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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.
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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 system-wide 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 ventilator-days • 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 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
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 non-sealed 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) NHSN Mean = 2.5 Target = 1.9
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