呼吸器是加護病房病人常見的醫療儀器，呼吸器相關肺炎的產生會增加加護病房住院天數及死亡率，美國醫療品質策進會提出組合式介入措施能有效降低呼吸器相關肺炎的發生。本單位醫護人員執行呼吸器相關肺炎組合式介入措施之完整率僅42%，其完整率低原因為：(一)未落實每日拔管評估；(二)口腔護理照護不完整；(三)床頭抬高未達30度；(四)排空呼吸器管路積水時機不足。改善對策為規劃拔管評估時機、規劃教育訓練、規劃落實「床頭抬高措施」、規劃排空呼吸器管路積水時機等措施。經專案介入後，醫護人員在執行呼吸器相關肺炎組合式介入措施完整率提升至96%，呼吸器相關肺炎感染密度由千分之2.55降至千分之1.58，達專案目標。透過專案期能建立臨床呼吸器相關肺炎組合式介入措施照護品質機制。

Ventilators are common medical equipment in intensive care units. Ventilator-associated pneumonia increases patients' lengths of hospital stay and mortality rates in intensive care units. The 2004 US medical quality policy proposed a new protocol for bundled care to effectively reduce the occurrence of ventilator-associated pneumonia. The completion rate of the bundled care for patients with ventilator-associated pneumonia had previously been only 42% in our unit. After following the aforementioned protocol, in our unit, the completion rate increased to 96%, and the incidence rate of ventilator-associated pneumonia infection decreased from 2.55 per mille to 1.56 per mille, thereby achieving our goal. We hope that this protocol can improve the quality of care for ventilator-associated pneumonia.