DefinitionVentilator-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. NOTE: 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 ventilator-associated pneumonia (VAP) rate is defined as the number of ventilator-associated pneumonias per 1,000 ventilator days. In this case, for a particular time period, we are interested in the total number of cases of ventilator-associated pneumonia in the ICU. For example, if in February there were 12 cases of VAP, the number of cases would be 12 for that month.
We want to be able to understand that number as a proportion of the total number of days that patients were on ventilators. Thus, if 25 patients were ventilated during the month and, for purposes of example, each was on mechanical ventilation for 3 days, the number of ventilator days would be 25 x 3 = 75 ventilator days for February. The Ventilator-Associated Pneumonia Rate per 1,000 Ventilator Days then would be 12/75 x 1,000 = 160.
Goal
Decrease the VAP rate per 1,000 ventilator days by 50 percent within 12 months.
Data Collection Plan
Report the monthly VAP rate for the last several months. This will serve as your baseline. Continue to track the measure monthly. If possible, track the rate in an annotated run chart, with notes reflecting any interventions you made to improve.
If your organization’s infection control practitioner reports data quarterly for other review or accreditation agencies, this data should be disaggregated and reported monthly.
Calculate this monthly measure as follows:
(Total number of VAPs in all ICUs) / (Total number of ventilator days in all ICUs) x 1,000
Sample Graph
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