis Screening Tool
  
  A single page document to assess whether patients in the emergency department, the clinical wards, or the intensive care unit meet criteria for entry into a severe sepsis treatment protocol.
• Surviving Sepsis Campaign Chart Review Database
  
  The Chart Review Database graphs your chart abstraction data and produces flow charts documenting your improvement efforts for the Severe Sepsis Quality Indicators.
• How-to Guide: Improving Hand Hygiene
  
  This How-to Guide is designed to help organizations reduce healthcare-associated infections, including infections due to antibiotic-resistant organisms, by improving hand hygiene practices and use of gloves among health care workers.
• Interim Glucocorticoid Administration Policy
  
  This policy was designed to account for the best known science regarding use of low-dose steroids and provides the user choice in whether to use glucocorticoids based upon several known contraindications and the option to declare other relative contraindications.
• Sepsis Median Plateau Pressure Calculation Tool
  
  Use this optional tool for easy calculation of the median inspiratory plateau pressure for a mecahnically ventilated patient with severe sepsis within the first 24 hours of presentation, then enter this data in the Sepsis Individual Chart Measurement Tool.
• Central Line Insertion Checklist
  
  Implementing a central line checklist at the time of insertion will help to ensure a reliable process.
• Sample Business Case for Reducing Ventilator-Associated Pneumonia
  
  This document provides a sample business case for reducing ventilator-associated pneumonia.
• Business Profile for Reducing Ventilator-Associated Pneumonia
  
  This example of a business profile stating the need for work to reduce ventilator-associated pneumonia explores the projected impact on resources for a hospital participating in such an initiative.
• Hospital-Acquired Venous Thromboembolism (VTE) Incidence Calculator
  
  Use this calculator tool to estimate the number of hospital-acquired venous thromboembolism (VTE) at your hospital, and the proportion that are potentially preventable.
• Infection Prevention Plus Measures Toolkit
  
  A toolkit for reducing healthcare-associated infections, including references, product information and tools.
• Patient Guides on Healthcare-Associated Infections
  
  These fact sheets for patients and families provide answers to frequently asked questions about various healthcare-associated infections.
• Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals
  
  The Compendium distills current guidelines for the prevention of healthcare-associated infections and includes recommendations for implementation in the clinical setting, along with metrics and indicators of success.
• Contact Precautions Monitoring Tool
  
  This data collection tool is used to monitor whether providers practice contact precautions and hand hygiene with patients in isolation.

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• Author in the Room: Gastric Acid-Suppressive Agents and C. difficile Risk
  
  January 2006 | A discussion with the author of the JAMA article "Use of Gastric Acid-Suppressive Agents and the Risk of Community-Acquired Clostridium difficile-Associated Disease."
• Author in the Room: Invasive MRSA Infections in the US
  
  November 2007 | A discussion with the author of the JAMA article "Invasive Methicillin-Resistant Staphylococcus aureus (MRSA) Infections in the United States."
• Passport Exclusive: Preventing Venous Thromboembolism in Hospitalized Patients
  
  This video addresses how to accurately and effectively identify VTE risk factors and how to implement those processes in your facility.
• Quality and Patient Safety on the Radio
  
  This series of downloadable podcasts on XM Radio's ReachMD taps into the thinking and activity of the quality improvement movement and features IHI experts and leaders.

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• Passport Exclusive: Developing, Testing, and Locally Adapting Sedation Protocols
  
  In this video, IHI faculty member Dr. Terry Clemmer details the steps to develop and test a sedation protocol at your organization.
• Passport Exclusive: Establishing Nurse-Driven Protocols
  
  Developing nursing protocols that allow for removal of urinary catheters if criteria for necessity are not met and there are no contraindications for removal (as defined in protocol) is one change that could lead to a reduction in unnecessary urinary catheterization.
• Passport Exclusive: Improving ICU Sedation and Delirium Monitoring
  
  In this video, Dr. Ely shares reliable tools for improving ICU sedation and delirium monitoring.
• Passport Exclusive: Reliable Practices to Prevent Hospital-Acquired Infections
  
  In this video, IHI Director Fran Griffin, RRT, MPA, reviews principles of reliability with examples to improve infection prevention processes.
• Passport Exclusive: Strategies to Prevent Catheter-Associated Urinary Tract Infections
  
  In this video IHI Director Fran Griffin, RRT, MPA reviews the four recommended components of care and the supporting evidence for improvement outlined in the Prevent Catheter-Associated Urinary Tract Infections How-to Guide.
• Passport Exclusive: Taking Steps to Improve Patient Mobility
  
  This video describes the effects of early activity for patients in the intensive care unit.
• Passport Exclusive: The Sepsis Bundle
  
  In this video, IHI faculty member Dr. Sean Townsend gives an overview of the Sepsis Bundle and how to get started on this work.