Transcript BSI & VAP in the PICU Jana Stockwell, MD, FAAP Why is this important?     BSI is the most common PICU nosocomial infection VAP is.

BSI & VAP in the PICU
Jana Stockwell, MD, FAAP
Why is this important?




BSI is the most common PICU
nosocomial infection
VAP is the second most common PICU
nosocomial infection
Any nosocomial infection prolongs ICU
days, hospital days, and increases cost
Morbidity and mortality effects
Definitions - BSI

BSI – blood stream infection

Central venous line present
Percutaneous
 PICC
 Broviac, Port

+ blood cx >48 hours after line placement
 Signs & sxs of infection

Definitions - VAP

VAP – ventilator associated pneumonia
>48 hours on vent
 Combination of:

CXR changes
 Sputum changes
 Fever, ↑ WBC
 + sputum cx


Distinguish from colonization of ETT and
tracheitis
Nosocomial vs. community
acquired infections



Community acquired – no healthcare
system exposure in past month
Healthcare associated infection – may be
patient with dialysis, clinic visits, nursing
facility
Hospital acquired (nosocomial) – infection
acquired AFTER admission to a hospital
Why these projects?

IHI – 100,000 Lives Campaign

NICHQ – Getting to zero: The Kids
Campaign
Concept of a Care Bundle

Care Bundle:

Groupings of best practices with respect to
a disease process that individually improve
care, but when applied together may result
in substantially greater improvement
BSI Reduction “Bundle” of Care

Hand hygiene




Alcohol foam, except when visibly soiled
Enter and exit room
Glove change when dealing with G-tube then IV (or
similar type situation)
CHG (chlorhexidine) – replaces alcohol

10 swipes, 10 sec to dry




Except open wounds
CNS procedures - LP, CSF cx or EVD care
Allergy
Daily assessment of need for line
CVL insertion






Hand washing
Proper drapes
Site prep with CHG
Sterile procedure
Biopatch
Occlusive dressing + Biopatch


Change Q Wed PM/Thurs AM or when visibly soiled
Re-wiring line INCREASES infection risk
Our BSIs

Bugs:
Candida
 Enterococcus
 Staph
 Enterobacter
 E coli



All types of CVLs
Not associated with use of Hyperglycemia
Protocol
BSI Reduction Project



Goal – to achieve and maintain a ZERO
BSI rate
National rate = 6.6 BSI/1000 CVL days
CHOA data:
2004 = 6.2 BSI/ 1000 CVL days
 2005 = 3.1 BSI/ 1000 CVL days
 2006 = 2.6 BSI/ 1000 CVL days
 YTD 2007 (Eg only) = 3.6 BSI/ 1000 CVL
days

VAP Project Aim


To decrease the
VAP rate systemwide by 50%
Measure
VAP/1000 vent
days
Benchmarks

National Healthcare Safety Network
(NHSN) mean rate for pediatric patients
in 2006 was 2.5 per 1000 ventilatordays

National Nosocomial Infections
Surveillance System (NNIS) mean rate
for pediatric patients in 2004 was 2.9 per
1000 ventilator-days
Identify Pediatric VAP bundle

IHI Bundle

How does it relate
to pediatrics?
Review of
supporting
evidence
 Discussions with
consulting
services

IHI Adult Bundle
• Elevation of the head of the bed
to between 30 and 45 degrees
• Daily sedation vacations
• Daily assessment of readiness
to extubate
• Peptic ulcer disease (PUD)
prophylaxis
• Deep venous thrombosis (DVT)
prophylaxis
CHOA VAP Bundle
• Elevation of the head of the bed 30-45o
• Use 15-30o for neonates and small infants,
otherwise
30-45o
• Daily sedation vacations
• Daily assessment of readiness to
extubate
• Peptic ulcer disease (PUD) prophylaxis
• Oral care protocol
• DVT prophylaxis option
Additional Care Aspects
Adopted

Keep the vent circuit free from condensate
by draining water away from patient every
2-4 hours and prior to repositioning

Change in-line suction catheter systems
only when soiled or otherwise indicated

Store oral suction devices in a clean nonsealed plastic bag when not in use
Head of Bed Elevation


