an epidemiological study of ventilator-associated

An epidemiological study of ventilator-associated pneumonia (VAP) and

ventilator-associated events (VAE) surveillance and preventative strategies

in critically ill children

Noor Azizah Mohd Ali

RN BHSc (Nursing) (Hons) MNSc Cert (Teaching)

A thesis submitted for the degree of Doctor of Philosophy at

The University of Queensland in 2019

School of Nursing, Midwifery, and Social Work

i

Abstract

Background: Ventilator-associated pneumonia (VAP) is an ongoing iatrogenic burden within the

healthcare system for both adults and paediatrics. Debate continues over the appropriateness of the

VAP surveillance tool in paediatrics. Implementation of the new ventilator-associated events (VAE)

surveillance tool in the adult setting have shown to overcome the subjectivity of the traditional

pneumonia 1 VAP (PNU1/VAP) surveillance tool. Unlike in adult units, the application of the VAE

surveillance tool in paediatrics has not been mandated, leaving a question as to its potential

application. The lack of VAP paediatric specific studies has hampered progress informing compliance

with VAP preventative strategies in paediatric intensive care units (PICUs). Despite good hand

hygiene practise being established as a vital infection control measure, perception of ‘Speaking up

for hand hygiene’ in PICU still under- research. Hence, it became a potential area to improve good

hygiene practice.

Aim: To determine the VAP and VAE incidence using two surveillance tools at two time points; at

baseline and post an education campaign aimed at both PICU staff and parents. In addition to testing

the two surveillance tools, compliance auditing and staff and parental perspectives of VAP/VAE and

preventative strategies was established.

Methods: Retrospective study: PNU1/VAP and VAE surveillance tools were applied to 262

mechanical episodes of 234 children who received invasive mechanical ventilation ≥48 hours in PICU

in 2015. The sensitivity and specificity of VAE surveillance tool was tested. Other epidemiological

data were recorded; demographic characteristics, risk factors and VAP preventative strategies

documented within the unit.

VAP education, VAP compliance auditing with feedback and surveys: reinforcement of updated VAP

education was launched for PICU staff, and a pamphlet focusing on ‘Speaking up for hand hygiene’

was developed primarily to educate parents. The information was delivered to parents (N=37) via a

pamphlet and face-to-face education. VAP compliance auditing was conducted for a two-month

period and involved 37 patients in PICU undergoing VAP preventative strategies implemented by

PICU staff and parents: hand hygiene, oral hygiene, endotracheal tube (ETT) suctioning, ETT cuff

pressure checks, head of bed elevation, ventilator circuit checks, and early enteral feeding

commencement. The parents’ and nurses’ perceptions of ‘Speaking up for hand hygiene’ were

examined through surveys undertaken by 19 parents and 34 nurses.

ii

Prospective study: a six-month prospective study was conducted to investigate any improvement in

incidence rates of VAP/VAE and estimate the compliance rate of VAP preventative strategies.

Results: The incidence rate of VAP/VAE was 9.3 per 1000 ventilator days (VAP/VAE) based on end

of ventilation and 10.2 (VAP) and 10.4 (VAE) per 1000 ventilator days based on when the patients

were no longer at risk. The specificity of the new VAE surveillance tool was high with a slight

agreement between the tools. The overall compliance with VAP preventative strategies was 89.0%.

The presence of gastrointestinal prophylaxis (GI) and the frequency of oral hygiene were predictors

of the potential incidence rate of VAE/hour of ventilation, but none were found for VAP.

Overall VAP preventative strategies compliance was measured at 83.1%. Hand hygiene compliance

among PICU staff was at >80% and 64.7% among parents. Oral hygiene and ETT cuff pressure

checks (sub-elements) reported a compliance rate of <80.0%. Parents and nurses agreed that the

‘Speaking up for hand hygiene’ initiative would increase hand hygiene practises and willingness to

be reminded to perform the practise in PICU. Some parents reported reason being at vulnerable

position to questioning, made them hesitate to remind nurses and other PICU staff to perform hand

hygiene. Nurses reported their concern for the parents’ emotional status and preconceptions that their

colleagues were unwilling to accept hand hygiene reminders as reasons for not reminding.

The reduction of the incidence rate for VAP/VAE showed a drop to 3.9 (VAP) and 4.4 (VAE) and to

2.8 (VAP) and 3.2 (VAE) per 1000 ventilator days based on end of ventilation and until the patients

were no longer at risk. There was a statistically significant improvement of VAP preventative

strategies’ compliance reported between prospective and retrospective studies.

Conclusions: The reduction of VAP/VAE incidence rates demonstrated in this study reinforces the

need for VAP education, compliance auditing with feedback, and hand hygiene education for parents

and staff. Surveys on ‘Speaking up for hand hygiene’ among parents and nurses provided improved

perceptions which may help promote infection control measures in PICUs. Although the VAE tool

had slight agreement with the PNU1/VAP tool, it suggested the merit of identification of non-VAP

complications through a high specificity result. No risk factors or VAP preventative strategies were

found to be predictive of VAP, although these factors may be potential factors for non-infectious

complications. The presence of GI prophylaxis and frequency of oral hygiene performance were

found to be associated with VAE development. These findings were not robust, due to the low events

rate, but they were worthwhile predictors to be researched further.

iii

Declaration by author

This thesis is composed of my original work, and contains no material previously published or written

by another person except where due reference has been made in the text. I have clearly stated the

contribution by others to jointly-authored works that I have included in my thesis.

I have clearly stated the contribution of others to my thesis as a whole, including statistical assistance,

survey design, data analysis, significant technical procedures, professional editorial advice, financial

support and any other original research work used or reported in my thesis. The content of my thesis

is the result of work I have carried out since the commencement of my higher degree by research

candidature and does not include a substantial part of work that has been submitted to qualify for the

award of any other degree or diploma in any university or other tertiary institution. I have clearly

stated which parts of my thesis, if any, have been submitted to qualify for another award.

I acknowledge that an electronic copy of my thesis must be lodged with the University Library and,

subject to the policy and procedures of The University of Queensland, the thesis be made available

for research and study in accordance with the Copyright Act 1968 unless a period of embargo has

been approved by the Dean of the Graduate School.

I acknowledge that copyright of all material contained in my thesis resides with the copyright

holder(s) of that material. Where appropriate I have obtained copyright permission from the copyright

holder to reproduce material in this thesis and have sought permission from co-authors for any jointly

authored works included in the thesis.

iv

Publication during candidature

Peer-reviewed paper

Mohd Ali, N. A., Jauncey-Cooke, J., & Bogossian, F. (2019). Ventilator-associated events in children:

A review of literature. Australian Critical Care, 32(1), 55-62. doi:10.1016/j.aucc.2018.11.063

Conference abstract

Mohd Ali, N. A., Bogossian, F., Jauncey-Cooke, J., & Ballard, E. (2017). Preventative strategies of

VAP: Lessons from a one-year retrospective study. Poster presented at the 42nd Australia and

New Zealand Annual Scientific Meeting on Intensive Care and the 23rd Annual Paediatric and

Neonatal Intensive Care Conference. Gold Coast, Australia, 11 October to 13 October.

v

Publications included in this thesis


A review of literature. Australian Critical Care, 32(1), 55-62. doi:10.1016/j.aucc.2018.11.063-

incorporated in Chapter 2.

Contributor Statement of contribution

Author Noor Azizah Mohd Ali Critically reviewed the paper (80%)

Wrote the paper (70%)

Author Jaqueline Jauncey-Cooke Critically reviewed the paper (20%)

Wrote and edited the paper (20%)

Author Fiona Bogossian Wrote and edited the paper (10%)

vi

Contributions by others to the thesis

Dr Jacqueline Jauncey-Cooke (Principal Advisor), Honorary Prof Fiona Bogossian (Associate

Advisor) and Dr Emma Ballard (Associate Advisor) provided substantial guidance and inputs into

development of this thesis and throughout the PhD candidature. All of the supervisors critically

reviewed and provided comprehensive feedback on the content of this thesis.

Statement of parts of the thesis submitted to qualify for the award of another degree

None

vii

Acknowledgements

By the name of Allah, the most compassionate and the most merciful, and blessing to Prophet

Muhamad s.a.w. All praises to Him who has given me strength to embark on this PhD journey. May

I be able to serve back society through the knowledge that I have gained during this journey. My

heartfelt appreciation goes to my advisory team, Dr. Jacqueline Jauncey-Cooke (principal advisor),

Honorary Prof. Fiona Bogossian (associate advisor), and Dr. Emma Ballard (associate advisor) for

their patience, guidance, encouragement, and meaningful suggestions from the beginning until the

end of this journey. I gratefully acknowledge the constructive comments and suggestions from

reviewers throughout my milestones (Dr. Sara Mayfield, Dr. Karen New, and Dr. Haakan Strand).

I also would like to express sincere thanks to A/Prof. Dr. Luregn Schlapbach, Ivy Chang, Andrew

Barlow, Kylie Pearson, Dr. Deborah Long, Liz Crowe, Marina Demosthenous, and Tara Williams for

their enormous support, especially during the preliminary stage of my proposal and throughout the

data collection process in the Queensland Children’s Hospital. I would like to give a heartfelt thanks

to all the PICU staff for their support, and a special thanks to the staff of the Centre for Children’s

Health Research Centre (CHRC) who provided me a work station close to the hospital during my data

collection.

Thank you to my family, my father Mohd Ali binYusof, and my mother Siti Selahah binti Ali for

their prayers, support, advice, and motivation. I would especially like to thank the Malaysian

Government and my employer, the International Islamic University of Malaysia, for their financial

support and study leave approval. I would further like to thank my fellow colleagues in the School of

Nursing, Midwifery and Social Work and fellow friends (Dr Alison Williams, Dr Adrienne Hudson

and families) for their support through the good times and the bad. Thank you to all who supported

me in writing and encouraged me to strive towards my goal.

