BSI

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

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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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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

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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

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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

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Why these projects?

• IHI 100,000 Lives Campaign
• NICHQ Getting to zero The Kids Campaign

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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

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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

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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

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Our BSIs

• Bugs
• Candida
• Enterococcus
• Staph
• Enterobacter
• E coli
• All types of CVLs
• Not associated with use of Hyperglycemia Protocol

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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

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VAP Project Aim

• To decrease the VAP rate system-wide by 50
• Measure VAP/1000 vent days

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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

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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

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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

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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

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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

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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

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Sedation Vacation

• Sedation Vacation added to Sedation Protocol

Standardized time for sedation vacation 0800
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Ulcer Prophylaxis

• Use of H2 blockers, PPI, or gastric coating agent
• Exceptions
• Enteral feeds
• Allergy to medication

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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

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Oral Care

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

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DVT Prophylaxis Option

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

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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

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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

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Key Measures

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

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Egleston PICU VAP Rate(2007 Eg YTD 0.9)
NHSN Mean 2.5
Target 1.9
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Egleston Bundle Compliance
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Egleston PICU Days Since Last Infection
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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