1. ©Copyright 2010 IHI/R. Lloyd Measurement Plan Worksheet VAP Measure NameType (Process, Outcome or Balancing) Driver addressed by this measure Operational Definition 1. Number of days between episodes of VAP. OutcomeAimNumber of days since last diagnosed VAP. 2. Rate of patients with VAP per 1000 ventilator days. OutcomeAImNumerator – Number of patients with diagnosed VAP Denominator – Number of ventilator days Per 1000 days - divide the numerator by the denominator and then multiply by 1000. 3. Percentage of ventilated patients who received all aspects of the VAP care bundle. ProcessStandardised care of the ventilated patient.  Measure 5-10 random patients per week  Measured during ongoing care of patient.  Numerator – total no of patients who received all process measures.  Denominator - total no of patients in sample.  % - divide the numerator by the denominator and then multiply by 100 4. Percentage of patients who received appropriate head of bed elevation. ProcessStandardised care of the ventilated patient.  Measure 5-10 random patients per week.  Measured during ongoing care of patient.  Neonates in babytherm - 15 degrees / children at least 30 degrees  Numerator – total no of patients who received appropriate head of bed elevation.  Denominator - total no of patients in sample.  % - divide the numerator by the denominator and then multiply by 100. 5. Percentage of patients with dependant ventilator tubing. ProcessStandardised care of the ventilated patient.  Measure 5-10 random patients per week.  Patients with visible south facing ventilator tubing which will prevent condensate dripping into ETT.  Numerator – total no of patients who have dependant ventilator tubing.  Denominator - total no of patients in sample.  % - divide the numerator by the denominator and then multiply by 100. 6. Percentage of patients not receiving routine instillation of saline during suction. ProcessStandardised care of the ventilated patient.  Measure 5-10 random patients per week.  Checking of nursing documentation for that day to identify whether or not saline was administered routinely ( each time) during suction. – yes / no  Numerator – total no of patients who did not receive routine installation of saline.  Denominator - total no of patients in sample.  % - divide the numerator by the denominator and then multiply by 100.

2. ©Copyright 2010 IHI/R. Lloyd Measure NameType (Process, Outcome or Balancing) Driver addressed by this measure Operational Definition 7. Percentage of patients receiving a daily review of sedation. ProcessDaily assessment of readiness to wean and extubate.  Measure 5-10 random patients per week.  Check daily goals sheet to evidence whether there was discussion re ability to wean sedation. Yes / no  Numerator – total no of patients who had a documented plan re ability to wean.  Denominator - total no of patients in sample.  % - divide the numerator by the denominator and then multiply by 100. 8. Percentage of patients receiving a daily review of ventilation. ProcessDaily assessment of readiness to wean and extubate  Measure 5-10 random patients per week.  Check daily goals sheet to evidence whether there was discussion re ability to wean ventilation. Yes / no  Numerator – total no of patients who had a documented plan re ability to wean.  Denominator - total no of patients in sample.  % - divide the numerator by the denominator and then multiply by 100. 9. Percentage of patients receiving x2 daily teeth brushed. ProcessStandardised oral hygiene. Measure 5-10 random patients per week.  Numerator – total no of patients who had documented evidence of teeth brushed x 2 daily. (patients with coagulopathy or heparinised to be marked as exemption)  Denominator - total no of patients in sample.  % - divide the numerator by the denominator and then multiply by 100. 10. Percentage of patients receiving 12 hourly chlorahexadine gel. ProcessStandardised oral hygiene. Measure 5-10 random patients per week.  Numerator – total no of patients > 1yr who had a documented evidence of receiving chlorahexadine gel 12hrly.  Denominator - total no of patients in sample.  % - divide the numerator by the denominator and then multiply by 100. 11. Number of unplanned extubations BalancingDaily assessment of readiness to wean and extubate Count per month of patients who extubated which was not co-ordinated by medical or nursing staff. 12. Number of blocked ETT.BalancingStandardised care of the ventilated patient. Count per month of patients who required their ETT to be changed which was visibly blocked with secretions on removal.