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Renee Lehane, BSN, RN
Infection Preventionist
Boston Children's Hospital, United States
Disclosure information not submitted.
Kevin Bullock, RT
Clinical Supervisor of Respiratory Care
Boston Children's Hospital, United States
Disclosure information not submitted.
Jennifer Ormsby, BSN,RN,CPN,CIC
Infection Preventionist
Boston Children's Hospital, United States
Disclosure information not submitted.
Jenny Yuen, MSPH
Analyst/Quality Improvement Consultant
Boston Children's Hospital, United States
Disclosure information not submitted.
Ana Vaughan, MD, MPH
Associate Hospital Epidemiologist
Boston Children's Hospital, United States
Disclosure information not submitted.
Thomas Sandora, MD, MPH
Senior Associate Physician
Boston Children's Hospital, United States
Disclosure information not submitted.
Gregory Priebe, MD
Associate Professor
Boston Children's Hospital, United States
Disclosure information not submitted.
Title: Kamishibai card rounding to prevent infection-related pediatric ventilator-associated events
Introduction: The US CDC introduced definitions for ventilator-associated events (VAE) in 2019 for children. Experts recommend classifying pediatric VAE (PedVAE) into AVAC (PedVAE with new antimicrobial coverage for 4 or more days) and PVAP (AVAC with a positive respiratory infection diagnostic test). An analysis of PedVAE in a 2017-2018 cohort at our center after retirement of VAP (ventilator associated pneumonia) surveillance in 2017 found a decreased proportion of AVAC (61% to 31%) but increased proportion of PVAP within AVAC (24% to 63%) compared to 2008-2013. Kamishibai cards (K-cards) are a commonly used quality improvement tool that can serve as a checklist of bundle elements. We hypothesized that implementation of K-card rounding with renewed attention to VAP prevention bundle elements would lead to a lower proportion of PVAP within AVAC.
Methods: We performed a retrospective cohort study of PedVAE from 1/2019 to 12/2020 at a single center. PedVAE cases were further classified as AVAC and PVAP following the proposed definitions. We used Fisher’s exact tests to compare the proportions of PedVAE that met criteria for AVAC, PVAP, and PVAP among AVAC between the 2019-2020 cohort and the 2017-18 cohort. We also assessed the trend in prevention bundle compliance over time.
Results: 51 PedVAE cases were identified (1.6/1000 ventilator days, compared to 1.3/1000 ventilator days in the 2017-2018 cohort, with unchanged centerline on a control chart), with 47% from the PICU, 25% from the NICU, and 27% from the CICU, and overall 30-day mortality of 33%. Of the 51 PedVAEs, 32 (63%) met AVAC criteria (vs. 31% in 2017-18, P=0.015), 6 (12%) met PVAP criteria (vs. 19%, P=0.49), and 19% of AVAC met PVAP criteria (vs. 63%, P=0.025). The positive respiratory diagnostic tests met “criterion 2” (purulent respiratory secretions and positive endotracheal aspirate cultures) in 4 patients, and “criterion 3” (positive viral test) in 1 patient with enterovirus and 1 patient with adenovirus. Overall bundle compliance increased from 20% to >85%.
Conclusions: After renewed attention to VAP prevention bundle elements, implementation of K-card rounding was followed by an increase of the proportion of PedVAE cases meeting criteria for AVAC, but the proportion of PVAP among AVAC dropped, suggesting less infection-related PedVAE.