docWhat is a “BUNDLE”?
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What is a “BUNDLE”?
Implementation of Bundles in NICU Rosana Richtmann, M.D. Instituto de Infectologia Emilio Ribas Hospital e Maternidade Santa Joana – São Paulo Presidente da Sociedade Paulista de Infectologia - SPI AGENDA What How is a “BUNDLE”? to develop a BUNDLE in a NICU? How to develop a BUNDLE in a Brazilian NICU? How to put the BUNDLE in practice, working with “Medical Doctors…”? AGENDA What How is a “BUNDLE”? to develop a BUNDLE in a NICU? › CVC › VAP How to develop a BUNDLE in a Brazilian NICU? How to put the BUNDLE in practice, working with “Medical Doctors…”? ➥Individual measures that when put together have much better results! ➥ Considered a standard of care! INSTITUTE FOR HEALTHCARE IMPROVEMENT Guidelines X Bundles: What is the difference? Which one is better to the ICC? X “Guidelines” are long Some recommendations are not well defined Just 3 to 5 recommendations 100% based on HIGH level of scientific evidence Guidelines are very hard to put in practice Easier to put in practice Many HCW ignore then 100% of HCW know then Guidelines X Bundles: What is the diference? “Bundles Brigde the Guideline Gap” Evidence Guideline Bundles Practice AGENDA What is a “BUNDLE”? How to develop a BUNDLE in a NICU? How to develop a BUNDLE in a Brazilian NICU? How to put the BUNDLE in practice, working with “Medical Doctors…”? “Healthcare-acquired infection (HAI) in children may have been considered inevitable in the past.” A ocorrência da IH não é mais aceita como uma consequência da internação em Unidade de terapia intensiva pediátrica ou neonatal The Classical Central Line Bundle (for adults…) Hand hygiene Maximum barrier precautions, Chlorhexidine site disinfection, Avoiding the femoral site, Promptly removing unnecessary central venous catheters The Yale–New Haven Children’s Hospital 54Beds. Decrease the BSI rate quasi-experimental study of an educational intervention July 2005 - June 2007 multidisciplinary quality improvement committee – Review published data – create guidelines for CVC placement and management. Post intervention Pre intervention 1. CVC insertion with different techniques 1. Insertion of CVC = HCW from the Catheter team 2. Use of Povidone iodine with 70% isopropyl alcohol 2. sustained 3. Dressing changes without routine recommendations 3. When damp, loosened or soiled 4. CVC exclusive for TPN 4. TPN infusion + other medicaments 5. 70% alcohol for hub disinfection 5. chlorhexidine gluconate on the hub 6. No routine in the decision to Remove CVCs (on medical demand) 6. Daily analysis on the necessity of the CVC Catheter-Associated Bloodstream Infections in the NICU: Getting to Zero Arkansas Children’s Hospital NCIU with 85 beds 800 admission /year PICC line/ Broviac (exclusive for GI surgery and TPN) NEONATAL NETWORK May/June 2009, VOL. 28, NO. 3 AGENDA What is a “BUNDLE”? How to develop a BUNDLE in a NICU? How to develop a BUNDLE in a Brazilian NICU? How to put the BUNDLE in practice, working with “Medical Doctors…”? CLABSI in Brazil? How big is the Problem? 181 published papers about CLABSI CLABSI rates: 3.2 - 40.4/1000 cvc-d Higher incidence in ICU (specially = NICU) Mortality rate: 6,7% a 75% – Higher mortality: Pseudomonas/Acineto/ Candida APECIH – Infecção Associada ao uso de Cateteres Vasculares, 2005 Mortality causes in < 1y in Latin America countries, OPS 2003 poorly defined 1% Parasitary Infections 4% GI infections 8% Meningites 1% IRA 5% Neonatal issues 61 % Total of Deaths: 325.763 Pneumonias 8% Nutricional issues 3% Sepsis 3% Mortality causes in < 1y in Latin America countries, OPS 2003 10% 5% 32 % 24% 29 % Sites of Neonatal Infections EUA: Gaynes, 1996 n = 13'179 Europa: Raymond, 2000 n = 80 15% 8% 40% 8% 68% 17% 14% BSI 14% 1% 15% PNEU EENT SST GI OTHERS Brasil: Pessoa-Silva, 2004 n = 1'494 BSI PNEU GI Outros BSI – Blood Stream infection PNEU - pneumonia 6% 8% EENT – eyes, ear, nose and mounth 7% 50% 14% GI - gastrointestinal 15% BSI PNEU SST – skin and soft tissues EENT SST GI Outros Neonatal Network Survey 1° 