Structural Assessment

AHRQ Safety Program for Mechanically Ventilated Patients

Date _____________ Hospital ________________________Unit________________________

This assessment is typically performed every 6 months. Please answer the following questions regarding your intensive care unit (ICU).

For patients who are intubated/have a tracheostomy, how often do you change the ventilator circuit?
- ___ Not routinely changed unless soiled or malfunctioning.
- ___ Routinely changed at regular interval; please specify in days ___________.
When used, how often do you change the closed endotracheal suction system?
- ___ Not used in this ICU.
- ___ Not routinely changed unless soiled or malfunctioning.
- ___ Routinely changed at regular interval; please specify in days ___________.
Does your ICU actively promote—

	Yes	No
Use of noninvasive ventilation protocol?	___	___
Early mobility protocol for patients receiving mechanical ventilation?	___	___

	Almost All the Time	More Than 50% of the Time	Less Than 50% of the Time	Almost Never
In the absence of a difficult airway, how often is an orotracheal route used for elective intubation in your ICU?	___	___	___	___
For patients receiving mechanical ventilation via an endotracheal tube, how often is a closed endotracheal suction system used in your ICU?	___	___	___	___
In your ICU, how often are patients placed with the head of bed elevated at least 30 degrees when there is no contraindication?	___	___	___	___
In your ICU, how often are standard precautions used while suctioning the respiratory tract?	___	___	___	___
In your ICU, how often do you take steps to ensure avoidance of gastric overdistention?	___	___	___	___
In your ICU, how often is condensate drained away from the patient while the circuit remains closed?	___	___	___	___
In your ICU, how often do health care providers perform hand hygiene before contact with respiratory equipment?	___	___	___	___
In your ICU, how often is an early mobility protocol used for patients receiving mechanical ventilation?	___	___	___	___

Regarding your written ICU, nursing, and/or respiratory therapy policies and procedures concerning patients receiving mechanical ventilation, is there guidance to—

	Yes	No
Avoid supine (flat) patient positioning unless clinically indicated (i.e., hemodynamic instability, orthopedic injury, etc.)?	___	___
Use standard precautions while suctioning the respiratory tract secretions?	___	___
Avoid nonessential tracheal suctioning?	___	___
Avoid gastric overdistention?	___	___
Periodically remove condensate from circuits?	___	___
Ensure that circuits are closed during removal of condensate to assure that condensate doesn’t drain toward the patient?	___	___
Perform hand hygiene before contact with respiratory equipment?	___	___