Terima kasih.

viii

Keywords

children, paediatric, epidemiology, ventilator associated pneumonia, ventilator associated events,

surveillance, preventative strategies

Australian and New Zealand Standard Research Classifications (ANZSRC)

ANZSRC code: 111002, Clinical Nursing: Primary (Preventative), 25%

ANZSRC code: 111403 Paediatrics, 25%

ANZSRC code: 110003, Clinical Nursing: Secondary (Acute Care), 20%

ANZSRC code: 111706, Epidemiology, 30%

Fields of Research (FoR) Classification

FoR code: 1110, Nursing, 50%

FoR code: 1117, Public Health and Health Services, 50%

ix

This thesis dedicated to my niece, Nurbatrisyia Khairina Khairul Anuar

x

Table of Contents

Abstract ………………………………………………………………………………………….i

Acknowledgements........................................................................................................................... vii

Table of Contents ............................................................................................................................... x

List of Figures ................................................................................................................................. xvii

List of Tables .................................................................................................................................xviii

List of Abbreviation ......................................................................................................................... xx

Thesis Introduction ...................................................................................................... 1

Introduction .......................................................................................................................... 1

Mechanical ventilation and VAP and VAE ......................................................................... 1

Aim ....................................................................................................................................... 5

Research questions ............................................................................................................... 5

Significance of the study ...................................................................................................... 6

Definitions ............................................................................................................................ 7

The flow of the thesis ........................................................................................................... 8

Summary ............................................................................................................................ 10

Literature Review: Epidemiology of VAP and VAE in paediatrics ...................... 11

Introduction to the literature review chapters .................................................................... 11

Timeline of surveillance of pneumonia (PNU) in healthcare settings ............................... 11

VAP and VAE: Pathogenesis and factors for acquiring VAP/VAE .................................. 14

The global incidence and the impact of VAP and VAE .................................................... 15

Risk factors for VAP and VAE .......................................................................................... 17

Diagnostic criteria for pneumonia (PNU/VAP) ................................................................. 20

The CDC alternative criteria for infants and children (PNU1) ...................................... 20

Diagnostic criteria for VAE surveillance ........................................................................... 21

Ventilator associated events (VAE) in children: A review of literature ............................ 24

Publication ..................................................................................................................... 24

Summary ............................................................................................................................ 35

Literature Review: Preventative strategies, compliance and VAP education ...... 37

Introduction ........................................................................................................................ 37

xi

Preventative strategies for VAP ......................................................................................... 37

Evidence of individual preventative strategies within the VAP bundle ............................ 41

Hand Hygiene ................................................................................................................ 41

Oral Hygiene .................................................................................................................. 42

Endotracheal Suctioning ................................................................................................ 44

Head of the bed (HOB) Elevation .................................................................................. 46

Endotracheal tube (ETT) and cuff pressure checks ....................................................... 46

Ventilator circuit checks ................................................................................................ 47

Sedation interruptions .................................................................................................... 48

Early enteral feeding commencement ............................................................................ 49

Gastrointestinal (GI) prophylaxis................................................................................... 50

Summary ........................................................................................................................ 51

Organisational and clinician compliance with VAP preventative strategies ..................... 51

Improving compliance with VAP preventative strategies via VAP education .................. 53

VAP Education .............................................................................................................. 53

The role of parents in VAP prevention and parental education on hand hygiene.............. 57

Perceptions of ‘Speaking up for hand hygiene’ among healthcare workers and parents ... 58

VAE and its preventative strategies ................................................................................... 61

Summary ............................................................................................................................ 61

Research Methodology .............................................................................................. 62

Introduction ........................................................................................................................ 62

Study setting ....................................................................................................................... 62

Study design ....................................................................................................................... 62

Phase 1: Retrospective study ......................................................................................... 63

Population and sample .......................................................................................... 64

Data collection ...................................................................................................... 64

VAP and VAE surveillance tools ......................................................................... 65

Demographic characteristics and admission-related variables ............................. 65

Potential risk factors ............................................................................................. 65

VAP preventative strategies ................................................................................. 65

Data analysis ......................................................................................................... 66

xii

Assessment of compliance of VAP preventative strategies ................................. 71

Ethical considerations ........................................................................................... 72

Phase 2: VAP education, VAP preventative strategies compliance auditing and surveys

………………………………………………………………………………………..72

VAP education and education engagement .......................................................... 73

Compliance auditing ............................................................................................. 80

Survey for parents ................................................................................................. 85

Surveys for nurses................................................................................................. 89

Phase 3: Prospective study ............................................................................................. 92

Population and sample .......................................................................................... 92

Data collection ...................................................................................................... 92

VAP and VAE surveillance tools ......................................................................... 93

Data analysis ......................................................................................................... 93

Ethical considerations ........................................................................................... 93

4.4 Summary .................................................................................................................................. 94

Results and discussion Phase 1: Retrospective study ............................................. 95

Introduction ........................................................................................................................ 95

Selection of patients with eligible mechanical ventilation episodes .................................. 95

Demographic characteristics of patients in PICU admission ......................................... 96

Outcome variables according to mechanical ventilation episodes ................................ 97

VAP and VAE counts according to mechanical ventilation episodes ........................... 98

Incidence and prevalence of VAP in PICU ................................................................... 98

Incidence and prevalence of VAE in PICU ................................................................... 99

The sensitivity and the specificity of the VAE surveillance tool ................................... 99

Agreement between the two surveillance tools............................................................ 100

Discussion .................................................................................................................... 100

Discussion of demographic characteristics of the patients ................................. 100

Discussion of VAP and VAE in the PICU of the QCH in 2015......................... 101

Potential risk factors for VAP and VAE .......................................................................... 103

Compliance of preventative strategies for VAP............................................................... 103

xiii

Univariate analysis ........................................................................................................... 104

Association between demographic characteristics and VAP and VAE ....................... 104

Association of outcome characteristics with VAP and VAE ....................................... 105

Association of possible risk factors with VAP and VAE ............................................ 106

Association of preventative strategies with VAP and VAE ........................................ 107

Summary of the significant explanatory variables found in the study ......................... 108

Discussion .................................................................................................................... 109

Possible risk factors and compliance of VAP preventative strategies ................ 109

Discussion of the association between study variables and VAP/VAE development

at univariate analysis level ................................................................................................... 110

Multivariate analysis ........................................................................................................ 112

VAP models ................................................................................................................. 112

Age and gender adjusted Poisson and negative binominal models .................... 112

VAE models ................................................................................................................. 112

Age and gender adjusted Poisson and negative binominal models .................... 112

The final modified Poisson and Negative Binominal models for VAE ............. 116

Discussion .................................................................................................................... 119

Discussion of potential risk factors and VAP preventative strategies and

association with VAP/VAE development by multivariate analysis ..................................... 119

Summary .......................................................................................................................... 120

Results and discussion Phase 2: VAP preventative strategy compliance and

surveys ................................................................................................................................. 122

Introduction ...................................................................................................................... 122

Results of compliance auditing of VAP preventive strategies ......................................... 122

Demographic characteristics of participants in VAP preventative strategy compliance

auditing ........................................................................................................................ 122

Hand hygiene ...................................................................................................... 122

Oral hygiene........................................................................................................ 123

Cuff pressure check ............................................................................................ 123

Endotracheal suctioning ...................................................................................... 123

Head of bed (HOB) elevation ............................................................................. 124

xiv

Ventilator circuits checks ................................................................................... 124

Enteral feeding commencement within 24 hours of admission .......................... 124

Discussion of compliance of VAP preventative strategies during auditing................. 124

Parental survey: ‘Speaking up for hand hygiene’ ........................................................ 127

Response rate ...................................................................................................... 127

Demographic characteristics of parents and their child’s admission history ..... 128

Perceptions of parents on VAP education .......................................................... 128

Parental perceptions on willingness to remind and to be reminded by nurses and

other PICU staff to perform hand hygiene ........................................................................... 128

Reasons parents would be reluctant to prompt nursing staff regarding hand hygiene

………………………………………………………………………………….128

Reasons parents would be reluctant to remind other PICU staff regarding hand

hygiene 129

Suggestions or comments to improve hand hygiene practise in the unit ............ 129

Discussion of parental perceptions on ‘Speaking up for hand hygiene’............. 129

Nursing staff survey ..................................................................................................... 132

Response rate ...................................................................................................... 132

Demographic characteristics of nursing staff participants .................................. 132

Nurses’ perceptions of their willingness to remind and be reminded by parents and

other PICU staff to perform hand hygiene ........................................................................... 132

Reasons nurses would be reluctant to prompt parents regarding hand hygiene . 132

Reasons nurses would be reluctant to prompt other PICU staff regarding hand

hygiene ……… .................................................................................................................... 133

Suggestions or comments to improve hand hygiene practise in the unit ............ 133

Discussion of nurses’ perceptions on ‘Speaking up for hand hygiene’ .............. 133

Summary .......................................................................................................................... 135

Results and discussion Phase 3: Prospective Study .............................................. 136

Introduction ...................................................................................................................... 136

Results .............................................................................................................................. 136

Baseline demographic characteristics .............................................................................. 136

xv

Demographic characteristics of patient based on PICU admission ............................. 136

Outcome variables according to mechanical ventilation episodes at prospective study....

………………………………………………………………………………………..138

Incidence of VAP and VAE at prospective study ........................................................ 139

Discussion .................................................................................................................... 140

Discussion of demographic and outcome variables of the prospective study .... 140

Discussion of incidence of VAP and VAE at prospective study ........................ 140

Potential risk factors according to mechanical ventilation episodes............................ 142

Compliance of preventative strategies of VAP in the prospective study ..................... 143

Compliance of VAP preventative strategies: Retrospective versus prospective

studies …….......................................................................................................................... 147

Discussion of VAP preventative strategies compliance — retrospective versus

prospective studies ....................................................................................................... 147

Univariate analysis ........................................................................................................... 148

Association of demographic characteristics with VAP and VAE in the prospective

study ............................................................................................................................. 149

Association of patient outcome characteristics with VAP and VAE ........................... 150

Association of possible risk factors with VAP and VAE ............................................ 150

Association of preventative strategies with VAP and VAE ........................................ 151

Discussion of demographic and outcome characteristics and VAP/VAE — prospective

versus retrospective studies .......................................................................................... 152

Discussion of potential risk factors and preventative strategies and VAP/VAE —

prospective versus retrospective studies ...................................................................... 153

Summary .......................................................................................................................... 154

General Discussion ................................................................................................... 155

Introduction ...................................................................................................................... 155

Summary of the thesis ...................................................................................................... 155

New VAE surveillance tool for global surveillance ........................................................ 158

The role of VAP education, compliance auditing with feedback, and parents’ involvement

in VAP/VAE prevention .................................................................................................. 160

Limitations and strengths ................................................................................................. 161

General implications and future directions ...................................................................... 164

xvi

Conclusion........................................................................................................................ 165

List of References ........................................................................................................................... 167

Appendices 188

Appendix A Data collection sheet (Retrospective study) ........................................................... 188

Appendix B HREC approval ........................................................................................................ 200

Appendix C Governance approval ............................................................................................... 203

Appendix D PHA approval ........................................................................................................... 204

Appendix E University of Queensland Ethical approval ........................................................... 205

Appendix F Updated VAP education package (PICU staff) ..................................................... 206

Appendix G Education for parents: Pamphlet ........................................................................... 207

Appendix H Survey Questionnaire (Parents) .............................................................................. 209

Appendix I Survey participant information sheets (Parents and Nurses) .............................. 213

Appendix J Survey Questionnaire (Nurses) ............................................................................... 217

Appendix K Data collection sheet (Prospective study) ............................................................... 219

Appendix L Parents information sheet and consent form for prospective study .................... 234

Appendix M Approval of waiver of consent for prospective study ........................................... 237

xvii

List of Figures

Figure 1.1: Flow of thesis presentation ................................................................................................ 9

Figure 2:1: Timeline for surveillance of pneumonia (PNU) in a healthcare setting .......................... 13

Figure 2:2: Ventilator-associated events in the respective tiers ......................................................... 15

Figure 2:3: PRISMA flow diagram of literature selection ................................................................. 27

Figure 4:1: Study timeframe with respective research activities undertaken .................................... 62

Figure 4:2: The research components involved in Phase 2 of the study ............................................ 73

Figure 5:1: 262 episodes of mechanical ventilation met the study criteria ........................................ 96

Figure 6:1: Endotracheal suctioning (open method) compliance .................................................... 123

Figure 7:1: Comparison of individual VAP preventative strategy compliance — retrospective versus

prospective studies; p-values given where change is statistically significant. .............. 147

xviii

List of Tables

Table 2.1: Risk factors for VAP in children: Studies published from 2005 to 2015 ......................... 19

