Establishing nurse-led ventilator-associated pneumonia surveillance in paediatric intensive care M. Richardson a , S. Hines a , G. Dixon b , L. Highe a , J. Brierley a, * a Paediatric and Neonatal Intensive Care Unit, Great Ormond Street Hospital for Children NHS Trust, London, UK b Microbiology Department, Great Ormond Street Hospital for Children NHS Trust, London, UK article info Article history: Received 26 June 2009 Accepted 4 December 2009 Available online 14 April 2010 Keywords: Healthcare-associated infection Paediatric intensive care Ventilator-associated pneumonia summary Preventing ventilator-associated pneumonia (VAP) is one of the Department of Health ‘Saving Lives’ initiatives. Whereas morbidity and mortality from VAP is well-documented in adults, it is poorly studied in children. We describe the establishment of a nurse-led VAP surveillance programme as part of an overall drive for patient safety and healthcare-associated infection reduction. All children admitted to a tertiary referral paediatric intensive care unit over a four- month period were studied. VAP was defined as pneumonia occurring >48 h post intubation. Diagnostic criteria were: (i) radiological: new/progressive infiltrates, consolidation or cavita- tion on chest X-ray; (ii) clinical: 3 of new onset purulent bronchial secretions, leucopaenia or leucocytosis, core temperature 38.5  C or 36  C without other cause, significant positive respiratory culture or culture from another relevant site of infection. A flow diagram and teaching programme was developed for bedside nurses to facilitate investigations of suspected VAP. The nurse in charge collected data daily at midnight until 24 h post extubation, discharge or death. Suspected cases of VAP were referred to infection control for secondary verification. A total of 158 intubated children were admitted over four months with 58 excluded (ventilated <24 h). Full data were obtained on all 100 children. VAP incidence was 5.6 per 1000 ventilator- days. We report successful introduction of a nurse-led VAP surveillance programme. Data acquisition in this study was dependent on nursing workload, however, and placed a signifi- cant time burden on the study leads. Although a relatively low VAP rate was demonstrated, VAP bundles with automated surveillance are being introduced. Ó 2009 The Hospital Infection Society. Published by Elsevier Ltd. All rights reserved. Introduction Ventilator-associated pneumonia (VAP), the second most common healthcare-associated infection (HCAI) in paediatric intensive care (PIC), accounts for 20% of nosocomial infections. 1,2 Defined as pneumonia developing later than 48 h after intubation and initiation of mechanical ventilation, VAP is associated with increased morbidity and mortality. 3 One prospective PIC study showed a 20% mortality rate for children with VAP compared with 7% in those without. 4 Significant morbidity is reported, between 3.7 and 10.0 additional ventilation days in neonates and children, resulting in prolonged admission and hospital costs. 2,4–6 The risk of developing VAP increases with duration of mechanical ventilation and is expressed as infectious episodes per 1000 venti- lator-days. Reported prevalence ranges from 2.9 to 11.6 per 1000 ventilator-days although data in children remain limited. 4,6,7 An established relationship exists between VAP and aspiration of colonised oropharyngeal secretions. 8 Factors contributing to colonisation include pH-altering drugs that permit overgrowth of gastric bacteria and feeding tubes that encourage bacterial migra- tion. 9 Micro-aspiration of colonised secretions occurs because of inadequate glottic closure around endotracheal tubes (ETTs) and also as neuromuscular blocking and sedative agents impair cough and mucociliary clearance, especially in those nursed supine. 10,11 Suctioning has also been implicated in VAP through direct contamination due to inadequate hand washing, oro/ * Corresponding author. Address: Consultant Paediatric and Neonatal Intensive Care Unit, Great Ormond Street Hospital for Children NHS Trust, Great Ormond St, London WC1N 3JH, UK. Tel.: þ44 2078298889; fax: þ44 2078138206. E-mail address: brierj@gosh.nhs.uk (J. Brierley). Available online at www.sciencedirect.com Journal of Hospital Infection journal homepage: www.elsevierhealth.com/journals/jhin 0195-6701/$ – see front matter Ó 2009 The Hospital Infection Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jhin.2009.12.015 Journal of Hospital Infection 75 (2010) 220–224