Improving ICU Care: Reducing Complications from Ventilators and Central Lines

Cape Coral Hospital
Cape Coral, Florida, USA


The team from Cape Coral Hospital, Lee Memorial Health System, is a participant in IHI’s Learning and Innovation Community on Improving Outcomes for High Risk and Critically Ill Patients.

Lawrence Antonucci, MD, Chief Administrative Officer, Cape Coral Hospital
Marilyn Kole, MD, Corporate Medical Director, Lee Memorial Health System
Donna Giannuzzi, RN, Chief Nursing Officer, Lee Memorial Health System
Wendy Piascik, RN, Vice President for Patient Care Services, Cape Coral Hospital
Razak Dosani, MD, ICU Medical Director, Cape Coral Hospital
Abusayeed Feroz, MD, ICU Medical Director, Cape Coral Hospital
Annette Forlenza, RN, ICU Director, Cape Coral Hospital
Sharon Ballard, RN, ICU Case Manger
Trilla Barr, MSW, Q Life Social Worker
Thomas Brenner, ICU Chaplain
John Gough, RRT, Respiratory Therapy Supervisor
Colleen Higgins, MBA, Senior Decision Support Analyst, Cape Coral Hospital
Georgine Kruedelbach, RN, Infection Control Practitioner, Cape Coral Hospital
Judith Newbury, RN, ICU Educator, Cape Coral Hospital
Diane Sobel, RRT, Respiratory Therapy Manager
Sonia Rangeloff, ARNP, Q Life Nurse Practitioner
Sabrina Sanford, RN, ICU Staff Nurse
Sandra West, RN, ICU Staff Nurse
Kirsten Williams, Physical Therapy Supervisor



In keeping with our mission of achieving the best patient outcomes for the critically ill in Southwest Florida, our overall aim for this project is to improve care in our ICU. Our specific aims for this project are to reduce complications in both ventilators and central lines. We will know that we have achieved this by:

  • Eliminating ventilator-associated pneumonia (VAP) as evidenced by one year or more between episodes by 8/08
  • Decrease incidence of central line-associated bloodstream infections (CL-BSI) as evidenced by one year or more between infections by 8/08
Our hospital is also seeking to improve care in other areas, including reducing urinary tract infections, maintaining optimal blood glucose levels in patients, implementing a Palliative Care Bundle, and implementing an Early Warning System. 





We have made many changes since joining the IHI Learning and Innovation Community three years ago. Listed below are the ones that have had the greatest impact. They are reported by category of change.

Established Daily Goals
  • Multiple revisions of daily goal sheet improved team communication by providing pertinent information succinctly
  • Institute multidisciplinary rounds (MDR); anticipate risk; review goals
Improved Communication, Especially at Transitions
  • “Scripted” shift-to-shift report and multidisciplinary rounds to ensure communication of daily goals and other key content and ensure input from each discipline
  • Use of “check-out list” to ensure removal of ICU devices and transfer of information to the next level of care
  • Instituted open visiting hours in the ICU
  • Revised visitor handbook used to orient patients and families to the ICU
  • Used chalkboard to convey daily goals to families and allow them to share questions and concerns
Established Reliable Processes/Apply Best Science
  • Monitor reliability of Ventilator Bundle and Central Line Bundle use and identify areas for improvement
  • Focus on infection prevention and control
    • Aggressive hand washing campaign increased compliance from 40 percent to 90 percent
    • Provide waterless soap and disinfectant wipes in multiple convenient locations
    • Families and visitors educated on hand hygiene and infection control procedures
  • Eliminate catheter-related bloodstream infections: Use of Central Line Bundle
    • All CVP line insertions were monitored and bundle compliance was documented with the Process Improvement (PI) tool from IHI’s Campaign How-to Guide; over time spread monitoring to other units
    • Made central venous pressure (CVP) line dressing kits available; barrier components were “bundled”
    • Change policy on care of central lines to include use of chlorhexidine instead of Betadine and the use of a closed system for blood sampling
  • Eliminate ventilator-associated pneumonia 
    • Implemented Ventilator Bundle
    • Head of bed (HOB) at 30 degrees at all times, including during transport; physician order now required for variance and flyer on each ventilator: “Artificial airway = HOB at 30 degrees”
    • Banned routine Yankauer suction (switch to covered system); use of saline lavage for routine suctioning
    • Changes:
      • Mouth care provided every two hours
      • Ambu bags filtered for bacteria; discarded after 7 days
      • Enteral feeding system changed from “open” to closed system exclusively to reduce contamination 
      • Individual rolls of tape for each room to secure endotracheal tube (ETT)
      • Ventilator control panel/ tubing cleaned with antiseptic wipes every 12 hours
    • Supra-glottic suction by Respiratory Therapist every four hours and as needed by nursing staff (i.e., HOB lowered for care, prior to “road trips”)
    • Ensured equipment is available in radiology for supra-glottic suctioning
    • Metered dose inhaler (MDI) replaced all nebulizers





Summary of Results / Lessons Learned / Next Steps

  • Never doubt that a committed group of caring people can move mountains. Allow the people doing the work to identify the goals, discuss the barriers, and make the changes happen.  
  • Don’t “assume”! Don’t assume you are “already doing that.” Don’t assume everyone wants to change, even if it seems like the right thing to do.
  • Be transparent; provide clear and convincing evidence regarding practice changes; set clear expectations at the beginning and hold people accountable.
  • Always identify and include key players, including those who you know will be your biggest opponents; align agendas.

Contact Information
Annette Forlenza, RN
ICU Director
Cape Coral Hospital

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