Reducing VAP by instituting a care bundle using improvement methodology in a UK Paediatric Intensive Care Unit

Abstract

Preventing ventilator-associated pneumonia (VAP) is one of the Department of Health Saving Lives initiatives. We describe the institution of a purpose-designed bundle of care in a tertiary paediatric ICU based on the available literature as part of our hospital's transformation project into reducing health-care-associated infection. A nurse-led VAP surveillance programme is in place, and we used this to compare VAP incidence before and after commencing a series of care measures aimed at reducing VAP as part of an overall drive for patient safety. The diagnostic criteria, surveillance methods and rates of VAP (5.6 per 1,000 ventilator days) have been previously reported. Nurse educators were added to the original core group, as a key feature is buy in from nursing staff. All nursing staff had multiple training opportunities, and VAP project education became a routine part of staff induction. The major features of the bundle of care were (1) elevation of bed to maximum (target, 45°; however, no beds currently permit this so achieved 20-30°), (2) mouth care using chlorhexidine or tooth brushing, (3) clean suctioning practice, (4) all patients not on full feeds commenced on ranitidine and (5) 4-hourly documentation. Compliance with these aspects was monitored. After the institution of the bundle, no paediatric case of VAP was recorded over a 12-month period, according to a priori definitions. One adult patient had a confirmed VAP over the same time interval. A paediatric VAP bundle was associated with reduced VAP on a UK PICU.

Bundle Method In Reducing Pneumonia Associated With Mechanical Ventilation In Newborns And Children: Integrative Review

“…The newborns should remain with head between 10° to 30° degrees, unlike pediatric patients with angles between 30° and 45°. The results of this review showed that only one study with newborns followed the recommendation [13], while in a study of pediatric patients the angle used was 20°-30° [14].…”

“…The intervention of the headboard elevation was present in most of the bundles [10][11][12][13][14][15], which is considered a weak evidence [25]. According to the CDC´s recommendation, there are differences in the angle of inclination for newborns and pediatric patients [27].…”

“…Among the interventions for maintenance of permeable airways, tracheal aspiration aseptically was identified with system closed and hands off use [9,10,13,14,16]. The use of the closed suction system has had low evidence in reducing PAV over the other technique of vacuum, with the system off [4,30].…”

Oral care in prevention of ventilator-associated pneumonia in neonatal and pediatric intensive care unit: protocol proposal

“…14,29 It is crucial to be careful on the guidance on adjuvant solutions to the mechanical methods used in the cleaning of the oral cavity due to risk of damage to the oral mucosa. 3 Bicarbonate water at 3% is recommended do its antimicrobial and alkalizing effects.…”

“…In addition, several studies used sponge swab as effective vehicle in the disorganization of the dental biofilm, showing the advantage of having low cost, being disposable and easy to handle. 1,4,6,19,25,[27][28][29]36 The use of sterile gauze can also be used for oral hygiene. 14,24,32,35,36,38 We do not recommend the use of cotton rods, as those used by Tinoco et al, 32 due to the risk of detachment of the cotton and difficulty of removal from the oral cavity.…”