The Centers for Disease Control and Prevention has reported that, each day in the United States, about 1 in every 31 hospital patients develops a health care–associated infection (HAI). This statistic is alarming; however, because the available data are limited by the scope and accuracy of reporting, the true prevalence and impact of HAIs are likely much larger. This article describes how a group of nurses in a pediatric cardiac intensive care unit (CICU) identified an overlooked infection, ventilator-associated tracheitis (VAT), that was occurring at concerning rates in their patient population and created and implemented an evidence-based prevention bundle to reduce the incidence of infection and improve patient outcomes.

Seattle Children’s Hospital is a 407-bed pediatric teaching hospital in Seattle, Washington. It is the pediatric referral center for the “WAMI” region, which includes Washington, Alaska, Montana, and Idaho. The 24-bed CICU serves patients from birth to young adulthood and...

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