Collaboration with ICU for VAP Reduction in Trauma Patients

General Information

Institution Name: Mercy Hospital Springfield

Author Name and Title: Liz Day BSN, RN, TCRN 

Name of Case Study: Collaboration with ICU for VAP Reduction in Trauma Patients

Identification of Local Problem

This problem was identified in early 2022 with our Spring 2022 TQIP report; our VAP numbers were an outlier in the tenth decile. This was then taken to the Neuro-Trauma ICU Manager for discussion with their team about nursing interventions to reduce VAP.

Context of the QI Activity

This activity was to address our high outlier of VAP in our trauma patients. These efforts were led by the Trauma Program Director, Trauma PI Coordinator, and Neurotrauma ICU nurse manager.

What were the interventions?

Interventions were both focused in on the PI process and the clinical care. Our PI coordinator collaborated with other Trauma Programs to develop a “VAP Worksheet,” which guides the evaluation of each suspected VAP through the same steps to ensure consistency and accuracy. This process is also only completed by one person, so there is no variance in identification.  Working with the ICU, we implemented consistent daily Trauma Rounds with a “rounding” tool that specifically addresses VAP protocol. These rounds include the Trauma Surgeon, Trauma Nurse Clinician, therapies, respiratory therapy, bedside nursing, charge nurse, and pharmacy. The ICU also implemented a tool called a K-Card, where management rounds on all intubated patients in the ICU to ensure that nurses are following all VAP protocols. This allows for real-time correction of any issues that need to be addressed and gives ownership to the ICU leadership team. The most important intervention was constant communication with the ICU team for collaboration and quality improvement.

Cost and Funding Sources

We had no costs with this project; it was a process change and collaboration with the nursing team.

Overall Results and Analysis

Overall, our work with the ICU team has shown great success through our TQIP report. In the Spring of 2022, we observed a 3.3% incidence of VAP, which was higher than the expected rate of 0.8%. Our most recent TQIP Report, released in the Fall of 2025, showed an observed rate of 0.4% for VAP, which aligns with the expected rate of 0.4%. Daily rounding continues Monday through Friday in the ICU, and the K-Cards are completed weekly by leadership. VAPs are tracked within our program and all are reviewed on, at minimum, a primary level.

Limitations

We did not identify any major limitations in this activity.

Lessons Learned

The largest lesson our team took from this was the importance of right relationships and collaboration with our nursing teams. There are no “problems” identified that can be solely fixed by our trauma program; we must rely on nursing and other specialties to work with our program to ensure high-quality patient care.