1. BSI & VAP in the PICU Jana Stockwell, MD, FAAP

2. Why is this important? BSI is the most common PICU nosocomial infection BSI is the most common PICU nosocomial infection VAP is the second 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 Any nosocomial infection prolongs ICU days, hospital days, and increases cost Morbidity and mortality effects Morbidity and mortality effects

3. Definitions - BSI BSI – blood stream infection BSI – blood stream infection Central venous line present Central venous line present Percutaneous Percutaneous PICC PICC Broviac, Port Broviac, Port + blood cx >48 hours after line placement + blood cx >48 hours after line placement Signs & sxs of infection Signs & sxs of infection

4. Definitions - VAP VAP – ventilator associated pneumonia VAP – ventilator associated pneumonia >48 hours on vent >48 hours on vent Combination of: Combination of: CXR changes CXR changes Sputum changes Sputum changes Fever, ↑ WBC Fever, ↑ WBC + sputum cx + sputum cx Distinguish from colonization of ETT and tracheitis Distinguish from colonization of ETT and tracheitis

5. Nosocomial vs. community acquired infections Community acquired – no healthcare system exposure in past month Community acquired – no healthcare system exposure in past month Healthcare associated infection – may be patient with dialysis, clinic visits, nursing facility Healthcare associated infection – may be patient with dialysis, clinic visits, nursing facility Hospital acquired (nosocomial) – infection acquired AFTER admission to a hospital Hospital acquired (nosocomial) – infection acquired AFTER admission to a hospital

6. Why these projects? IHI – 100,000 Lives Campaign IHI – 100,000 Lives Campaign NICHQ – Getting to zero: The Kids Campaign NICHQ – Getting to zero: The Kids Campaign

7. Concept of a Care Bundle 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 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 Hand hygiene Alcohol foam, except when visibly soiled Alcohol foam, except when visibly soiled Enter and exit room Enter and exit room Glove change when dealing with G-tube then IV (or similar type situation) Glove change when dealing with G-tube then IV (or similar type situation) CHG (chlorhexidine) – replaces alcohol CHG (chlorhexidine) – replaces alcohol 10 swipes, 10 sec to dry 10 swipes, 10 sec to dry Except open wounds Except open wounds CNS procedures - LP, CSF cx or EVD care CNS procedures - LP, CSF cx or EVD care Allergy Allergy Daily assessment of need for line Daily assessment of need for line

9. CVL insertion Hand washing Hand washing Proper drapes Proper drapes Site prep with CHG Site prep with CHG Sterile procedure Sterile procedure Biopatch Biopatch Occlusive dressing + Biopatch Occlusive dressing + Biopatch Change Q Wed PM/Thurs AM or when visibly soiled Change Q Wed PM/Thurs AM or when visibly soiled Re-wiring line INCREASES infection risk Re-wiring line INCREASES infection risk

10. Our BSIs Bugs: Bugs: Candida Candida Enterococcus Enterococcus Staph Staph Enterobacter Enterobacter E coli E coli All types of CVLs All types of CVLs Not associated with use of Hyperglycemia Protocol Not associated with use of Hyperglycemia Protocol

11. BSI Reduction Project Goal – to achieve and maintain a ZERO BSI rate Goal – to achieve and maintain a ZERO BSI rate National rate = 6.6 BSI/1000 CVL days National rate = 6.6 BSI/1000 CVL days CHOA data: CHOA data: 2004 = 6.2 BSI/ 1000 CVL days 2004 = 6.2 BSI/ 1000 CVL days 2005 = 3.1 BSI/ 1000 CVL days 2005 = 3.1 BSI/ 1000 CVL days 2006 = 2.6 BSI/ 1000 CVL days 2006 = 2.6 BSI/ 1000 CVL days YTD 2007 (Eg only) = 3.6 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% To decrease the VAP rate system- wide by 50% Measure VAP/1000 vent days 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 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 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 Bundle IHI Bundle How does it relate to pediatrics? How does it relate to pediatrics? Review of supporting evidence Review of supporting evidence Discussions with consulting services Discussions with consulting services 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