Table 2.2: CDC PNU1/VAP Tool: Alternative Criteria for Infants and Children ............................. 22

Table 2.3: The CDC VAE tiers with respective requirements and criteria ........................................ 23

Table 2.4: Study summaries and agreement between surveillance tools ........................................... 28

Table 3.1: Additional preventative strategies to consider for the paediatric VAP bundle ................. 38

Table 3.2: Individual VAP preventative strategies used in paediatrics and VAP rates (in order of

publication date) .............................................................................................................. 39

Table 3.3: Oral hygiene protocol for mechanically ventilated children ............................................ 43

Table 3.4: Paediatric studies involving VAP education and VAP preventative strategy

implementation ................................................................................................................ 55

Table 4.1: Compliance standard for VAP preventative strategies according to PICU and national

standard for hand hygiene ............................................................................................... 71

Table 4.2: The content of updated VAP education in PICU .............................................................. 74

Table 4.3: The content of VAP preventative strategies poster .......................................................... 75

Table 4.4: The summary of content validation for bi-fold pamphlet, ‘VAP: How I Can Help my Child

in PICU’ .......................................................................................................................... 77

Table 4.5: The VAP education engagement in PICU at Phase 2 ....................................................... 79

Table 4.6: VAP compliance data auditing ......................................................................................... 82

Table 4.7: Elements in parents’ survey .............................................................................................. 88

Table 4.8: Elements in nurses’ survey ............................................................................................... 91

Table 5.1: Demographic characteristics according to patient admission (n=253) ............................. 97

Table 5.2: Outcome variables according to mechanical ventilation episodes (n=262) ..................... 98

Table 5.3: Contingency table of VAE versus VAP ........................................................................... 99

Table 5.4: Risk factors according to mechanical ventilation episodes (n=262) .............................. 103

Table 5.5: Comparison between VAP preventative strategies compliance and PICU/national standard

practise .......................................................................................................................... 104

Table 5.6: Univariate analysis for association of demographic characteristics with VAP/VAE (n=262)

....................................................................................................................................... 105

Table 5.7: Univariate analysis for association of patient outcome characteristics with VAP and VAE

(n=262) .......................................................................................................................... 106

Table 5.8: Univariate analysis for association of possible risk factors with VAP and VAE (n=262)

....................................................................................................................................... 107

xix

Table 5.9: Univariate analysis for association of VAP preventative strategies with VAP/VAE (n=262)

....................................................................................................................................... 108

Table 5.10: Explanatory variables with a significant association with VAP or VAE by univariate

analysis .......................................................................................................................... 108

Table 5.11: Age and gender adjusted Poisson and Negative Binominal regression models of risk

factors and preventative strategies for incidence of VAP/hour of ventilation .............. 114

Table 5.12: Age and gender adjusted Poisson and Negative Binominal regression models of risk

factors and preventative strategies for incidence of VAE/hour of ventilation .............. 115

Table 5.13: Final Poisson models of risk factors and preventative strategies for incidence of VAE/

hour of ventilation ......................................................................................................... 117

Table 5.14: Final Negative Binominal regression models of risk factors and preventative strategies

for incidence of VAE/hour of ventilation ..................................................................... 118

Table 7.1: Demographic characteristics comparison of patients in prospective study versus

retrospective study on PICU admission (n=115; n= 253) respectively......................... 137

Table 7.2: Outcome variables according to mechanical ventilation episodes prospective versus

retrospective study (n=120; n= 262) ............................................................................. 138

Table 7.3: Comparison of VAP and VAE incidence between retrospective and prospective studies

measured on end of ventilation and until the patient is no longer at risk ...................... 139

Table 7.4: VAP and VAE counts (tiers) according to mechanical ventilation episode prospective and

retrospective studies ...................................................................................................... 140

Table 7.5: Potential risk factors according to mechanical ventilation episode (n= 120) in prospective

study, compared to retrospective study (n= 262) .......................................................... 143

Table 7.6: Comparison of VAP compliance preventative strategy performance with PICU

standard/National standard ............................................................................................ 145

Table 7.7: Univariate analysis for association of demographic characteristics with VAP and VAE

(n=120) .......................................................................................................................... 149

Table 7.8: Univariate analysis for association of outcome characteristics with VAP and VAE (n=120)

....................................................................................................................................... 150


....................................................................................................................................... 151

Table 7.10: Univariate analysis for association of VAP preventative strategies with VAP and VAE

(n=120) .......................................................................................................................... 152

xx

List of Abbreviation

CDC Centre for Disease Control and Prevention

CI Confidence Interval

FiO2 Fraction Inspired Oxygen

HCAIs Healthcare-Associated Infections

HR Hazard Ratio

IHI Institute for Healthcare Improvement

IQR Interquartile Range

IVAC Infection-Related Associated Condition

NHSN National Healthcare Safety Network

OR Odd Ratio

PEEP Positive End Expiratory Pressure

PICU Paediatric Intensive Care Unit

PNU Pneumonia

PVAP Possible Ventilator- Associated Pneumonia

SD Standard deviation

VAC Ventilator-Associated Condition

VAE Ventilator-Associated Events

VAP Ventilator-Associated Pneumonia

1

Thesis Introduction

Introduction

This thesis investigates ventilator-associated pneumonia (VAP) and ventilator-associated events

(VAE) in mechanically ventilated children. Within the thesis, the incidence and risk factors of VAP

and VAE are explored using surveillance tools recognised for adults and children. Preventative

strategies for VAP incorporating both staff and parents are implemented and their impact is measured.

This chapter introduces the epidemiology of the healthcare-associated infections (HAIs) of VAP and

VAE and discusses the significance of this study. The research questions, aims, and definitions of

key terms are described.

Mechanical ventilation and VAP and VAE

Mechanical ventilation is a life-saving option when the airway requires protection and respiratory

effort and/or gas exchange is compromised (Arca, Uhing, & Wakeham, 2015). Invasive mechanical

ventilation requires an endotracheal tube as the interface between the ventilator and lungs. The

presence of an endotracheal tube and concomitant sedation impairs the natural mechanisms of

breathing by suppressing reflexes such as coughing and gagging (Mietto, Pinciroli, Patel, & Berra,

2013). The endotracheal tube also provides a pathway for pathogenic oro/nasopharyngeal secretions

to flow directly to the lower respiratory tract, and these can induce respiratory inflammation and

complications such as VAP (Mietto et al., 2013).

VAP describes a ventilator-associated complication focusing on a single infection or pneumonia

affecting a patient receiving invasive mechanical ventilation for a period of greater than, or equal to,

48 hours (American Thoracic & Infectious Diseases Society, 2005; Foglia, Meier, & Elward, 2007).

VAP in both paediatric and adult settings is a constant challenge to the healthcare system. In

developed countries such as the USA, adult VAP incidence rates are reported to be between 0.0 to

5.8 per 1000 ventilator days (Dudeck et al., 2011); however, in developing countries, the rate is

significantly higher at 10 to 41.7 per 1000 ventilator days (Arabi, Al-Shirawi, Memish, & Anzueto,

2008). Recent literature on children suggests that VAP occurs in 1.3% to 36.2% of ventilated children

(Awasthi, Tahazzul, Ambast, Govil, & Jain, 2013; Jordan Garcia et al., 2014; Navoa-Ng et al., 2011;

Patria et al., 2013) with the incidence rates ranging from 0.3 to 31.8 per 1000 ventilator days (Al-

Mousa et al., 2016; Gautam et al., 2012; Rosenthal, Bijie, et al., 2012). VAP is associated with

2

increased duration of mechanical ventilation and subsequent increased length of hospital stay

(Balasubramanian & Tullu, 2014; Gautam et al., 2012; Gupta et al., 2015; Srinivasan, Asselin,

Gildengorin, Wiener-Kronish, & Flori, 2009).

Surveillance of HAIs which can detect the incidence and possible risk factors for VAP is the

cornerstone of every acute care setting’s infection control program (Klompas, Branson, et al., 2014;

Rebmann & Greene, 2010). Surveillance allows hospitals and clinicians to measure the effectiveness

of strategies that are implemented to decrease infection rates (Klompas, Branson, et al., 2014). To be

specific, surveillance is referred to the monitoring and reporting of HAIs events (which are including

VAP and VAE as the focus of interest in this study) as follow:

(1) presence of infection,

(2) the magnitude of the problem and,

(3) the factors that contribute to infections (VICNISS Healthcare Associated Infection

Surveillance, 2015).

A VAP surveillance tool used in adults was first established in 1988 and has undergone serial updates

until 2013 (Mohd Ali, Jauncey-Cooke, & Bogossian, 2019). The VAP surveillance tool relied on

three main criteria:

(1) radiological criteria (chest x-ray);

(2) clinical signs and symptoms;

(3) microbiological laboratory results (Centers for Disease Control and Prevention (CDC) &

National Healthcare Safety Network (NHSN), 2015a; Horan, Andrus, & Dudeck, 2008).

Recently, attention has broadened from VAP to VAE necessitating the development of a more

inclusive surveillance tool incorporating non-infectious ventilator-associated complications; not

limited solely to pneumonia. These complications include pulmonary oedema, barotrauma, acute

respiratory distress syndrome (ARDS) and atelectasis (Klompas, 2013a). The inclusion of a VAE

surveillance tool by the Centers for Disease Control and Preventions (CDC) was partly to address the

limitations of the former VAP surveillance tool and also aimed to improve patient safety by creating

the role of a pay performance indicator (Klompas, 2013b; Muscedere et al., 2013; Septimus, Green,

& Klompas, 2015). VAE is determined using the criteria, which has three ordinal tiers:

(1) ventilator-associated condition (VAC), assessing respiratory deterioration;

(2) infection-related ventilator-associated complication (IVAC), assessing signs of

infection/inflammation;

3

(3) Possible ventilator-associated pneumonia (PVAP), assessing the presence of pathogenic

organisms. The VAE surveillance definition measures VAP as PVAP (Centers for Disease

Control and Prevention (CDC) & National Healthcare Safety Network (NHSN), 2015b).

Given the shift of surveillance tools from VAP to VAE it is important that it’s application in

paediatrics is tested. The surveillance tool developed for children is the PNU1/VAP (Alternative

Criteria for Infants and Children). It relies on similar criteria as described for adults but excludes

microbiological laboratory results (Centers for Disease Control and Prevention (CDC) & National

Healthcare Safety Network (NHSN), 2015a; Horan et al., 2008).

However, the VAP surveillance tools have been criticised because they were found in some studies

to be neither sensitive nor specific sufficiently to detect VAP (Raoof, Baumann, Critical Care

Societies Collaborative, & The Society of Critical Care Medicine, 2014). For example, the

radiological criteria of consolidation may be interpreted as atelectasis or pneumonia or a pleural

effusion. Clinical signs and symptoms (i.e., fever, changes in sputum character, increased suctioning

requirements, worsening cough) are highly subjective and vary from one examiner to another, and

microbiological results may be a consequence of colonisation or infection (Turton, 2008). Hence, the

accuracy of the data derived from these surveillance tools is questionable (Raoof, Baumann, &

Critical Care Society Collaborative, 2014).

