BSI & VAP in the PICUBSI & VAP in the PICU

Jana Stockwell, MD, FAAPJana Stockwell, MD, FAAP

Why is this important? Why is this important?

BSI is the most common PICU BSI is the most common PICU nosocomial infectionnosocomial infection

VAP is the second most common PICU VAP is the second most common PICU nosocomial infectionnosocomial infection

Any nosocomial infection prolongs ICU Any nosocomial infection prolongs ICU days, hospital days, and increases costdays, hospital days, and increases cost

Morbidity and mortality effectsMorbidity and mortality effects

Definitions - BSIDefinitions - BSI

BSI – blood stream infectionBSI – blood stream infection Central venous line presentCentral venous line present

PercutaneousPercutaneous PICCPICC Broviac, PortBroviac, Port

+ blood cx >48 hours after line placement+ blood cx >48 hours after line placement Signs & sxs of infectionSigns & sxs of infection

Definitions - VAPDefinitions - VAP

VAP – ventilator associated pneumoniaVAP – ventilator associated pneumonia >48 hours on vent>48 hours on vent Combination of:Combination of:

CXR changesCXR changes Sputum changesSputum changes Fever, ↑ WBCFever, ↑ WBC + sputum cx+ sputum cx

Distinguish from colonization of ETT and Distinguish from colonization of ETT and tracheitistracheitis

Nosocomial vs. community Nosocomial vs. community acquired infectionsacquired infections

Community acquired – no healthcare Community acquired – no healthcare system exposure in past monthsystem exposure in past month

Healthcare associated infection – may be Healthcare associated infection – may be patient with dialysis, clinic visits, nursing patient with dialysis, clinic visits, nursing facilityfacility

Hospital acquired (nosocomial) – infection Hospital acquired (nosocomial) – infection acquired AFTER admission to a hospitalacquired AFTER admission to a hospital

Why these projects? Why these projects?

IHI – 100,000 Lives CampaignIHI – 100,000 Lives Campaign

NICHQ – Getting to zero: The Kids NICHQ – Getting to zero: The Kids CampaignCampaign

Concept of a Care BundleConcept of a Care Bundle

Care Bundle:Care Bundle: Groupings of best practices with respect to Groupings of best practices with respect to

a disease process that individually improve a disease process that individually improve care, but when applied together may result care, but when applied together may result in substantially greater improvementin substantially greater improvement

BSI Reduction “Bundle” of CareBSI Reduction “Bundle” of Care

Hand hygieneHand hygiene Alcohol foam, except when visibly soiledAlcohol foam, except when visibly soiled Enter and exit roomEnter and exit room Glove change when dealing with G-tube then IV (or Glove change when dealing with G-tube then IV (or

similar type situation)similar type situation) CHG (chlorhexidine) – replaces alcoholCHG (chlorhexidine) – replaces alcohol

10 swipes, 10 sec to dry10 swipes, 10 sec to dry Except open woundsExcept open wounds CNS procedures - LP, CSF cx or EVD careCNS procedures - LP, CSF cx or EVD care AllergyAllergy

Daily assessment of need for lineDaily assessment of need for line

CVL insertionCVL insertion

Hand washingHand washing Proper drapesProper drapes Site prep with CHGSite prep with CHG Sterile procedureSterile procedure Biopatch Biopatch Occlusive dressing + BiopatchOcclusive dressing + Biopatch

Change Q Wed PM/Thurs AM or when visibly soiledChange Q Wed PM/Thurs AM or when visibly soiled

Re-wiring line INCREASES infection riskRe-wiring line INCREASES infection risk

Our BSIsOur BSIs

Bugs:Bugs: CandidaCandida EnterococcusEnterococcus StaphStaph EnterobacterEnterobacter E coliE coli

All types of CVLsAll types of CVLs Not associated with use of Hyperglycemia Not associated with use of Hyperglycemia

ProtocolProtocol

BSI Reduction ProjectBSI Reduction Project

Goal – to achieve and maintain a ZERO Goal – to achieve and maintain a ZERO BSI rateBSI rate

National rate = 6.6 BSI/1000 CVL daysNational rate = 6.6 BSI/1000 CVL days CHOA data:CHOA data:

