Benefits Of Implementing A Pediatric VAP Bundle
Hospital-acquired infections are an unfortunate risk of hospitalization for adult and pediatric intensive care units (ICUs). According to a 2009 study in the Journal of Pediatrics, up to 12% of patients in Pediatric ICUs (PICUs) acquire these infections, and of those, 22.7% are typically pneumonia.(1) Mechanical ventilation is “the main contributing factor” for pneumonia, and “increases the infection risk 6- to 21-fold.” (1)
While all intubated patients are at risk of ventilator-associated pneumonia (VAP) due to “poor cough and gag reflexes” as well as immobility, according to a 2013 study in Critical Care Nurse, children are at greater risk than adults due to factors that include “developmental and physiological differences.”(2) VAP is also linked to an increased length of stay in PICU and is associated with a significant increase in the number of days that patients remain on ventilation as well as an increased trend in mortality rates (1).
“Health care providers need to be aware of the risk for VAP in infants and children and should have preventive programs in place,” write the authors of the 2013 study. They recommend a VAP “care bundle” that takes into account a number of factors including “pathophysiology and etiology of pneumonia, mechanical ventilation, duration of ventilation and age of the child.” (2)
In the 2009 study, researchers created and implemented one such pediatric VAP bundle, a series of best practices and strategies, with the hopes it would help to decrease rate of VAP in the PICU. (1) A VAP bundle was counted as successful when compliance was at 90% with each element of the bundle. (1)
The VAP procedures for respiratory therapists and critical care nurses suggested the following strategies: (1)
- Only change ventilator circuits and in-line suction catheters when they are “visibly soiled”
- Drain ventilator circuits at least every 2 to 4 hours
- Oral suction devices not in use should be stored in un-sealed plastic bags, and then rinsed
- Uphold standard practices of good hand hygiene before and after every contact with the ventilator circuit
- Wear a gown before providing care to patient
- Practice regular oral hygiene (1), which includes brushing teeth twice a day, apply mouth moisturizer every 2 to 4 hours, and suction the oral cavity and pharynx frequently. (2)
Additionally they recommended that respiratory therapists and critical care nurses implement strategies to prevent aspiration of contaminated secretions as follows (1):
- Elevating the head of bed 30 to 45 degrees, unless contraindicated
- Draining the ventilator circuit before any patient repositioning occurs
- For children under the age of 12, they suggest using an endotracheal tube in which the dorsal lumen is above the endotracheal cuff, which helps suction secretions that collect about the cuff.
Over the course of the three-year study, before the VAP bundle was fully implemented, the infection rate of VAP was 2.8% at baseline and 4.9% during the implementation period. The rate dropped to 0.2% post-implementation. (1)
“VAP rates were significantly lower post-implementation compared with the pre-implementation and implementation periods,” the study authors concluded. (1)
- Bigham, Michael MD. Ventilator-Associated Pneumonia in the Pediatric Intensive Care Unit: Characterizing the Problem and Implementing a Sustainable Solution. Jour of Ped. April, 2009. Volume 154, Issue 4. Pages 582-587.
- Cooper Bonsal, Virginia, CCRN. Preventing Ventilator-Associated Pneumonia in Children: An Evidence-Based protocol. Crit Care Nurse. June 2013. Vol 33. no 3. 21-29.