Despite this, surveillance data provides important information on VAP preventative strategy

implementation and is an important focus for VAP research (Nair & Niederman, 2015). When VAP

is identified, the treatment relies on the type of organism identified by microbiological sampling

(Kollef, 2011). Treatment of VAP is typically commenced using broad-spectrum antibiotics

considering both patient factors and the pattern of institutional antibiotic resistance (Muscedere et al.,

2008). Ideally, the antibiotic course should start with a broad-spectrum prescription, and be

downscaled after the microbiological results become available (Foglia et al., 2007). This strategy

aims to avoid multi-drug resistant (MDR) strains (Chastre et al., 2003; Nair & Niederman, 2015).

The issue of MDR has become a major threat in intensive care settings and is further hampered by

the decline in production of new drugs (Amin & Deruelle, 2015). However, delays in antibiotic

commencement have been shown to be associated with an increased healthcare burden (Iregui, Ward,

Sherman, Fraser, & Kollef, 2002). Thus, the focus of the VAP/VAE surveillance tools is on

prevention rather than treatment options which aligns with the work of previous scholars such as

Magill et al., (2013) and Magill, Rhodes, and Klompas, (2014).

4

The VAE surveillance tool used in adults also identified most of the events being due to pulmonary

oedema, atelectasis, acute respiratory distress syndrome and pneumonia, which the treatment is then

dependent upon the physiological events identified in each patient (Boyer et al., 2015; Hayashi et al.,

2013; Klein Klouwenberg et al., 2014; Klompas et al., 2011). The potential preventative strategies

for VAE in adults are breathing trials and paired daily spontaneous wakening, early exercise and

mobility, low tidal volume ventilation, fluid management and conservative blood transfusion

thresholds (Klompas, 2015). One study has applied this surveillance definition to paediatrics

(Phongjitsiri et al., 2015). The authors found that VAE was most commonly due to atelectasis, sepsis,

ARDS and shock. This surveillance tool also targets constructing preventative strategies that aim to

improve patient outcomes (Hayashi et al., 2013; Klompas, Magill, et al., 2012). Yet, no study to date

has examined the preventative strategies of VAE in paediatrics which increased the interest in this

study.

Preventative strategies for VAP often can be addressed by the education of staff. Education on VAP

preventative strategies (commonly known as the ‘Ventilator bundle’ or ‘VAP bundle’) and strict

compliance monitoring are crucial in minimising VAP occurrence (Gupta et al., 2014; Jansson,

Kääriäinen, & Kyngäs, 2013; Rello et al., 2002; Smiddy, O' Connell, & Creedon, 2015). VAP

preventative strategies need to be regularly updated and tailored to specific populations with

understanding of the disease emergence and prevalence (Hellyer, Ewan, Wilson, & Simpson, 2016;

Pittet, 2010). VAP preventative strategies are well established in the adult population and have

consistently proven to reduce VAP rates (Khosim et al., 2015; Lu, Shin, & Ding, 2015; Morris et al.,

2011). In contrast, the preventative strategies for VAP in paediatric patients are considered

inconclusive and variable, requiring substantial further research (Brierley, Highe, Hines, & Dixon,

2012; Cooper & Haut, 2013). As a consequence of inadequate paediatric data, the adult VAP

preventative strategies are often adapted to paediatric settings (Cooper & Haut, 2013).

For adult patients, the VAP preventative strategies consist of four to six components:

(1) head of the bed (HOB) elevation greater than 30 degrees;

(2) daily sedation break and daily assessment of readiness to extubate;

(3) the use of gastrointestinal (GI) prophylaxis;

(4) the use of deep vein thrombosis (DVT) prophylaxis;

(5) oral decontamination with chlorhexidine 0.12% and

(6) continuous aspiration of subglottic drainage (Eom et al., 2014; Resar, Griffin, Haraden, &

Nolan, 2014; Wip & Napolitano, 2009).

5

Not all of these preventive strategies suit the paediatric population. Some strategies, such as the daily

sedation break and daily assessment of readiness to extubate may increase the chances of unplanned

extubations and reintubations in infants and young paediatric patients (Klompas, Branson, et al.,

2014). The lack of updated paediatric specific VAP prevention strategies in PICUs suggests there are

grounds for further research to inform paediatric evidence-based VAP preventative strategies. Scant

evidence exists around preventative strategies specifically for VAE in PICU patients (Cocoros,

Priebe, Gray, et al., 2017; Phongjitsiri et al., 2015).

Despite the fact that compliance with VAP preventative strategies (the ventilator bundle) is crucial to

minimise VAP occurrences, modest compliance in implementing the VAP preventive strategies

among healthcare workers has been reported (Cooper & Haut, 2013; Nair & Niederman, 2015); the

prevention of HAIs such as VAP therefore requires education of healthcare workers (Klompas,

Branson, et al., 2014). Several studies have demonstrated improved compliance through education

(Flodgren et al., 2013; Jansson et al., 2013). In addition to the concern for healthcare workers’

compliance, evidence describing the role of PICU parents in HAI minimisation through simple

measures such as hand hygiene is currently also lacking.

Aim

Therefore, this study aims to:

• test the use of the VAE surveillance tool in paediatric patients,

• determine the influence of the updated VAP education focused on specific paediatric VAP

preventative strategies for staff and parents in the PICU, and

• assess the impact following implementation of updated VAP education on VAP and VAE

rates, and VAP preventative strategy compliance.

Research questions

This study addresses four research questions:

1. What is the baseline status of VAP and VAE in paediatric patients as defined by the

PNU1/VAP surveillance and the VAE surveillance tools?

2. What are the current VAP preventative strategies in the PICU?

3. What are the perceptions of parents and nurses in the PICU on the ‘Speaking up for hand

hygiene’ component of the VAP education?

4. Does VAP education and compliance auditing of the preventative strategies with feedback,

reduce VAP and VAE incidence and improve compliance of the VAP preventative strategies?

6

Significance of the study

Reliable VAP and VAE surveillance tool is important to capture the incidence and risk factors that

could be a benchmark for preventative strategies planning in PICU. There is currently no reliable

surveillance tool available to provide precise surveillance data in paediatric patients with ventilator

related complications (Gautam et al., 2012; Klompas, 2010; Srinivasan et al., 2009). Moreover, the

present PNU1/VAP surveillance tool in children is challenging to implement and the effectiveness of

the preventative strategies is difficult to assess (Chang & Schibler, 2016; Cocoros et al., 2016;

Phongjitsiri et al., 2015). Nonetheless, the VAE surveillance tool in adults has shown promising

benefits, and potentially this could be extended to paediatrics (Boyer et al., 2015; Septimus et al.,

2015). With that, both PNU1/VAP surveillance tool and VAE surveillance tool in paediatric need to

be tested.

The significance of the study is link to the concern on continuous challenges in the impact of VAP in

children in PICU. This includes mechanical ventilation-associated complications, lengthened

duration of PICU and hospital stay as well as significant healthcare costs (Chang & Schibler, 2016;

Curley et al., 2006; Foglia et al., 2007; Gautam et al., 2012; Gupta et al., 2015; Srinivasan et al., 2009;

Turton, 2008). Although VAE knowledge in children is not as advanced as our understanding of

VAP, it is estimated that its prevalence ranges from 4.2 to 20.9 episodes per 1000 ventilator days

(Cocoros et al., 2016; Iosifidis et al., 2016; Narayanan, Dixon, Chalkley, Ray, & Brierley, 2016;

Phongjitsiri et al., 2015). Children with VAE have significantly increased hospital morbidity and

mortality (Beardsley, Nitu, Cox, & Benneyworth, 2016; Cocoros et al., 2016; Phongjitsiri et al.,

2015). Given the impact of VAP and VAE on patient safety and healthcare expenditure, these

problems need to be addressed.

Adding to the above, HAIs including VAP are associated with substantial economic and health

burdens which lead to surveillance activities becoming compulsory in many of the parts of the world

for minimising the burden (Martin et al., 2013). In the USA, for example, all healthcare facilities are

required to report their VAP surveillance to the National Healthcare Safety Network (NHSN) as one

indicator of quality assessment, affecting subsequent determination of hospital reimbursement

(Stoeppel et al., 2014). Research on the use of benchmarking and public reporting through

surveillance activities in high-income countries (England, Germany, France and the USA) shows that

these practises help to effect substantial organisational change for patient safety (Haustein et al., 2011;

Klompas, 2013a); this has influenced treatment options and preventative strategy development and

implementation (Haustein et al., 2011; Klompas, 2013a).

7

In developing countries such as the Philippines, India and Argentina, VAP surveillance data is

submitted to the International Nosocomial Infection Consortium (INICC) for benchmarking and

evaluation of inpatient quality reporting programs (Rosenthal, Alvarez-Moreno, et al., 2012).

However, in Australia, VAP surveillance is an optional module, possibly due to the challenging and

labour-intensive application of the surveillance tool (Friedman, Russo, & Richards, 2005). Moreover,

surveillance of VAE in paediatric patients in Australia is not undertaken, and implementation of

preventative strategies into clinical practise for the evaluation of quality improvement thus remains

difficult to measure (Magill et al., 2013; Mietto et al., 2013).

Definitions

The key terms used in this thesis are given below.

Ventilator-associated pneumonia (VAP)

VAP refers to pneumonia, which occurs among children who receive invasive mechanical ventilation

via an endotracheal tube for a period of time greater than, or equal to, 48 hours in PICU. This study

uses the criteria of the PNU1/VAP (Alternative Criteria for Infants and Children) surveillance

definition as outlined by the CDC and NHSN (Centers for Disease Control and Prevention (CDC) &

National Healthcare Safety Network (NHSN), 2015a).

Ventilator-associated events (VAEs)

VAEs1 are ventilator-associated events that occur in ventilated patients in the PICU, according to the

criteria outlined by the CDC and NHSN. These events are divided into three ordinal tiers:

Tier 1: Ventilator-associated condition (VAC);

Tier 2: Infection-related ventilator-associated complications (IVAC); and

Tier 3: Possible ventilator-associated pneumonia (PVAP).

VAP preventative strategies

In this study, the VAP preventative strategies consist of seven individual preventative strategies:

(1) Hand hygiene of PICU staff and parents;

(2) Oral hygiene;

1 In this study, the VAE surveillance definition currently used for adults is applied to paediatric patients in PICU (Centers

for Disease Control and Prevention (CDC) & National Healthcare Safety Network (NHSN), 2015b). IVAC and PVAP

will be mentioned specifically; otherwise, in this study VAC represents VAE. The term ‘surveillance definition’ is used

interchangeably with the term ‘surveillance tool’. ‘VAP/Ventilator bundle’ is used interchangeably with ‘VAP

preventative strategies’.

8

(3) Endotracheal suctioning (open suction);

(4) Endotracheal cuff checks;

(5) Head of the bed (HOB) elevation;

(6) Ventilator circuit checks; and

(7) Early initiation of enteral feeding (Queensland Children's Hospital Paediatric Intensive

Care Unit, 2016).

‘Speaking up for hand hygiene’

‘Speaking up for hand hygiene’ is an initiative or campaign to promote patient safety and prevent the

spread of infection (The Joint Commission, 2018). In this study, ‘Speaking up for hand hygiene’ is

delivered through a pamphlet, educating and reminding parents of the importance of performing hand

hygiene and when they should perform it, and a message encouraging parents to check if they are

washing their hands and check whether healthcare workers or visitors have washed their hands.

