H-ER-O-S: A Quality Improvement Initiative to Reduce Ventilator-Associated Pneumonia in a Level IIIb Neonatal Intensive Care Unit of a Tertiary Care Public Hospital.

Objective: To reduce the ventilator-associated pneumonia (VAP) rate by improving the compliance of components of the VAP prevention bundle to > 90% over a period of 35 weeks.

Methods: This quality improvement study was conducted in the neonatal intensive care unit (NICU) of a tertiary care public hospital from May 2023 to March 2025. Baseline VAP rate was determined, and a team of all the stakeholders was formed. The problem was analyzed using various tools, and the main contributing factors for poor compliance with VAP bundle care were identified with the corresponding solution framed using the mnemonic H-ER-O-S: hand hygiene/head-end elevation, education/extubation readiness, oral care, suction care. Multiple plan-do-study-act (PDSA) cycles were done using point-of-care quality improvement (POCQI) methodology. The data were collected prospectively and analyzed regularly with the team members, and actions were planned accordingly.

Results: The VAP rate (per 1000 ventilator days) decreased significantly from 49.5 at baseline (May 2023) to 32.51 (95% CI 18.66-46.37) in the intervention phase and sustained at 6.40 (95% CI 4.58-8.93) for a consecutive 14 months (February 2024 till March 2025). The baseline compliance for components of VAP care bundle increased from 57.9% (95% CI 54.5-61.2) to 88.3% (95% CI 86.9-89.7) and was sustained for 14 months at 94.0% (95% CI 93.3-94.8, P < 0.001).

Conclusion: POCQI principles targeting the H-ER-O-S protocol help reduce VAP rates by increasing the compliance with the VAP care bundle.