2004 = 6.2 BSI/ 1000 CVL days2004 = 6.2 BSI/ 1000 CVL days 2005 = 3.1 BSI/ 1000 CVL days2005 = 3.1 BSI/ 1000 CVL days 2006 = 2.6 BSI/ 1000 CVL days2006 = 2.6 BSI/ 1000 CVL days YTD 2007 (Eg only) = 3.6 BSI/ 1000 CVL YTD 2007 (Eg only) = 3.6 BSI/ 1000 CVL

daysdays

VAP Project AimVAP Project Aim

To decrease the To decrease the VAP rate system-VAP rate system-wide by 50%wide by 50%

Measure Measure VAP/1000 vent VAP/1000 vent daysdays

BenchmarksBenchmarks

National Healthcare Safety Network National Healthcare Safety Network (NHSN) mean rate for pediatric patients (NHSN) mean rate for pediatric patients in in 20062006 was was 2.5 per 1000 ventilator-2.5 per 1000 ventilator-daysdays

National Nosocomial Infections National Nosocomial Infections Surveillance System (NNIS) mean rate Surveillance System (NNIS) mean rate for pediatric patients in for pediatric patients in 20042004 was was 2.9 per 2.9 per 1000 ventilator-days1000 ventilator-days

Identify Pediatric VAP bundleIdentify Pediatric VAP bundle

IHI BundleIHI Bundle How does it relate How does it relate

to pediatrics?to pediatrics? Review of Review of

supporting supporting evidenceevidence

Discussions with Discussions with consulting consulting servicesservices

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 BundleCHOA 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 Additional Care Aspects AdoptedAdopted

Keep the vent circuit free from condensate Keep the vent circuit free from condensate by draining water away from patient every by draining water away from patient every 2-4 hours and prior to repositioning2-4 hours and prior to repositioning

Change in-line suction catheter systems Change in-line suction catheter systems only when soiled or otherwise indicatedonly when soiled or otherwise indicated

Store oral suction devices in a clean non-Store oral suction devices in a clean non-sealed plastic bag when not in usesealed plastic bag when not in use

Head of Bed ElevationHead of Bed Elevation

30-4530-45oo standard standard 15-3015-30oo infants infants

Infant beds/cribs unable to achieve > 30Infant beds/cribs unable to achieve > 30oo

Difficulty maintaining baby’s positionDifficulty maintaining baby’s position Reverse Trendelenberg for patients with: Reverse Trendelenberg for patients with:

Spine precautions Spine precautions Prone positioningProne positioning

Daily Sedation VacationsDaily Sedation Vacations

Included in sedation protocolIncluded in sedation protocol 8 a.m. each morning sedation is held unless order 8 a.m. each morning sedation is held unless order

written that contraindication existswritten that contraindication exists Contraindications:Contraindications:

Critical airwayCritical airway Unstable respiratory or CV statusUnstable respiratory or CV status

Restart sedatives and analgesics at ½ previous Restart sedatives and analgesics at ½ previous dosedose

Nurse driven protocolNurse driven protocol Education of bedside care teamEducation of bedside care team

Sedation VacationSedation Vacation

Sedation Vacation Sedation Vacation added to Sedation added to Sedation ProtocolProtocol

Standardized time for sedation vacation: 0800

Ulcer ProphylaxisUlcer Prophylaxis

Use of HUse of H22 blockers, PPI, or gastric coating blockers, PPI, or gastric coating

agentagent Exceptions:Exceptions:

Enteral feedsEnteral feeds Allergy to medicationAllergy to medication

Oral CareOral Care

Oral cavity assessed upon admission and Oral cavity assessed upon admission and Q 12 hQ 12 h

Only performed on unconscious or Only performed on unconscious or intubated patients with teethintubated patients with teeth

Suctioning every 4 hoursSuctioning every 4 hours Brush teeth twice a dayBrush teeth twice a day Use toothette to clean the oral mucosa Use toothette to clean the oral mucosa

and tongue every 4 hoursand tongue every 4 hours

Oral CareOral Care

Oral care cleansing Oral care cleansing and suctioning and suctioning systemsystem

System includes:System includes: Covered YankauerCovered Yankauer Suction ToothbrushSuction Toothbrush Sodium Bicarbonate, Sodium Bicarbonate,

Antiseptic Oral RinseAntiseptic Oral Rinse Applicator SwabApplicator Swab 1 Suction Catheter1 Suction Catheter