The flow of the thesis

This thesis consists of eight chapters (refer to Figure 1.1).

• Chapter 1 is an introductory chapter, which includes study aims, significance of the study,

research questions and definitions of key terms.

• Chapter 2 provides a literature review of the VAP and VAE epidemiological data

and surveillance in paediatrics. This chapter outlines the current debate and ongoing issues

regarding VAP and VAE and discusses the relevance of the existing surveillance definitions

in ventilated paediatric patients.

• Chapter 3 provides a literature review of the current preventative strategies for VAP and VAE

in paediatric patients and the challenges for healthcare workers in implementing the VAP

preventative strategies. This chapter also examines the role that parents play, particularly in

the ‘Speaking up for hand hygiene’ initiative. The review also includes the data that VAP

education may assist in the reduction of VAP prevalence.

• Chapter 4 details the methodologies used in this thesis.

• Chapter 5 presents results and discussion of Phase 1: Retrospective study, which provides the

baseline VAP and VAE status in paediatric patients.

• Chapter 6 describes the implementation of the updated VAP education package and presents

the results and discussion related to Phase 2: VAP compliance auditing. This chapter also

includes survey results from parents and nurses about the ‘Speaking up for hand hygiene’

initiative in PICU.

9

• Chapter 7 presents the results and discussion of Phase 3: Prospective study to assess the

change in VAP and VAE prevalence and preventative strategies compliance following

implementation of the updated VAP education program. This chapter also compares the

findings between Phase 1: Retrospective and Phase 3: Prospective study.

• Finally, Chapter 8 provides a general discussion, limitations, implications and

recommendations for future studies.

Chapter 1

Thesis Introduction

Chapter 2

Literature

Review

Epidemiology

of VAP and

VAE in

children

Chapter 3

Literature

Review

Preventative

strategies,

compliance

issues &

VAP

education

Chapter 4

Methodology

Phase 1:

Retrospective

study

Phase 2:

VAP

education,

VAP

compliance

auditing &

surveys

Phase 3:

Prospective

study

Chapter 5

Results and

discussion:

Phase 1:

Retrospective

study

Chapter 6

Results and

discussion:

Phase 2: VAP

education,

VAP

preventative

strategies

compliance

auditing &

surveys

Chapter 7

Results and

discussion:

Phase 3:

Prospective

study

Chapter 8

General discussion, limitations & conclusion

Figure 1.1: Flow of thesis presentation

10

Summary

This chapter has highlighted the significance of VAP and VAE in critically ill paediatric patients on

invasive mechanical ventilation — in particular, the complexities of the surveillance definitions,

implementation of preventative strategies and ongoing compliance challenges. The chapter concluded

with an overview of the thesis.

11

Literature Review: Epidemiology of VAP and VAE in paediatrics

Introduction to the literature review chapters

A literature search was conducted based on the following electronic databases: PubMed, CINAHL,

Science Direct, Cochrane Review library and Cochrane Database of Systematic Reviews and

Medline. The literature is reviewed over two chapters: (1) epidemiology of VAP and VAE in

paediatrics and (2) preventative strategies, compliance issues and VAP education. This chapter aims

to describe the epidemiology of VAP and VAE in paediatrics and identifies gaps in the literature.

Timeline of surveillance of pneumonia (PNU) in healthcare settings

The surveillance of nosocomial pneumonia was initiated by the Centre for Disease Control and

Prevention (CDC) in 1988 and relied on the combination of three criteria: (1) Radiological findings,

(2) Subjective clinical signs and symptoms, and (3) Laboratory data (Garner, Jarvis, Emori, Horan,

& Hughes, 1988). The CDC criteria remained the same until 2003 when VAP was categorised into

early and late onset (Tablan, Anderson, Besser, Bridges, & Hajjeh, 2004). In 2005, The American

Thoracic Society & Infectious Diseases Society of America limited the tool of VAP to pneumonia in

patients on mechanical ventilation for at least 48 hours (American Thoracic & Infectious Diseases

Society, 2005). The CDC further classified pneumonia (PNU) into three categories (PNU1, PNU2,

and PNU3) and provided alternative criteria for infants and children (PNU1/VAP) (see Figure 2.1)

(Horan et al., 2008). The current VAP criteria for infants and children are available in the CDC and

NSHN document ‘Device-associated modules; pneumonia (ventilator-associated [VAP] & non-

ventilator associated pneumonia [PNU]) event’ (Centers for Disease Control and Prevention (CDC)

& National Healthcare Safety Network (NHSN), 2015a). The current tool, however, is frequently

questioned due to its subjective criteria and inter-observer variability between infection control

personnel and assessors (Chang & Schibler, 2016; Hayashi et al., 2013; Klompas, 2010).

In 2013, the CDC released a new surveillance tool to capture events extending beyond VAP. This

new tool is referred to as VAE and it contains three nested tiers:

(1) Tier 1 is the ventilator-associated condition (VAC);

(2) Tier 2 is the infection-related ventilator-associated complication (IVAC); and

(3) Tier 3 is the possible ventilator-associated pneumonia (PVAP) (Centers for Disease


A diagnosis of VAE can be made when the patient’s physiological or mechanical ventilation

parameters meet the first-tier criteria. If the first-tier (Ventilator associated condition (VAC) criteria

12

are met, the second tier (Infection-related ventilator-associated complications (IVAC)) is examined.

If the second-tier criteria are met, the third tier (Possible ventilator-associated pneumonia (PVAP) is

examined. The timeline for surveillance of pneumonia, with its complex and changing criteria, is

illustrated in Figure 2.1.

13

Figure 2:1: Timeline for surveillance of pneumonia (PNU) in a healthcare setting

7 10 13 16 19 22 25 28 31

7 10 13 16 19 22 25 28 31

CDC definition for

nosocomial

infection

1988

Differentiated

pneumonia into two age

categories:

Patient ≤ 12 months and

> 12 months using:

Combination of clinical,

radiological &

laboratory findings

CDC Guidelines for

preventing

healthcare-associated

pneumonia

2003

VAP classified into either

early-onset (develops

within 96 hours of patients’

admission to an ICU or

intubation for mechanical

ventilation); late onset

(develops after 96 hours of

patients’ admission to an

ICU or intubation for

mechanical ventilation)

2005

CDC Guidelines

published for the

management of adults

with hospital acquired,

ventilator-associated &

healthcare-associated

pneumonia

Defined VAP as

pneumonia in

mechanical ventilation in patients with

mechanical ventilation

of at least 48 hours CDC/NSHN surveillance

tool of healthcare

associated infection &

criteria for specific types

of infections in acute care

settings

Revised in 2002 &

widely used in 2008

Replaced term “nosocomial” to healthcare-associated infection”

(HAI) and classified Pneumonia

into three categories: 1. PNU1 (Clinical Defined

Pneumonia)

i) For any patient

ii) Alternate criteria for infant ≤ 1

year old & for child > 1 year old

or ≤ 12 years old

2. PNU2 (Pneumonia with

Specific Laboratory Findings) 3. PNU3 (Pneumonia in

Immunocompromised Patients)

2013 until present

Ventilator-associated

Events (VAE) -

Surveillance/ protocol

mandated to adult

patient population only

Retained the surveillance tool

for children as stated in the

2008 guideline: available in a

document titled as Device-

associated module;

pneumonia (Ventilator-

associated (VAP) & non-

ventilator associated

Pneumonia (PNEU) Event

History of surveillance of pneumonia in healthcare settings

Ventilator associated

consist of three tiers:

1. VAC (Ventilator

associated condition)

2. IVAC (Infection-

related ventilator-

associated

complications)

3. PVAP (Possible

ventilator-associated

pneumonia)

Minor changes for PNU 1 (Clinical Defined

Pneumonia) For ii) alternate criteria for

child >1 year old or ≤ 12

years old.

- Fever (>38.0 oC) or

hypothermia (<36.0 oC)

14

VAP and VAE: Pathogenesis and factors for acquiring VAP/VAE

The development of VAP is predominantly related to oro-digestive tract colonisation and pathogenic

bacteria aspiration from invasive devices such as the endotracheal tube (Coffin et al., 2008; Foglia et

al., 2007; Kollef, 2004; Safdar, Crnich, & Maki, 2005; Tablan et al., 2004; Zolfaghari & Wyncoll,

2011). Additionally, ventilator circuits and suction equipment are associated with pathogenic bacteria

aspiration (Safdar et al., 2005; Tablan et al., 2004). This theory is supported by the microbiological

examination of the endotracheal secretions of VAP patients which is similar to the organisms found

in the naso-oropharyngeal and gastric secretions (Chastre & Fagon, 2002). The common organisms

for VAP are Staphylococcus aureus, Klebsiella pneumonia, Acinetobacter baumannii and

Enterobacter species (Cooper & Haut, 2013; Sachdev et al., 2013). Factors associated with the

development of VAP are (1) aspiration of pathogenic secretions, (2) colonisation of the oro-digestive

tract and (3) use of contaminated equipment (Coffin et al., 2008; Hellyer et al., 2016).

VAE as a broader phenomenon extends beyond a pneumonic process. VAE identifies infectious and

non-infectious ventilator-associated complications based on the three nested tiers. The first tier,

referred to as VAC, mainly focuses on respiratory and non-respiratory complications or conditions

by evaluating the deterioration of oxygenation parameters — thus the patient requires a sustained

increase in ventilatory support. The second tier is the infection-related IVAC that emerges from the

first-tier of the VAC and further defines whether VAC is due to an infection or not. This is

accomplished by adding another two criteria: abnormal body temperature or abnormal white blood

cell (WBC) count, and the initiation of new antibiotics for four days or more. The final tier is called

PVAP, which is a subset of IVAC that may indeed be pneumonia. In these circumstances, positive

microbiological findings from the respiratory secretions with specific thresholds are required (Figure

2.2) (Centers for Disease Control and Prevention (CDC) & National Healthcare Safety Network

(NHSN), 2015b; Goutier et al., 2014). Thus, the pathogenesis of the VAC, IVAC and PVAP relate to

the type of complications or conditions involved (Klompas, 2015).

15

Figure 2:2: Ventilator-associated events in the respective tiers

The global incidence and the impact of VAP and VAE

The incidence of VAP among paediatric patients varies across the globe. The incidence in paediatrics

is reported to be as high as 31.8 per 1000 ventilator days (Rasslan et al., 2012). A smaller study in

2002 in the USA reported the rate of 11.6 per 1000 ventilation days involving 34 episodes of

mechanical ventilation in 30 patients (Elward, Warren, & Fraser, 2002). More than 10 years later, in

2015, the VAP rate in a multicentred PICU study in the USA reported a rate of 7.1 per 1000 ventilator

days (Gupta et al., 2015).

In Europe, the VAP rate in a single PICU in Greece was found to be 15.3 per 1000 ventilator days

with an incidence density of 24.4% (30/127 patients) in a one-year retrospective study (Stabouli et

al., 2012). A retrospective study in the United Kingdom in 2012 revealed that the incidence was 9.2

per 1000 ventilator days (Ismail, Darbyshire, & Thorburn, 2012). A six month prospective study in

the United Kingdom reported a VAP rate of 2.4 per 1000 ventilator days (4/325 patients) with a 1.7%

incidence density (Narayanan et al., 2016) compared to a prospective study by Patria et al. (2013),

which found that the incidence density in Italy (30/451 patients) was 6.6%.