2° 1° 3° 2° Healthcare-Associated Infections Among Neonates in Brazil Pessoa da Silva, Richtmann R at all. – 7 NICU – 4878 Neonates 22% NI 24.9/1000 neonate.day – 28% early onset 72% late onset – Ranged: 12,3% > 2500g - 51,9% <1000g – 40% of deaths related to NI – 50% BSI CNS: 1st microrganism ICHE, September 2004;25:772-777 1° 2◦ ICHE, September 2004;25:772-777 • To evaluate DA-HAI • From sept 2003 to Feb 2010 • 13.251 patients • 30 NICU • 15 countries CLA-BSI and PAV Low-income Lower-middle-income Upper-middle-income CID, 2009 Post intervention Pre intervention 1. CVC insertion with different techniques 1. Insertion of CVC = HCW from the Catheter team 2. Use of Povidone iodine with 70% isopropyl alcohol 2. 3. Dressing changes without routine recommendations sustained chlorhexidine gluconate (CHG) 3. 1. loosened Maintenance of When damp, or CVC = Catheter soiled 4. TPN infusion + other medicaments team 4. CVC exclusive for TPN 5. 70% alcohol for hub disinfection 5. chlorhexidine gluconate on the hub 6. No routine in the decision to Remove CVCs (on medical demand) 6. Daily analysis on the necessity of the CVC Monthly feedback and discussion of all data with neonatologists, nurses, etc Pneumonia Bundle Prevenção de Pneumonia Associada a Ventilação Mecânica 1-Elevação da cabeceira entre 30 a 45 graus 2-“Despertar diário” 3-Prevenção de úlcera péptica 4-Profilaxia de trombose venosa Institute for Healthcare Improvement Fatores de risco para aquisição de BCP associada à VM Adulto: – – – – Duração da VM Aspiração orofaríngea Uso de antibiótico Dispositivos respiratórios RN: – – – – – – – IG Peso Sexo Duração VM Aspiração traqueal Reintubação Dreno de tórax How-to-guide Pediatric supplement Ventilator Associated Pneumonia Pediatric Affinity Group Modificações para o Bundle Pediátrico/RN Manter decúbito 15 – 30 º para RN . Despertar diário da sedação não é recomendado pelo risco de extubação não planejada. Recomenda-se avaliação diária para a possibiidade de extubação através de check list diário ou durante as rondas. Profilaxia de úlcera gástrica de acordo com a idade da criança Profilaxia de trombose venosa de acordo com a idade da criança respeitando sempre as contra indicações. CUIDADOS ADICIONAIS A SEREM CONSIDERADOS 1-Higiene oral apropriada para idade do paciente. Considerar o uso da clorexidina para crianças acima de 2 meses de vida. + 2- Mantenha o circuito do ventilador livre de condensado. Drenar a água a cada 2 –4 horas + 3- Realizar a troca do circuito apenas quando apresentar sujeira visível ou mal funcionamento 4-.Realizar meticulosa higiene das mãos sempre antes e após a manipulação do circuito +/+ 5- Trocar o cateter de aspiração quando estiver visivelmente sujo. No sistema aberto deverá ser descartado a cada uso. +/6-. Armazenar dispositivo de sucção oral em saco plástico limpo e seco quando não estiver em uso. Cincinnati Children’s Hospital Medidas implementadas de acordo com as recomendações do IH para pediatria. Educação dos profissionais envolvidos Implementação das medidas Início em agosto de 2005 Agosto de 2006 6.0/1000vm dia 1.4/1000vm dia Creating and Implementing a Bundle to Reduce VAP in the NICU (IMPROVEMENT REPORT) Cuidados com tubo endotraqueal Instalar cord clamp apenas após IOT Evitar ao maximo extubações não programadas . Utilização de sistema de fechado para aspiração traqueal. Avaliação cuidadosa para indicar intubação. Escolher suporte ventilatório menos invasivo possível Central DuPage Hospital Winfield, Illinois, USA - IHI Massachusetts Hospital Association (MHA) have been offering programming to support the prevention of hospital-acquired infections throughout the Bay State Analise geral Bundle BCP em Neonatologia Número maior de medidas X adulto Medidas que se repetem: – Troca do circuito – Sistema de aspiração fechado – Higiene oral – Decúbito elevado Prevenção de úlcera gástrica? Prevenção de trombose venosa? AGENDA What is a “BUNDLE”? How to develop a BUNDLE in a NICU? How to develop a BUNDLE in a Brazilian NICU? How to put the BUNDLE in practice, working with “Medical Doctors…”?
