Introducing a Ventilator Associated Pneumonia Care Bundle in

Introducing a Ventilator Associated Pneumonia Care Bundle in Paediatric Intensive Care Lesley Macfarlane SCN, Richard Levin PICU Consultant

Why? q. Associated with significant mortality and morbidity. q. HAI – physical harm to the child q. Emotional Stress to family. q. Increase PICU length of stay approx 6 days. q. Cost approx £ 12, 000 per episode.

Aims and Measures q. Overall compliance with VAP care bundle q. VAP Rate q. Days between episodes. q. SPSP target > 300 days.

Driver Diagram: Implementation of Ventilator Associated Pneumonia (VAP) Care Bundle in RHSC Lesley Macfarlane Aim To reduce the rate of ventilator associated pneumonia in the Paediatric Intensive Care Unit by 50% by January 2014 through implementation of a best practices care bundle. The Scottish Patient Safety Paediatric Program (SPSPP) has recognised VAP reduction as one of the key components within the Paediatric Critical Care Change Package. Their aim is to achieve > 300 days between VAP by June 2013. Where Paediatric Intensive Care Unit (PICU), RHSC, Yorkhill. Primary Drivers / Key Elements Head of Bed Elevation to 30°angle rules in paediatric a (processes, of conduct, or structure) 15° angle in neonatal patients. Standardised routine oral care. Daily assessment of readiness to extubate. To monitor and report VAP rate on a monthly basis. Secondary Drivers/ Suggested Changes Identify quick and simple method of measuring the angle of the head of bed. Include head of bead elevation and ensure dependant ventilator tubing within the daily goals. Liaise with CIS manager to introduce an hourly check box on the electronic recording sheet to demonstrate that the head of bed elevation has been assessed. Liaise with lead nurse re funding for electric cots. Create visual clues to promote compliance with mouth care Teeth brushing twice daily for all children with teeth. All children >1 yr 12 hourly chlorhexadine. 4 hourly routine oral care Include daily assessment of readiness to wean and extubate on daily goals sheet. Assess daily and plan to reduce sedation as appropriate. Determine appropriate definition and diagnostic tools for VAP within PICU. Liaise with CIS manager re development of search tool for audit purposes Use search to determine baseline VAP rate. Staff education and feedback Develop written guidelines for prevention of VAP care. Staff road shows for education. Identify and liaise with link nurses from each team. Monitor compliance with the care bundle. Develop VAP compliance check sheet and monitor and report compliance initially weekly and progressing to monthly. Liaise with CIS manager to have this incorporated within the electronic recording sheet.

VAP PDSA CYCLES HOB measurement tool. Currently sourcing material and means to make HOB tool a bit more robust as issues with bending and kinking. Insertion of reminder for nurses at start of ventilation timeline “ Does this pt require chlorahexadine gel? ” Testing with all ventilated patients in unit. Good feedback. Looking toward implementation. Complete redesign of tool as a result of feedback from staff. Addition of warning for prescribers into CIS “not to be given if <1 yr Design further amended as not suitable for all patients Design amended with laminate card Tool rejected by infection control. HOB measurement tool Addition of comments for prescribers “ not to be given if <1 yr Amended and operational definitions added. Insertion of default prescription into ventilator order sets. Chlorahexadine Oral Gel. Template design tested. Data Collection Sheet

VAP PDSA CYCLES Set up process with microbiology to receive monthly reports re positive cultures on ET secretions. Insertion of required information fields re “chest concerns” into PICANET data sets. Form will not save without required info. Development of spreadsheet on ward round laptop to identify potential VAP patients Asked consultants to inform R Levin of any patient who the have “concerns re chest” Identify potential VAP patients to aid diagnosis and data collection Addition of an N/A field for non ventilated patients. Addition of “Teeth not brushed” option with drop down menu with reason for exemption. Insertion of a teeth brushed icon into CIS to improve documentation Twice daily teeth brushing Insertion of compulsory questions into daily goals sheet. (unable to save and close document until questions answered. ) Insertion of prompts into daily goals sheet. Daily sedation and ventilation review.

VAP Bundle Compliance Exploring avenues of funding for new cots PICU cots not fit for purpose – Head of bed will not achieve 30˚

VAP Rate

Keys to Successes and Challenges • Education / staff engagement. Staff Newsletter Intranet Page Discussion sessions • Team approach Use peer groups to effect change • Identify and overcome barriers – Improve compliance with documentation. Perseverance!!!