In Japan, Hatachi, Tachibana, and Takeuchi (2015) retrospectively examined 426 patients during the

2013 calendar year, reporting a VAP rate of 3.5 per 1000 ventilator days, and an incidence density of

1.2% (5/426 patients). In India, the incidence density of VAP was substantially higher; 36.2% (38/105

VAC

• Identification of respiratory and non-respiratory complications based on increased requirement in ventilatory support

IVAC• Further identification of VAC;

with or without an identified infectious source

PVAP • Identification of IVAC that may indeed be pneumonia

16

patients) (Awasthi et al., 2013). In Australia, a study in 2010 reported an incidence density of 6.7%

(18/269 patients) with a VAP rate of 7.02 per 1000 ventilator days (Gautam et al., 2012).

A few paediatric studies have evaluated epidemiological data across multi-centered PICUs. One study

in the USA collected data from 2007–2012 in 64 PICUs (Patrick et al., 2014). This study revealed

that the VAP rate declined over time from 1.9 to 0.7 per 1000 ventilator days (Patrick et al., 2014). A

multi-centered prospective study across six PICUs (300 patients) in Spain reported a VAP rate of 9.4

per 1000 ventilator days (Jordan Garcia et al., 2014). A prospective study involving 16 PICUs (2081

patients) in the USA revealed the VAP rate was 7.1 per 1000 ventilator days (Gupta et al., 2015). In

a study that reported VAP data under the International Nosocomial Infection Consortium (INICC)

involving eight PICUs, the VAP rate was 8.1 per 1000 ventilator days (Rosenthal, Alvarez-Moreno,

et al., 2012). This study was conducted in five developing countries, including Columbia, El-

Salvador, India, the Philippines and Turkey, in 2012.

The implication of high incidence rates on critically ill children contributes to a burden on the

healthcare system. The burden of VAP is primarily due to the increased duration of mechanical

ventilation. Gautam et al. (2012), reported that a child with VAP spends seven extra days on a

ventilator compared to those without VAP (11.9 days versus 4.9 days). Balasubramanian and Tullu

(2014) reported similar findings; 22 days versus five median days, p < 0.001 for a patient with VAP

and without VAP respectively. Gupta et al. (2015), found that children with VAP spend 11 days on

ventilator in the PICU versus three median days, p < 0.001 in patient without VAP.

VAP also contributes to a significant increase in the length of PICU stays (mean 46.0 ± SD 43.7 days

versus mean 9.1- ± SD 9.3 days, p< 0.001) in patients with VAP compared to those without VAP

(Stabouli et al., 2012). A prolonged PICU stay correlates with higher hospital costs (Elward et al.,

2002; Foglia et al., 2007). The cost of VAP has been calculated at US$308,534 compared to

US$252,652 in those patients without VAP (Srinivasan et al., 2009). Brilli et al. (2008), reported that

the extra hospital costs for VAP patients were US$156,110 compared with US$104,953 for non-VAP

patients, or approximately US$50,000 in additional hospital costs per ventilator episode. Utilisation

of PICU beds (without treatment) costs incurred are as high as €9207.4 +/-8737.8 versus €1820.0 +/-

1850.5, p < 0.001 in those children with VAP compared to those without VAP (Stabouli et al., 2012).

Such costs pose a significant financial burden on hospitals when a limited reimbursement for hospital

costs is mandated (Agarwal et al., 2010; Restrepo et al., 2010).

17

In some paediatric studies, those with VAP have been shown to have a threefold increased probability

of mortality (p < 0.007) (Gupta et al., 2015). Absolute hospital mortality has been shown to increase

by 8.1% in children with VAP compared to those without (10.5% versus 2.4%) (Srinivasan et al.,

2009). The mortality of VAP patients in a study conducted by Bigham et al. (2009) was 19.1% versus

the non-VAP at 7.2 %, (p= 0.01).

There is currently limited data on the incidence of VAE in children but it is estimated to range from

1.1 to 20.9 per 1000 ventilator days as a result of variations in the surveillance criteria across studies

(Beardsley et al., 2016; Cocoros et al., 2016; Iosifidis et al., 2016; Narayanan et al., 2016; Phongjitsiri

et al., 2015). Two of these five studies report significantly high incidence rates of VAE — 20.9 and

11.2 per 1000 ventilator days (Iosifidis et al., 2016; Phongjitsiri et al., 2015). The remaining three

studies reported incidence rates of 1.1, 2.1 and 4.2 per 1000 ventilator days respectively (Beardsley

et al., 2016; Cocoros et al., 2016; Narayanan et al., 2016). The majority of these studies support the

view that patients with VAE have a significantly increased duration on mechanical ventilation support

and longer PICU and hospital stays (Beardsley et al., 2016; Cocoros et al., 2016; Iosifidis et al., 2016;

Phongjitsiri et al., 2015).

Overall, recent VAP incidence rates show wide inter- and intra-continent variability, reflecting the

variation in resource distribution, VAP/VAE surveillance and the application of the surveillance tools

(Aelami, Lotfi, & Zingg, 2014; Mourani & Sontag, 2017). Despite this heterogeneity, the incidence

in single PICUs is still considered high and indicates that appropriate attention should be given to

address this threat to patient safety.

Risk factors for VAP and VAE

The study of risk factors for VAP offers the opportunity to improve our understanding of the

likelihood of developing an infection, enabling targeted direct interventions (Cook & Kollef, 1998;

Gautam et al., 2012; Kollef, 2004). Various factors may contribute to the development of VAP in

paediatric patients, including age-related physiological differences and comorbidities

(Balasubramanian & Tullu, 2014; Mourani & Sontag, 2017), but a limited number of specific

paediatric studies evaluate risk factors for VAP (Liu et al., 2013; Srinivasan et al., 2009).

Table 2.1 illustrates the paediatric studies published in the last 10 years (2005–2015) that focus on

the risk factors associated with VAP development. The majority of the studies were conducted in the

USA and in single PICU centers (Bigham et al., 2009; Srinivasan et al., 2009), with only one

multicentered study (Gupta et al., 2015). Two studies were conducted in Brazil (Casado, de Mello,

18

de Aragão, de Albuquerque, & Correia, 2011; Kusahara, Enz Cda, Avelar, Peterlini, & Pedreira Mda,

2014) and one study each in India, Australia and the Netherlands (Awasthi et al., 2013; Gautam et

al., 2012; Roeleveld et al., 2011). The risk factors reported vary across studies, with reintubation the

highest reported risk factor for the development of VAP (Awasthi et al., 2013; Gautam et al., 2012;

Gupta et al., 2015; Kusahara et al., 2014; Srinivasan et al., 2009). This is also one of the risk factors

identified in a systematic review by Liu et al. (2013). The second most reported risk factor is

microaspiration secondary to reduced tolerance of enteral feeding (Casado et al., 2011; Kusahara et

al., 2014; Srinivasan et al., 2009). These findings suggest that the modifiable risk factors of VAP

outweigh the non-modifiable risk factors such as subglottic/tracheal stenosis, trauma, female gender,

post-surgical admission diagnosis and paediatric risk index of mortality version 3 score (PIMS 3)

(Bigham et al., 2009; Roeleveld et al., 2011; Srinivasan et al., 2009).

To date, three studies have examined the risk factors for VAE in children. According to Phongjitsiri

et al. (2015) the risk factors for VAE among paediatric patients include immunocompromised status,

chronic respiratory disease and tracheostomy dependence. Cocoros, Priebe, Gray, et al. (2017),

identified, through a nested case-control study, neuromuscular blockade (OR, 2.29; 95% CI, 1.08–

4.87), positive fluid balance (OR, 7.76; 95% CI, 2.10–28.6), and blood product use (OR, 1.52; 95%

CI, 0.70–3.28) as risk factors for VAE. Beardsley et al. (2016), reported trauma as an independent

risk factor based on multivariate analysis (adjusted OR= 3.10%, CI= 1.15-8.38), but this study was

limited only to children who had positive respiratory cultures.

In Australia, there has been only one study of a PICU during the past 10 years, and it only examined

epidemiological data for VAP (Gautam et al., 2012). The lack of evidence regarding the risk factors

for VAE has significant implications for the development of preventive strategies (Cocoros et al.,

2016; Liu et al., 2013; Phongjitsiri et al., 2015; Srinivasan et al., 2009) and the effectiveness of

existing interventions in reducing the incidence of VAP/VAE is not able to be reliably determined.

Hence there is an urgent need to measure the potential risk factors for VAP and VAE to inform the

planning of preventative strategies.

19

Table 2.1: Risk factors for VAP in children: Studies published from 2005 to 2015

No Authors Country Single/

Multicentred

Risk factors of VAP

1 Bigham et al. (2009) USA Single Subglottic/tracheal stenosis, trauma, and tracheostomy

2 Srinivasan et al. (2009) USA Single Univariate analysis: the use of metoclopromide, reintubation, worsening oxygenation

(measured by partial pressure of oxygen (PaO2/ FiO2 ratio), recipient of blood products and

the presence of enteral feeding.

Multivariate analysis; female gender, postsurgical admission diagnosis, the presence of

enteral feeding, and use of narcotic medications.

3 Roeleveld et al. (2011) Netherland Single PIMS 3 and transfusion of fresh frozen plasma

4 Casado et al. (2011) Brazil Single Longer stay on ventilation (OR), 1.04; 95% (CI), 1.01–1.08), use of gastric tube (OR, 2.88;

95% CI, 1.41–5.87), and of sedatives/analgesics (OR, 2.45; 95% CI, 1.27–4.72)

5 Gautam et al. (2012) Australia Single Univariate analysis: reintubation, the absence of tube feeding and absence of stress ulcer

prophylaxis.

Multivariate analysis: tube feeding (HR), 0.27; 95% CI, 0.09–0.85; p=0.02) and stress ulcer

prophylaxis (HR), 0.29; 95% CI, 0.11–0.76; p=0.01) reduced the incidence of VAP

6 Awasthi et al. (2013) India Single Reintubation within 72 hours of extubation

7 Kusahara et al. (2014) Brazil Single The use of nasogastric tubes (OR, 5.278; p<0.001), intermittent administration of nutritional

formula (OR, 6.632; p=0.005), emergency reintubation (OR, 2.700; p=0 .02), use of

vasoactive drugs (OR, 5.108; p=0.009), duration of mechanical ventilation (p< 0.001)

8 Gupta et al. (2015) USA Multicentred (16

PICUs)

Reintubation and ‘part-time’ ventilation

Notes: PIMS 3: paediatric risk index of mortality score 3; OR: odds ratio; CI: confidence interval; HR: hazard ratio

20

Diagnostic criteria for pneumonia (PNU/VAP)

According to the CDC and NHSN, there are three categories of ventilator associated pneumonia:

PNU1, PNU2 and PNU3. Each category requires two to three criteria to be met, for a diagnosis of

VAP.

