Reduction in Ventilator-Associated Pneumonia Following Application of a Pediatric Ventilatory Care Bundle

Abstract

ISSUE: Ventilator-associated pneumonia (VAP) is a leading cause of morbidity and mortality in pediatric intensive care units. The incidence of VAP varies greatly depending on patient risk factors and duration of mechanical ventilation. PROJECT: In January 2005, a multidisciplinary team was convened to develop strategies to reduce VAP. The team adapted the Institute for Healthcare Improvement's adult ventilatory care bundle to pediatric patients to include elevation of the head of the bed, mouth care, proper storage of oral suction devices, changing of circuits and in-line suction catheters only when soiled, and daily review of ventilator needs. Following a trial of the VAP bundle, heated circuits to reduce condensation and a checklist were added. Education was provided to staff utilizing inservices, e-mails, posters, and computer screen savers. Real time reporting of VAP cases was implemented and root cause analysis of each case performed. Staff was informed of progress through weekly unit posters highlighting days since last VAP. RESULTS: Reliable implementation of the bundle resulted in reduced VAP rates per 1000 device days for each intensive care unit. For comparison purposes, the preceding annual rate for each unit was compared to a 4-month post-intervention rate. The PICU rate decreased from 5.8 to 0.0, the CICU from 9.6 to 6.1, and the NICU from 5.8 to 1.1. LESSONS LEARNED: Staff education alone did not improve compliance. Unit-specific respiratory therapy leadership was instrumental in developing reliability and key to the project's success. Prepackaged, single-use kits to facilitate every four-hour mouth care, the introduction of heated circuits to reduce condensation, and the implementation of a staff checklist were essential for maintaining improvement. Strategies to sustain reliability are being developed.