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Infection Prevention

Ventilator Associated Pneumonia

What are we measuring?

The percentage of intensive care patients on ventilators receiving all of the interventions known as the "ventilator bundle."

Why is this important?

Ventilator Associated Pneumonia (VAP) is a serious lung infection that can develop in patients who are put on ventilators (a machine to help them breathe). Doctors, nurses, and respiratory therapists can help to prevent VAP by implementing the ventilator bundle.

What is our most recent performance and trend?


What are we doing to improve our performance?

The ventilator bundle includes:

  • Elevation of the head of the bed
  • Daily removal of sedation medication
  • Daily assessment of a patients' readiness to breathe off the ventilator.
  • Medication to prevent stomach ulcers
  • Preventing blood clots when a patient is bedridden

Central Line Bloodstream Infections

What are we measuring?

The rate of patients with healthcare-associated central line bloodstream infections in intensive care units.

Note: Hospitals use different ways to calculate rates. We calculate our rates using 1000 catheter days as the denominator.

Why is this important?

A central line is a device inserted directly into a major blood vessel to allow delivery of medications and fluids. Patients in ICUs may also have these lines placed to monitor their condition.  Sometimes central lines can become infected. These infections can be very serious because they can lead to damage of other vital organs.

What is our most recent performance and trend?

*The Internal Benchmark for FY 2015 is the mean FY 2014 rate for all intensive care units combined.  

What are we doing to improve our performance?

We are working to reduce the risk of these infections by providing a special insertion kit, standardizing the insertion and care of central lines, and providing daily surveillance of central lines. We review every healthcare-associated bloodstream infection that occurs to determine its cause so corrective measures can be taken that may prevent future infections.

Hand Hygiene

What are we measuring?

Hand hygiene performance in intensive care units (ICUs) and in general medical-surgical wards.

Why is this important?

Hand hygiene is the cleaning of the hands with either soap and water or an alcohol-based agent. It is the single most important way to prevent the spread of infection.

What is our most recent performance and trend?


*There are no benchmarks for Hand Hygiene. The current internal goal is 90% due to potential inaccuracies in the measurement system and will be increased to 100% over time.

Note that different hospitals measure hand hygiene performance differently, so that rates may not be directly comparable. BIDMC's hand hygiene performance rate is calculated by measuring the expected soap and hand-sanitizer usage based on the number of patients on the units as well as spot checks through direct observation of practice throughout the hospital. While some individual units have achieved or surpassed goal in each period, there are enough sufficient outliers that we have not met our overall goal. Hand hygiene performance continues to show some improvement in all patient care units, most significantly in the intensive care units, but we won't be satisfied until we reach our goal in all units.

What are we doing to improve our performance?

The specific steps we are taking to improve performance include:

  • Making sure that soap and water, as well as alcohol-based hand cleaners are easily accessible.
  • Educational campaigns
  • Feedback to all units and recognition for high achieving units

Other Publicly Reported Measures:

Last updated: October 2015

Contact Information

Silverman Institute for Health Care Quality and Safety
Beth Israel Deaconess Medical Center
330 Brookline Ave
Boston, MA 02215