ISSUE: With a mortality rate of 20-50%, pneumonia is the second most common heathcare associated infection (HAI) and the leading cause of HAI deaths with conservative cost estimates at over $1.2 billion annually. Over the last five years Overton Brooks VA Medical Center has utilized multiple performance improvement tools (i.e. Performance Improvement (PI) Model: Plan, Design, Measure, Assess and Improve, Process Action Team (PAT), Healthcare Failure Mode Effects and Analysis (HFMEA) team, and Root Cause Analysis (RCA) team) to successfully decrease rates of nosocomial aspiration pneumonia in their high risk patient population.

PROJECT: With the identification of increased rate of aspiration pneumonia in 1999, a multidisciplinary PAT was charter in January 2000 to review and evaluate tube feeding practices, policies, and equipment. In 2003 in an effort to further reduce aspiration pneumonia rates, a multidisciplinary HFMEA team investigated the vulnerabilities in current patient care processes. Due to the identification of a sentinel event, healthcare acquired aspiration pneumonia death, a RCA team was chartered in January 2005. In all team processes, data collection tools were developed, data was analyzed, continuous monitoring and educational tools were created.

RESULTS: The 2000 PAT recommendations resulted in the reduction of the 1999 aspiration pneumonia rate of 0.6/1000 patient days to 0.3 in 2000 and 0.2 in 2001. Recommendations from the 2003 HFMEA team resulted in the incidences of aspiration pneumonia related to vomiting and procedures decreasing from 0.5/1000 patient days in 2003 to 0.4 in 2004 and 0.2 in 2005. No further aspiration pneumonia related deaths have occurred since the implementation of the 2005 RCA recommendations.

LESSONS LEARNED: Each of the PI tools utilized over the past five years have proved successful in decreasing the HAI aspiration pneumonia rate. However, the use of multiple PI tools has allowed the focusing of interventions resulting in efficient and effective utilization of finite resources. Further, the continuous monitoring methods required with these PI tools are credited with maintaining the low incidence of aspiration pneumonia in this high risk population.