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Rebound in ventilator-associated pneumonia rates during a prevention checklist washout period
  1. Ali A Cheema1,
  2. Annette M Scott2,
  3. Karen J Shambaugh2,
  4. Jacqueline N Shaffer-Hartman3,
  5. Ronald E Dechert3,
  6. Susan M Hieber3,
  7. John W Gosbee3,
  8. Matthew F Niedner2
  1. 1Department of Health Management and Policy, University of Michigan, School of Public Health, Ann Arbor, Michigan, USA
  2. 2Pediatric Intensive Care Unit, University of Michigan, Ann Arbor, Michigan, USA
  3. 3University of Michigan Health System, Ann Arbor, Michigan, USA
  1. Correspondence to Matthew F Niedner, Associate Medical Director, Paediatric Intensive Care Unit, Assistant Professor of Pediatrics and Communicable Diseases, Paediatric Critical Care Medicine and Paediatric Palliative Care Service, University of Michigan Medical Center, Mott Children's Hospital, 1500 East Medical Center, Ann Arbor, MI 48109-0243, USA; mniedner{at}


Objective To describe the washout effect after stopping a prevention checklist for ventilator-associated pneumonia (VAP).

Methods VAP rates were prospectively monitored for special cause variation over 42 months in a paediatric intensive care unit. A VAP prevention bundle was implemented, consisting of head of bed elevation, oral care, suctioning device management, ventilator tubing care, and standard infection control precautions. Key practices of the bundle were implemented with a checklist and subsequently incorporated into the nursing and respiratory care bedside flow sheets to achieve long-term sustainability. Compliance with the VAP bundle was monitored throughout. The timeline for the project was retrospectively categorised into the benchmark phase, the checklist phase (implementation), the checklist washout phase, and the flowsheet phase (cues in the flowsheet).

Results During the checklist phase (12 months), VAP bundle compliance rose from <50% to >75% and the VAP rate fell from 4.2 to 0.7 infections per 1000 ventilator days (p<0.059). Unsolicited qualitative feedback from frontline staff described overburdensome documentation requirements, form fatigue, and checklist burnout. During the checklist washout phase (4 months), VAP rates rose to 4.8 infections per 1000 ventilator days (p<0.042). In the flowsheet phase, the VAP rate dropped to 0.8 infections per 1000 ventilator days (p<0.047).

Conclusions Salient cues to drive provider behaviour towards best practice are helpful to sustain process improvement, and cessation of such cues should be approached warily. Initial education, year-long habit formation, and effective early implementation demonstrated no appreciable effect on the VAP rate during the checklist washout period.

  • Paediatric critical care
  • ventilator-associated pneumonia
  • checklists
  • form fatigue
  • human factors engineering
  • inattentional blindness
  • continuous quality improvement
  • human factors
  • PDSA
  • significant event analysis
  • statistical process control

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  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.