BSI & VAP in the PICU Jana Stockwell, MD, FAAP

1. BSI & VAP in the PICU Jana Stockwell, MD, FAAP

2. 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

3. 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

4. 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

5. 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

6. Why these projects? • IHI – 100,000 Lives Campaign • NICHQ – Getting to zero: The Kids Campaign

7. 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

8. 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

9. 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

10. Our BSIs • Bugs: • Candida • Enterococcus • Staph • Enterobacter • E coli • All types of CVLs • Not associated with use of Hyperglycemia Protocol

11. 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

12. VAP Project Aim • To decrease the VAP rate system-wide by 50% • Measure VAP/1000 vent days

13. Benchmarks • National Healthcare Safety Network (NHSN) mean rate for pediatric patients in 2006 was 2.5 per 1000 ventilator-days • National Nosocomial Infections Surveillance System (NNIS) mean rate for pediatric patients in 2004 was 2.9 per 1000 ventilator-days

14. Identify Pediatric VAP bundle • 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 • IHI Bundle • How does it relate to pediatrics? • Review of supporting evidence • Discussions with consulting services

15. 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

16. 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 non-sealed plastic bag when not in use

17. 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

18. 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

19. Sedation Vacation • Sedation Vacation added to Sedation Protocol Standardized time for sedation vacation: 0800

20. Ulcer Prophylaxis • Use of H2 blockers, PPI, or gastric coating agent • Exceptions: • Enteral feeds • Allergy to medication

21. 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

22. Oral Care • Oral care cleansing and suctioning system • System includes: • Covered Yankauer • Suction Toothbrush • Sodium Bicarbonate, Antiseptic Oral Rinse • Applicator Swab • 1 Suction Catheter

23. DVT Prophylaxis Option • Shown to decrease ventilator days in adult population • No data in peds • Lovenox, SCD (sequential compression devices)

24. 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

25. 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

26. Key Measures • Ventilator Associated Pneumonia rate per 1000 ventilator-days • Bundle compliance • Component • Total bundle compliance • Days since last infection

27. Egleston PICU VAP Rate(2007 Eg YTD = 0.9) NHSN Mean = 2.5 Target = 1.9

28. Egleston Bundle Compliance

29. Egleston PICU Days Since Last Infection

30. 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