30-45o standard
15-30o infants
Infant beds/cribs unable to achieve > 30o
 Difficulty maintaining baby’s position


Reverse Trendelenberg for patients with:
Spine precautions
 Prone positioning

Daily Sedation Vacations

Included in sedation protocol

8 a.m. each morning sedation is held unless
order written that contraindication exists
 Contraindications:
Critical airway
 Unstable respiratory or CV status

Restart sedatives and analgesics at ½
previous dose
 Nurse driven protocol


Education of bedside care team
Sedation Vacation

Sedation Vacation
added to Sedation
Protocol
Standardized time for
sedation vacation: 0800
Ulcer Prophylaxis

Use of H2 blockers, PPI, or gastric coating
agent

Exceptions:
Enteral feeds
 Allergy to medication

Oral Care





Oral cavity assessed upon admission and
Q 12 h
Only performed on unconscious or
intubated patients with teeth
Suctioning every 4 hours
Brush teeth twice a day
Use toothette to clean the oral mucosa
and tongue every 4 hours
Oral Care


Oral care cleansing
and suctioning
system
System includes:
Covered Yankauer
 Suction Toothbrush
 Sodium Bicarbonate,
Antiseptic Oral Rinse
 Applicator Swab
 1 Suction Catheter

DVT Prophylaxis Option



Shown to decrease ventilator days in adult
population
No data in peds
Lovenox, SCD (sequential compression
devices)
The Pediatric Case for Preventing
VAP

VAP is the second most common
nosocomial infection in PICU patients

The highest rates of VAP occur in the 2-12
month old population

Four-fold ↑ in PICU length of stay with VAP

Three-fold ↑ in hospital length of stay with
VAP
Determining a VAP

Follow NHSN Pneumonia
Guidelines

Positive deep culture

New chest x-ray infiltrate
Worsening gas exchange
Combination of three:








Temperature
White count
Change in sputum
Change in pulse
Wheezing and/or cough
Change in heart rate
Key Measures

Ventilator Associated Pneumonia rate per
1000 ventilator-days

Bundle compliance
Component
 Total bundle compliance


Days since last infection
Egleston PICU VAP Rate
(2007 Eg YTD = 0.9)
Egleston Pediatric ICU - VAP Rate
20.0
16.0
14.0
Feb 2006 Sedation
Vacation
implemented
12.0
10.0
UCL
June 2005 VAP Bundle
implemented
8.0
1s
Mean = 3.81
4.0
NHSN Mean = 2.5
Target = 1.9
2.0
Mean = 1.24
Month
Aug-07
Jul-07
Jun-07
May-07
Apr-07
Mar-07
Feb-07
Jan-07
Dec-06
Nov-06
Oct-06
Sep-06
Aug-06
Jul-06
Jun-06
May-06
Apr-06
Mar-06
Feb-06
Jan-06
Dec-05
Nov-05
Oct-05
Sep-05
Aug-05
Jul-05
Jun-05
LCL
May-05
0.0
2s
Nov 2006 Oral Care reeducation
6.0
Feb-05
Ventilator Associated Pneumonias per 1000
ventilator days
18.0
HOB
PUD
Sedation Vacation
Aug-07
Jul-07
Jun-07
May-07
Apr-07
Mar-07
Feb-07
Jan-07
Dec-06
Nov-06
Oct-06
Sep-06
Aug-06
Jul-06
Jun-06
May-06
Apr-06
Mar-06
Feb-06
% of patients with component
(contraindicated patients excluded)
Egleston Bundle Compliance
EG PICU VAP Bundle Compliance
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Extubation Readiness
Egleston PICU Days Since Last
Infection
Egleston PICU VAP
Days Since Last Infection
140
120
100
80
60
42
40
20
Jul-07
May-07
Mar-07
Jan-07
Nov-06
Sep-06
Jul-06
May-06
Mar-06
Jan-06
0
Nov-05
Days between infection
160
Results Summary

Egleston:




Avoided 6.24 VAPs
Decreased rate by 68%
Cost savings of $249,747
Scottish Rite:



Avoided 8.3 VAPs
Decreased rate by 89%
Cost savings of $332,294