• The first criterion is radiological: this requires two or more serial imaging test results (with

underlying cardiac or respiratory disease) or one or more imaging test results (without

underlying cardiac or respiratory disease). The imaging test requires at least one of the

following: new and persistent or progressive and persistent: (a) consolidation, (b) infiltration,

(c) cavitation and pneumatoceles.

• The second criterion is clinical: i.e., clinical signs and symptoms characterised by an abnormal

WBC count; body temperature instability; abnormal respiratory signs and symptoms (such as

changes in sputum character or increased suctioning requirements); new onset or worsening

cough; dyspnoea or tachypnoea or apnoea; tachycardia or bradycardia; rales or bronchial

breath sounds; wheezing or rhonchi; worsening oxygenation.

• The final criterion is based on laboratory results with or without positive microbiological

findings (Centers for Disease Control and Prevention (CDC) & National Healthcare Safety

Network (NHSN), 2015a; Horan et al., 2008).

The CDC alternative criteria for infants and children (PNU1)

To addresses the physiological differences in paediatrics the CDC has developed alternative criteria

for a diagnosis of VAP.

PNU1 in adults is ‘clinically defined pneumonia’, a diagnosis that requires radiological criteria and

the signs and symptoms but without an identified pathogen. The paediatric PNU1 (alternative criteria

for infants and children) is divided into two age categories: infants ≤ 1 year old and children > 1 or ≤

12 years (Table 2.2) (Centers for Disease Control and Prevention (CDC), 2015). PNU2 is pneumonia

with common bacterial or filamentous fungal pathogens and has specific laboratory findings or

pneumonia with viral, Legionella and other bacterial pneumonia with definitive laboratory findings.

PNU3 is pneumonia in immuno-compromised patients. PNU2 and PNU3 requires all three criteria

regardless of the age of the patients (Centers for Disease Control and Prevention (CDC) & National

Healthcare Safety Network (NHSN), 2015a; Horan et al., 2008).

The PNU1 (alternative criteria for infants and children) tool remain the main surveillance tool for

VAP in children (Centers for Disease Control and Prevention (CDC) & National Healthcare Safety

Network (NHSN), 2015a; Horan et al., 2008). However, the tool is highly subjective, correlates

21

poorly with histology, is neither sensitive nor specific and it is time consuming when using the tool

because complexities of criteria involved, making it difficult to conduct the surveillance (Klompas,

2010; Klompas et al., 2011; Venkatachalam, Hendley, & Willson, 2011).

Moreover, the exclusive focus on VAP as the main ventilator-associated complication fails to

acknowledge that there are other potential complications related to mechanical ventilation (Klompas,

2013a, 2013b; Klompas, Kleinman, & Murphy, 2014).

Diagnostic criteria for VAE surveillance

VAE is a new paradigm that views ventilator-associated complications from a different and broader

perspective (Muscedere et al., 2013; Septimus et al., 2015). The diagnostic criteria have been divided

into three tiers. The requirements for each tier are as follows:

• Tier 1: VAC — requires the objective data derived from ventilator settings; fraction of

inspired oxygen (FiO2) or positive end expiratory pressure (PEEP) to evaluate worsening

oxygenation within a certain period of stability;

• Tier 2: IVAC — requires meeting tier 1 (VAC) criteria plus demonstrate infection indicators;

body temperature or WBC count, inclusive of the antibiotic initiation and continued for at

least four days;

• Tier 3: PVAP — requires meeting tier 1 (VAC) and tier 2 (IVAC) criteria plus confirmed

microbiological findings from the respiratory secretions (Centers for Disease Control and

Prevention (CDC) & National Healthcare Safety Network (NHSN), 2015b).

A summary of the VAE tiers with their respective requirements and criteria is given in Table 2.3.

22

Table 2.2: CDC PNU1/VAP Tool: Alternative Criteria for Infants and Children

PNU1 VAP Tool Radiological criteria

For both aged categories a) Patient with underlying diseases has two or more imaging test results with one of the following; b)

Patient without underlying diseases has 1 or more imaging test results with one of the following:

New and persistent OR progressive and persistent:

1. Infiltrate

2. Consolidation

3. Cavitation

Pneumatoceles, in ≤1 year old

Signs and symptoms

Alternate criteria for infant ≤ 1

year old

Worsening gas exchange (e.g., oxygen desaturations)

[e.g., pulse oximetry <94%], ↑ oxygen requirement or ↑ ventilation demand) and three of the following:

▪ Temperature instability

▪ Leukopenia (≤4,000 WBC/mm3) or leucocytosis (≥15,000 WBC/mm3) and left shift (≥10%

band forms)

▪ New onset of purulent sputum, or change in the character of the sputum, or ↑respiratory

secretions, or ↑ suctioning requirements

▪ Apnoea, tachypnoea, nasal flaring with retraction of the chest wall or grunting

▪ Wheezing, rales, or rhonchi

▪ Cough

▪ Bradycardia (<100 beats/min) or tachycardia (>170 beats/min)

Alternate criteria for Children >1

or ≤ 12 year old

At least three of the following:

▪ Fever (>38.0°C/100.4°F) or hypothermia (<36.0°C/96.8°F)

▪ Leukopenia (≤4,000 WBC/mm3) or leucocytosis (≥15,000 WBC/mm3)

▪ New onset of purulent sputum, or change in the character of the sputum, or ↑ respiratory

secretions, or ↑ suctioning requirements

▪ New onset of worsening cough, or dyspnoea, apnoea, or tachypnoea

▪ Rales or bronchial breath sounds

▪ Worsening gas exchange (e.g., oxygen desaturations [e.g., pulse oximetry <94%]↑ oxygen requirement

or ↑ ventilation demand)

23

Table 2.3: The CDC VAE tiers with respective requirements and criteria

VAE Tier Requirements and criteria

1. Ventilator associated condition

(VAC)

Pre-requirement: The patient is required to have a baseline period of stability or improvement on

ventilator for ≥ 2 calendar days of stable or decreasing *daily minimum FiO2 or PEEP values.

VAC criteria:

1. Increase FiO2 ≥ 0.20 OR PEEP ≥3 cmH2O

2. Sustained for 2 days

*Daily minimum defined by the lowest value of FiO2 or PEEP during a calendar day that is maintained

for at least 1 hour.

2. Infection- related ventilator

associated complications (IVAC)

Pre-requirement: The patient is required to meet the VAC criteria

IVAC criteria:

1. Temperatures <36oC or >38oC OR abnormal white blood cell (WBC) count (≤ 4,000 cells/mm3 or ≥

12, 000 cells/mm3)

AND

2. New antimicrobial agent (s) is started and continued for ≥ 4 days within 2 days of the increase in PEEP

or FiO2.

3. Possible ventilator associated

pneumonia (PVAP)

Pre-requirement: The patient is required to meet the IVAC criteria

PVAP criteria:

1. Positive culture of respiratory secretion (via endotracheal aspirate, bronchoalveolar lavage (BAL), lung

tissue, or protected specimen brush)-met the quantitative or semi-quantitative thresholds OR

2. Purulent respiratory secretions and positive culture via specimens in criteria 1, but not meeting those

thresholds for growth OR

3. One positive test from the pleural fluid or lung histopathology or diagnostic test for Legionella species

or respiratory secretion positive for the viral organism, within 2 calendar days of meeting the IVAC

criteria

Notes: Purulent secretions=≥25 polymorphonuclear cells (PMNs), ≤10 squamous epithelial cells per low-powered field (LPF); Positive

culture=endotracheal aspirate ≥105 colony forming units (CFU)/ml

24

Ventilator associated events (VAE) in children: A review of literature

Publication

A literature review of ventilator-associated events in children was undertaken by this author and

supervisors and was published in Australian Critical Care (see below). The focus was on the

application of the new VAE surveillance tool in the paediatric population and the potential challenges

in clinical practise. This chapter is presented mostly as per the published version, but some

information is presented in other chapters, such as Chapter 1, Chapter 2 (sub-sections), and figures

and tables within this thesis. The page numbering has been adjusted to fit the overall thesis style, and

references listed will be at the end of the thesis.

Publication

Mohd Ali, N. A., Jauncey-Cooke, J., & Bogossian, F. (2019). Ventilator-associated events in

children: A review of literature. Australian Critical Care, 32(1), 55-62.

doi:10.1016/j.aucc.2018.11.063

ABSTRACT

Background: The complexity and variation in ventilator associated pneumonia (VAP) tools in

paediatrics may pose threats to the reliable identification of VAP. The revision of the surveillance

tool to ventilator-associated event (VAE) has been mandated in adult populations to overcome these

issues. However, the evidence for application of this tool is unknown in children.

Objectives: To review the evidence on the application of the new VAE surveillance tool in the

paediatric population and examine the potential challenges in clinical practise.

Review methods: A systematic approach was used to locate and synthesise the relevant paediatric

literature. Studies were appraised according to epidemiological appraisal instrument (EAI) and the

grades of evidence in the National Health Medical Research Council (NHMRC) guidelines.

Results: Seven studies met the inclusion criteria. Quality of study methods was above 50% on the

EAI. The overall grade of evidence was assessed as C (satisfactory). The incidence of VAE in

children ranged from 1.1 to 20.9 per 1000 ventilator days as a result of variations in surveillance

criteria across included studies. There is little agreement between the new VAE and PNU/VAP

surveillance tool in the identification of VAP. Challenges in the application of VAE surveillance were

related to: the difference in modes of ventilation used in children versus adults; inconclusive criteria

25

tailored to paediatric samples; and a lack of data. The latter problem provides support for automatic

data extraction to be applied in paediatric studies.

Conclusion: This review demonstrated promising evidence using the new VAE surveillance tool to

define the VAE in children, but the level of the evidence is low. Before the possibility of real

implementation in clinical settings, challenges related to VAE paediatric specific criteria and the

value of automated data collection need to be considered.

AIMS/OBJECTIVES

This literature review was conducted to synthesise the available literature on VAE to answer the

following research questions:

1. Is the VAE surveillance tool used in adults able to identify ventilator-associated complications in

the paediatric population?

2. What are the potential challenges in the application of the new VAE surveillance tool in paediatric

clinical practise?

MATERIAL AND METHODS

A systematic literature search was conducted using the following electronic databases: PubMed,

CINAHL, ScienceDirect, Cochrane Review library and Cochrane Database of Systematic Reviews,

and MEDLINE. Subject headings (MeSH or CINAHL headings) were included as follows:

‘pneumonia, ventilator-associated’, ‘complication, ventilator-associated’, ‘surveillance’, and some

minor/subheadings. Key search terms were ‘ventilator associated pneumonia’, ‘ventilator associated

event’, ‘child*’, ‘criteria’, ‘surveillance’, ‘p(a)ediatric’, ‘pneumonia’, ‘intensive care unit’. The

Boolean operators OR, AND, and NOT were applied. The wildcard symbols were not applied in

Google scholar searches. The search considered all relevant literature related to VAEs (as per the new

surveillance tool) and was limited to English language publications from January 2010 to February

2018.

The reference lists from identified articles were also hand searched to reduce the possibility of

excluding relevant literature. To maximise the effectiveness of search strategies, the literature search

was undertaken in consultation with an expert health librarian. Screening by the title and abstract was

carried out by one author if this was insufficient to make a decision on the article, the full text was

obtained. The inclusion of retrieved publications was reviewed and agreed by two authors, and there

was no disagreement. The predefined inclusion criteria were the following: (1) paediatric patients

aged 0 to18 years and (2) received invasive mechanical ventilation.