15. CHOA VAP Bundle Elevation of the head of the bed 30-45 o Use 15-30 o for neonates and small infants, otherwise 30-45 o 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 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 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 Store oral suction devices in a clean non- sealed plastic bag when not in use

17. Head of Bed Elevation 30-45 o standard 30-45 o standard 15-30 o infants 15-30 o infants Infant beds/cribs unable to achieve > 30 o Infant beds/cribs unable to achieve > 30 o Difficulty maintaining baby’s position Difficulty maintaining baby’s position Reverse Trendelenberg for patients with: Reverse Trendelenberg for patients with: Spine precautions Spine precautions Prone positioning Prone positioning

18. Daily Sedation Vacations Included in sedation protocol Included in sedation protocol 8 a.m. each morning sedation is held unless order written that contraindication exists 8 a.m. each morning sedation is held unless order written that contraindication exists Contraindications: Contraindications: Critical airway Critical airway Unstable respiratory or CV status Unstable respiratory or CV status Restart sedatives and analgesics at ½ previous dose Restart sedatives and analgesics at ½ previous dose Nurse driven protocol Nurse driven protocol Education of bedside care team Education of bedside care team

19. Sedation Vacation Sedation Vacation added to Sedation Protocol Sedation Vacation added to Sedation Protocol Standardized time for sedation vacation: 0800

20. Ulcer Prophylaxis Use of H 2 blockers, PPI, or gastric coating agent Use of H 2 blockers, PPI, or gastric coating agent Exceptions: Exceptions: Enteral feeds Enteral feeds Allergy to medication Allergy to medication

21. Oral Care Oral cavity assessed upon admission and Q 12 h Oral cavity assessed upon admission and Q 12 h Only performed on unconscious or intubated patients with teeth Only performed on unconscious or intubated patients with teeth Suctioning every 4 hours Suctioning every 4 hours Brush teeth twice a day Brush teeth twice a day Use toothette to clean the oral mucosa and tongue every 4 hours Use toothette to clean the oral mucosa and tongue every 4 hours

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

23. DVT Prophylaxis Option Shown to decrease ventilator days in adult population Shown to decrease ventilator days in adult population No data in peds No data in peds Lovenox, SCD (sequential compression devices) Lovenox, SCD (sequential compression devices)

24. The Pediatric Case for Preventing VAP VAP is the second most common nosocomial infection in PICU patients VAP is the second most common nosocomial infection in PICU patients The highest rates of VAP occur in the 2-12 month old population The highest rates of VAP occur in the 2-12 month old population Four-fold ↑ in PICU length of stay with VAP Four-fold ↑ in PICU length of stay with VAP Three-fold ↑ in hospital length of stay with VAP Three-fold ↑ in hospital length of stay with VAP

25. Determining a VAP Follow NHSN Pneumonia Guidelines Follow NHSN Pneumonia Guidelines Positive deep culture Positive deep culture New chest x-ray infiltrate New chest x-ray infiltrate Worsening gas exchange Worsening gas exchange Combination of three: Combination of three: Temperature Temperature White count White count Change in sputum Change in sputum Change in pulse Change in pulse Wheezing and/or cough Wheezing and/or cough Change in heart rate Change in heart rate

26. Key Measures Ventilator Associated Pneumonia rate per 1000 ventilator-days Ventilator Associated Pneumonia rate per 1000 ventilator-days Bundle compliance Bundle compliance Component Component Total bundle compliance Total bundle compliance Days since last infection Days since last infection

27. Egleston PICU VAP Rate (2007 Eg YTD = 0.9) Target = 1.9 NHSN Mean = 2.5

28. Egleston Bundle Compliance

29. Egleston PICU Days Since Last Infection

30. Results Summary Egleston: Egleston: Avoided 6.24 VAPs Avoided 6.24 VAPs Decreased rate by 68% Decreased rate by 68% Cost savings of $249,747 Cost savings of $249,747 Scottish Rite: Scottish Rite: Avoided 8.3 VAPs Avoided 8.3 VAPs Decreased rate by 89% Decreased rate by 89% Cost savings of $332,294 Cost savings of $332,294