Evidence-Based Bundle for Adults Is Adapted by Pediatric Intensive Care Units, Reducing Ventilator-Acquired Pneumonia and Lowering Costs

Problem Addressed

• Common problem: VAP is the second most common hospital-acquired infection in pediatric ICU patients (after blood infections), accounting for 21 percent of such infections. The highest rates occur in patients from 2 to 12 months old.¹ In 2006, the mean VAP rate for pediatric patients was 2.5 per 1,000 ventilator days.²
• Longer ICU and hospital stays: VAP quadruples a patient's length of stay (LOS) in the pediatric ICU and triples LOS for the entire hospital stay.¹
• Increased costs: Although estimates of the added costs of VAP in children are not available, they are likely quite high, given that VAP adds an estimated $40,000 to the cost of a typical adult hospital admission.³

Description of the Innovative Activity

• Bed elevation: Nurses raise the head of the bed for ICU patients 15 to 30 degrees. This is a slight modification of the measure used for adults, whose beds are raised 30 to 45 degrees. In addition, nurses use the Reverse Trendelenburg technique (elevating the head higher than the feet) for pediatric patients with spine injuries. 
• Sedation vacations: Each morning, nurses temporarily discontinue sedatives and analgesics (unless a physician has left a written order advising against doing so). The goal is to more quickly wean patients from the ventilator. Sedation vacations last anywhere from 15 minutes to several hours. When medication resumes, the dosage is reduced (typically to one-half of the previous dose), and nurses may titrate up if needed based on their nurse-driven protocol.
• Daily assessment of readiness to extubate: During bedside rounds, a physician evaluates whether the patient can be taken off the ventilator and removes the ventilator if appropriate.
• PUD prophylaxis: Patients receive medication to prevent PUD, such as an H2 blocker, a proton pump inhibitor, or a gastric coating agent. Patients receiving enteral feeds or who are allergic to PUD medication are exempted.
• Regular oral care: Patients' mouths are assessed on admission and every 12 hours. For patients with teeth, nurses use a suction device and a foam brush to clean the oral mucosa and tongue every 4 hours, and they brush the patient's teeth twice a day. (Infants whose teeth have yet to come in receive suction and foam brushing but do not need toothbrushing.) Nurses use an oral care kit that includes all the dental devices in one packet, making it easy to check whether a particular oral care intervention has been provided on schedule.
• Other supporting interventions: Related VAP reduction measures include keeping the ventilator circuit free from condensation by draining water away from the patient every 2 to 4 hours and before repositioning, changing inline suction catheter systems only when soiled or otherwise indicated, and storing oral suction devices in a clean nonsealed plastic bag when not in use.
• Family education on interventions: CHOA developed parental education materials to explain the significance of VAP and encourage parents of intubated patients to ask staff whether all the measures in the bundle are being used.

References/Related Articles

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Results

• Reduced VAPs and significant cost savings: In the Egleston Hospital pediatric ICU, the VAP rate fell by 63 percent from February 2005 to December 2007, leading to an estimated reduction of 8.6 VAPs and estimated savings of $344,473. In the Scottish Rite Hospital pediatric ICU, the VAP rate fell by 74 percent from January 2005 to December 2007, leading to an estimated 8.5 avoided VAPs and $339,858 in cost savings. In the Egleston Hospital cardiac ICU, the VAP rate fell by 87 percent from May 2006 to December 2007, leading to an estimated 13.7 avoided VAPs and cost savings of $548,154.
• Driven by high levels of compliance: These improvements have been driven by high compliance with the bundle of evidence-based interventions. In the two pediatric ICUs, compliance with individual bundle components range from about 70 to 100 percent. Compliance has been highest for assessing readiness for extubation and lowest for providing regular oral care.

Evidence Rating (What is this?)

Context of the Innovation

Planning and Development Process

• Team formation: CHOA formed a VAP project team consisting of critical care physicians, nurses, and nursing managers; respiratory therapists; an infection control practitioner; and a quality improvement consultant.
• Bundle adaptation: The team reviewed research on adult VAP reduction programs and consulted with other hospitals to learn how they handled pediatric VAP. Based on this review, the team made a number of changes from the standard adult VAP bundle, such as modifying the elevation of the head of the bed protocol (from 30 to 45 degrees for adults to 15 to 30 degrees for pediatrics), eliminating deep venous thrombosis prophylaxis (because there was no data to support DVTs prolonging the ventilator course), and adding an oral care component.
• Staff education and training:  At the Egleston campus, the VAP protocol is discussed daily during patient rounds. At Scottish Rite Hospital, the unit educator, who is also the representative on the VAP team, partnered with a critical care physician to provide education at staff meetings. The educator was also able to check for bundle compliance and perform real-time education with staff. In addition, posters highlighting key points were hung.
• Program rollout: CHOA introduced the program in stages. It debuted in the Egleston pediatric ICU in June 2005. This unit first focused on improving compliance with VAP measures it was already using, such as raising the head of the bed, daily assessment of readiness to extubate, and PUD prophylaxis. The unit added the oral care component in January 2006 and sedation vacations in February 2006. The bundle was introduced in the Scottish Rite pediatric ICU and the Egleston cardiac ICU in February 2006, and these units also introduced the measures gradually.

Resources Used and Skills Needed

• Staffing: The program did not require hiring any additional personnel.
• Resources: CHOA purchased oral care kits for the oral care component. The other measures in the VAP do not require additional resources.

Funding Sources

Tools and Other Resources

Getting Started with This Innovation

• Emphasize staff education: A VAP program's success depends on the physician and nursing staff's willingness to follow the measures in the bundle as close to 100 percent of the time as possible. Strong education is the key to getting this buy-in. The VAP team can make the case for the program by using research to show that each component has a direct effect in reducing VAP and setting a strong example on the job for others to follow.
• Use pediatric-specific data: Although much more data on adult VAP is available, it is worth the effort to search for studies on pediatric VAP and include them in staff education. Pediatric nurses typically find pediatric data more compelling than adult data.
• Use a gradual rollout: Introducing the entire VAP bundle at once may be overwhelming, so consider rolling out the easiest measures first and then introducing the more difficult measures once the initial measures are established. Similarly, focus first on compliance with the measures in the bundle rather than the VAP rate; it may take time, but strong compliance should gradually lead to a reduction in the VAP rate.

Sustaining This Innovation

• Circulate VAP data: Posting data on VAP incidence, compliance with bundle components, and days since the last infection is an effective motivational tool. Program leaders can highlight positive results in posters and via e-mail and also post or circulate statistics comparing different ICUs.
• Avoid complacency through ongoing monitoring and education: Once the program is underway, closely monitor compliance rates with each bundle element. Some backsliding can be expected. When CHOA found compliance with the oral care component was falling, the VAP team held an educational session to review the importance of strong oral care.