BSI & VAP in the BSI & VAP in the PICU PICU Jana Stockwell, MD, FAAP Jana Stockwell, MD, FAAP
Dec 17, 2015
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