BSI & VAP in the PICU

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 gt48 hours after line placement
• Signs sxs of infection

4
Definitions - VAP

• VAP ventilator associated pneumonia
• gt48 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 gt 30o
• Difficulty maintaining babys 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