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…”?