Tailoring the Institute for Health Care Improvement 100,000 Lives Campaign to Pediatric Settings: The Example of Ventilator-Associated Pneumonia

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Prevalence, impact, cause, and diagnosis of ventilator-associated pneumonia

VAP in adult patients is the second most commonly occurring nosocomial infection composing nearly 15% of all hospital-acquired infections in adults [6]. The incidence of VAP is reported as low as 9% or as high as 70% [7], [8] of patients on mechanical ventilation and is clearly influenced by the patient population served and the type of intensive care unit. The burden to the patient of VAP is significant, accounting for increased lengths of stay in the ICU by 4.3 to 6.1 days [7], [9] and

Interventions to prevent ventilator-associated pneumonia

Although clinicians cannot impact an individual patient's inherent risk for VAP, clinicians can ensure the consistent application of evidence-based practices known to favorably impact VAP rates. In the 100K Lives Campaign, the IHI took the lead in identifying a package of evidence-based interventions (known as a bundle) that, when implemented together, resulted in a dramatic reduction in the incidence of VAP in adult patients supported on mechanical ventilation [15]. This VAP bundle includes:

Ventilator-associated pneumonia bundle in adult intensive care

The fundamental premise behind bundle practices is that the science behind the bundle is so well established that it should be considered a standard of care. The adult VAP bundle focuses on preventing VAP and also preventing complications associated with the critically ill sedentary adult patient supported on mechanical ventilation.

VAP is prevented by elevating the patient's head of bed to between 30 and 45 degrees and instituting a daily sedation vacation and extubation readiness test.

Pediatric ventilator-associated pneumonia bundle

Given the fundamental premise behind bundle practices—specifically, that the science behind the bundle is so well established that it should be considered a standard of care—it is challenging to consider which essential elements should be included in a pediatric VAP bundle. When compared with adults, intubated children supported on mechanical ventilation present with both similar and unique risks. Similar is the risk for aspiration of oropharyngeal or gastric secretions. That dentition is

Examples of unit-based approaches to ventilator-associated pneumonia

Impacting VAP rates requires a multidisciplinary approach. The experiences at Children's Hospital Boston (CHB) and Monroe Carell Jr Children's Hospital at Vanderbilt (VCH) demonstrate the effect that the team approach can have on VAP rates. At CHB, respiratory therapists take the lead in monitoring ETT cuff pressures and draining ventilator tubing away from the patient. Nurses take the lead in keeping the patient's head of bed up 30 to 45 degrees and providing mouth care and oral hygiene.

Summary

The IHI 100K campaign includes areas of relevance to children's health care. Specific interventions suggested by research in adult settings must be assessed with regard to their appropriateness and safety in pediatric settings. We present efforts in two different institutions to implement interventions to reduce VAP in pediatric settings. During the initial period of observation, these efforts appear to be successful in reducing VAP. Continued surveillance in each hospital is necessary to

Acknowledgments

Thanks to the nurses, respiratory therapists, and physicians of the Pediatric Critical Care Unit and the VCH Performance Management and Improvement Group, whose hard work made possible the improvements at Monroe Carell Jr. Children's Hospital at Vanderbilt.

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  • Cited by (40)

    • Risk factors and interventions for ventilator-associated pneumonia in pediatric patients

      2012, Journal of Pediatric Nursing
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      The secondary aim of this study was to identify nursing and respiratory interventions routinely performed to prevent VAP. A list of these interventions was compiled based on an extensive literature review as to interventions shown to prevent VAP in the adult population (Abdel-Gaward, El-Hodhod, Ibrahim, & Michael, 2009; Alumuneef et al., 2004; ATS & IDSA, 2005; Bigham et al., 2009; Bonten et al., 2004; Collard et al., 2003; Curley et al., 2006; daSilva et al., 2010; Fulbrook & Mooney, 2003; Hsieh et al., 2010; Patra et al., 2007; Taira et al., 2009; Yuan et al., 2007). Nursing interventions included oral care every 2 hours, patient repositioning every 2 hours, HOB elevation, suctioning method (open vs. closed), and suctioning every 2 hours (ATS & IDSA, 2005; Curley et al., 2006).

    • Establishing nurse-led ventilator-associated pneumonia surveillance in paediatric intensive care

      2010, Journal of Hospital Infection
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      Historically, VAP has been viewed as an inevitable consequence of critical illness, but increasingly it is accepted as an avoidable adverse healthcare incident. Although its prevention is a core element in the US 5 Million Lives campaign, there have been concerns raised about the suitability of such a generic programme to PIC, with similar concerns relating to the Department of Health Saving Lives initiative.15,16 For this reason we describe our establishment of a purpose-designed nurse-led VAP surveillance programme within our PIC, which formed part of our overall HCAI reduction programme.

    • Prevention strategy of ventilator-associated pneumonia in children

      2010, Annales Francaises d'Anesthesie et de Reanimation
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