DVT Prophylaxis OptionDVT Prophylaxis Option

Shown to decrease ventilator days in adult Shown to decrease ventilator days in adult populationpopulation

No data in pedsNo data in peds Lovenox, SCD (sequential compression Lovenox, SCD (sequential compression

devices)devices)

The The Pediatric Pediatric Case for Preventing Case for Preventing VAP VAP

VAP is the second most common VAP is the second most common nosocomial infection in PICU patients nosocomial infection in PICU patients

The highest rates of VAP occur in the 2-12 The highest rates of VAP occur in the 2-12 month old populationmonth old population

Four-fold ↑ in PICU length of stay with VAPFour-fold ↑ in PICU length of stay with VAP

Three-fold ↑ in hospital length of stay with Three-fold ↑ in hospital length of stay with VAP VAP

Determining a VAPDetermining a VAP

Follow NHSN Pneumonia Follow NHSN Pneumonia GuidelinesGuidelines Positive deep culturePositive deep culture New chest x-ray infiltrateNew chest x-ray infiltrate Worsening gas exchangeWorsening gas exchange Combination of three: Combination of three:

Temperature Temperature White countWhite count Change in sputumChange in sputum Change in pulseChange in pulse Wheezing and/or coughWheezing and/or cough Change in heart rateChange in heart rate

Key MeasuresKey Measures

Ventilator Associated Pneumonia rate per Ventilator Associated Pneumonia rate per 1000 ventilator-days1000 ventilator-days

Bundle complianceBundle compliance ComponentComponent Total bundle complianceTotal bundle compliance

Days since last infectionDays since last infection

Egleston PICU VAP RateEgleston PICU VAP Rate(2007 Eg YTD = 0.9)(2007 Eg YTD = 0.9)

Egleston Pediatric ICU - VAP Rate

Mean = 1.24

Mean = 3.81

UCL

LCL

1s

2s

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

16.0

18.0

20.0

Feb-0

5

May-0

5

Jun-0

5

Jul-05

Aug-0

5

Sep-0

5

Oct-

05

Nov-0

5

Dec-0

5

Jan-0

6

Feb-0

6

Mar-

06

Apr-

06

May-0

6

Jun-0

6

Jul-06

Aug-0

6

Sep-0

6

Oct-

06

Nov-0

6

Dec-0

6

Jan-0

7

Feb-0

7

Mar-

07

Apr-

07

May-0

7

Jun-0

7

Jul-07

Aug-0

7

Month

Ven

tila

tor

Asso

cia

ted

Pn

eu

mo

nia

s p

er

1000

ven

tila

tor

days

June 2005 - VAP Bundle implemented

Nov 2006 - Oral Care re-

education

Feb 2006 -Sedation Vacation

implemented

Target = 1.9

NHSN Mean = 2.5

Egleston Bundle Compliance Egleston Bundle Compliance

EG PICU VAP Bundle Compliance

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Feb-0

6

Mar-

06

Apr-

06

May-0

6

Jun-0

6

Jul-06

Aug-0

6

Sep-0

6

Oct-

06

Nov-0

6

Dec-0

6

Jan-0

7

Feb-0

7

Mar-

07

Apr-

07

May-0

7

Jun-0

7

Jul-07

Aug-0

7

% o

f p

ati

en

ts w

ith

co

mp

on

en

t

(co

ntr

ain

dic

ate

d p

ati

en

ts e

xclu

ded

)

HOB PUD Sedation Vacation Extubation Readiness

Egleston PICU Days Since Last Egleston PICU Days Since Last InfectionInfection

Egleston PICU VAPDays Since Last Infection

42

0

20

40

60

80

100

120

140

160

No

v-0

5

Jan

-06

Ma

r-0

6

Ma

y-0

6

Jul-

06

Se

p-0

6

No

v-0

6

Jan

-07

Ma

r-0

7

Ma

y-0

7

Jul-

07

Days b

etw

een

in

fecti

on

Results SummaryResults Summary

Egleston:Egleston: Avoided Avoided 6.246.24 VAPs VAPs Decreased rate by Decreased rate by 68%68% Cost savings of Cost savings of $249,747$249,747

Scottish Rite:Scottish Rite: Avoided Avoided 8.38.3 VAPs VAPs Decreased rate by Decreased rate by 89%89% Cost savings of Cost savings of $332,294$332,294