26

A purpose-built data extraction form consisted of study setting, aims, participant population, and

outcome measure. One author extracted data from the included articles. The data were then evaluated

by the first author to obtain the methodological quality using an epidemiological appraisal instrument

(EAI) described by Genaidy et al. (2007). There were 39 of 43 items in the EAI applicable for the

purpose of review. Four items that were not applicable were the following: (1) adverse effects

reported that may be consequences of the intervention, (2) newly incident cases consideration

‘(applied only in case-control design)’ (3) subjects randomisation, and (4) randomisation assignments

concealment. The scoring for the items was either “yes” (2 points), “partial” (1 point), “no” (0 point),

or “unable to determine” (0 point) (Genaidy et al., 2007). Cut-off points between high and low

quartiles were based on EAI scores, (more than 50% as higher quality and less than 50% as low

quality) as described in a study conducted by Nix, Smith, and Vicenzino (2010). Discussions were

held, and consensus was obtained for any disagreements with the other two authors. Finally, grading

was undertaken using the NHMRC Description of Evidence Levels, Grade of Recommendation and

Body of Evidence Assessment Matrix (The National Health and Medical Research Council

(NHMRC), 2000).

SEARCH RESULTS

The search retrieved a total of 328 potential articles during the initial stage of screening. The authors

then excluded publications that did not use the new VAE surveillance tool, duplicates, and those

studies undertaken in adults and animal models. A total of seven articles remained for inclusion in

this review, which was conducted in accordance with the Preferred Reporting Items for Systematic

Reviews and Meta-Analyses (Figure 2.3) (Moher, Liberati, Tetzlaff, Altman, & The PRISMA Group,

2009). Two included studies were conducted in Europe (Iosifidis et al., 2016; Narayanan et al., 2016)

and the remaining included studies were from the USA (Beardsley et al., 2016; Cirulis, Hamele,

Stockmann, Bennett, & Bratton, 2016; Cocoros et al., 2016; Phongjitsiri et al., 2015; Taylor,

Noronha, Wichman, & Varman, 2014). Six included studies were retrospective in design, and one

was a prospective study (Narayanan et al., 2016). Overall, the level of evidence was level III-3

prognosis with a satisfactory body of evidence (Grade C) based on The National Health and Medical

Research Council (NHMRC) guidelines (The National Health and Medical Research Council

(NHMRC), 2000). The summaries of the individual study are provided in Table 2.4. The quality of

most of the studies was more than 50% (high) (Beardsley et al., 2016; Cirulis et al., 2016; Cocoros et

al., 2016; Iosifidis et al., 2016; Phongjitsiri et al., 2015; Taylor et al., 2014) with only one study

reported of low quality (less than 50%) (Narayanan et al., 2016) on the EAI. In all studies, the study

design and source of the population are clearly described.

27

Figure 2:3: PRISMA flow diagram of literature selection

Records identified through

database searching

(n=478)

Screen

ing

Inclu

ded

E

ligib

ilit

y

Iden

tifi

cati

on

Additional records

identified through other

sources

(n=1)

Records after duplicates removed

(n=151)

Records screened

(n=328)

Records excluded by

title and abstract

(n=182)

Full-text articles

assessed for eligibility

(n=146)

Full-text articles

excluded, with reasons

(n=139)

Adult=36

Animal=4

Did not include/use the

VAE surveillance tool=99

Studies included in the

review

(n=7)

28

Table 2.4: Study summaries and agreement between surveillance tools

Authors Location Study

design/population

NHMRC Level of

evidence

Incidence or prevalence of VAE

Agreement between surveillance

tools

Phongjitsiri et al.

(2015)

USA Retrospective cohort

(606 patients)

III-2 aetiology

evidence

VAC=20.9/1000 ventilator days.

IVAC=12.9/1000 ventilator days.

PVAP=7.1/1000 ventilator days.

Probable VAP (PrVAP)=3.7/1000

ventilator days, 16.3% Undetermined

infection=2.1 /1000 ventilator days.

New VAE versus PNU/VAP=41

patients versus 9 patients

Cocoros et al.

(2016)

USA Multicentre

Retrospective cohort

(8862 patients)

III-3 prognosis

evidence

VAC=1.1-4.6/1000 ventilator days

depending to ICU types.

No comparison of tools was carried

out, however, attempted to test

different thresholds of VAC -

proposed Fi02 of 0.25 & mean

arterial pressure (MAP) at 4 for

paediatric patients

Narayanan et al.

(2016)

United

Kingdom

Prospective cohort

(258 patients)

III-3 prognosis

evidence

VAC= 4.2/1000 ventilator days.

PVAP=1.8/1000 ventilator days.



Beardsley et al.

(2016)


(217 patients)

III-3 prognosis

evidence

IVAC=2.16/1000 ventilator days.


mechanical ventilation episodes

versus 5 mechanical ventilation

episodes

Only 1 mechanical ventilation met

both tool

Cirulis et al.

(2016)


(119 patients)

III-3 prognosis

evidence

9 patients met the new VAE surveillance

tool.

22 patients identified using the modified

VAE surveillance tool.

New VAE & Modified New VAE=

versus PNU/VAP=Poor sensitivity

but good specificity

Iosifidis et al.

(2016)

Greece Retrospective cohort

(119 patients)

III-3 prognosis

evidence

11.2/1000 ventilator days. New VAE versus PNU/VAP=12


Agreement= Poor agreement (5

patients met both surveillance tools)

Taylor et al.

(2014)


(285 patients)

III-3 prognosis

evidence

17 patients experienced PVAP. New VAE versus PNU/VAP =17

patients versus 15 (9 patient met

both surveillance tools)

29

RESULTS

Is the new VAE surveillance tool used in adults able to identify ventilator-associated

complications in the paediatric population?

Four studies adopted the new VAE surveillance tool in paediatric patients to describe the prevalence

of VAE in their respective units. Iosifidis et al. (2016) conducted a retrospective study to evaluate the

new surveillance tool for VAC, IVAC and PVAP and compared this to an earlier CDC VAP tool

referred to as PNU1/VAP (Table 2.2). The study, undertaken in 2011, involved 119 children admitted

to PICU. It found that 19 patients met the VAC tier with the incidence rate of 11.2 per 1000 ventilator

days. Of 19 patients meeting the VAC tier, 14 met the IVAC tier and from those 14 cases, 12 met the

PVAP tier. The researchers also evaluated the same cohort of patients using the PNU1/VAP

surveillance tool and the results demonstrate poor agreement between the two surveillance tools,

despite the same incidence reported. Only five patients met the VAP criteria classified by both

surveillance tools.

Phongjitsiri and collegues (2015), using a similar study design with a larger cohort of patients’ records

(n= 606), reported the incidence rate of VAE was 20.9 per 1000 ventilator days (Phongjitsiri et al.,

2015). Of these, the incidence of IVAC, PrVAP (probable pneumonia), PVAP and undetermined

infections was 12.9, 7.1, 3.7and 2.1 per 1000 ventilator days respectively. The study did not assess

the agreement of surveillance tools, but the authors mention that 41 patients met the PrVAP and

PVAP tier of the new VAE surveillance versus nine patients using PNU/VAP.

A study by Taylor et al. (2014) evaluating two surveillance tools in 285 patients in a single PICU

revealed that seventeen patients met the PVAP tier using the new VAE surveillance tool, and 15 met

the VAP criteria using the older PNU2/VAP surveillance tool. However, only nine patients were

detected by both tools. The comparison between proportions of patients who met the PVAP tier by

the new VAE surveillance tool and those who met the VAP by PNU/VAP surveillance tool was not

significant (p= 0.78).

The prospective study by Narayanan et al. (2016) demonstrated that the new VAE surveillance tool

was unable to identify any additional VAP cases to those detected using the PNU/VAP surveillance

tool. In this study, children (n=325) were prospectively evaluated over a six-month period and it was

found that seven met the VAC tier. Out of these seven children, six met the IVAC tier and from those

six, three met the PVAP tier. The incidence rate for VAC and PVAP was 4.2 and 1.8 per 1000

30

ventilator days respectively and the VAP rate using the PNU/VAP surveillance tool was 2.4 per 1000

ventilator days.

Three studies evaluated the new VAE surveillance tool but with modification of some criteria or

parameters for a paediatric sample (Beardsley et al., 2016; Cirulis et al., 2016; Cocoros et al., 2016).

A multi-centre retrospective cohort study undertaken by Cocoros et al. (2016) involved 8862 patients

across five hospitals. To detect VAC, instead of using a daily minimum PEEP value increase of at

least 3cm H2O in the adult VAE surveillance tool, they replaced the PEEP value with Mean Airway

Pressure (MAP) 4, 5, 6, and 7 cmH2O. Furthermore, they tested an increment of daily minimum FiO2

into three thresholds, 0.20, 0.25 and 0.30, instead of only the daily minimum FiO2 0.20 threshold used

in the adult VAE surveillance tool. Using the MAP≥ 4/FiO2 ≥ 0.20, the VAC incidence rates were

3.3 to 4.6 per 1000 ventilator days. The cardiac ICU patients had a higher incidence rate as compared

to PICU and Neonatal ICU. Using the MAP ≥4/ FiO2 ≥ 0.20, the incidence rates were 2.9 to 3.2 per

1000 ventilator days. Using MAP ≥7/ FiO2 ≥ 0.30, the incidence rates were 1.1 to 1.3 per 1000

ventilator days (Cocoros et al., 2016). The main findings of the study supported the position that the

tool was able to detect VAC regardless of thresholds and was associated with higher morbidity and

mortality with hazard ratios ranging from 1.6 (95% CI, 0.7-3.4) to 6.8 (2.9-16.0), depending on ICU

types (four PICUs, three cardiac ICUs and one Neonatal ICU). The study proposed the application of

FiO2 of 0.25 and MAP of 4 cmH2O thresholds to identify VAC in paediatric patients (Cocoros et al.,

2016).

Beardsley et al. (2016) applied a daily minimum PEEP of at least 2cmH2O instead of 3cmH2O used

in the adult VAE surveillance tool to evaluate VAC in 300 episodes of mechanical ventilation (217

PICU patients). They also evaluated various ventilator-associated infections criteria such as

PNU/VAP (Horan et al., 2008), ventilator associated tracheobronchitis (VAT) (Craven, Chroneou,

Zias, & Hjalmarson, 2009; Tamma et al., 2011) and lower respiratory tract infection criteria (LRTI)

(Horan et al., 2008). The results showed that the VAE surveillance tool used was consistent with

PNU1/VAP surveillance tool. The incidence of IVAC was 2.16 per 1000 ventilator days (four

mechanical ventilation episodes) that met the VAE surveillance tool versus the incidence of VAP,

which was 2.60 per 1000 ventilator days (five mechanical ventilation episodes) that met the

PNU/VAP surveillance tool. However, only one mechanical ventilation episode met both surveillance

tools. The incidence of VAT and LRTI was 5.19 (four mechanical ventilation episodes) and 6.92 (16

mechanical ventilation episodes) per 1000 ventilator days respectively.

31

Cirulis et al. (2016) found high levels of specificity of both VAE surveillance tools — the new VAE

surveillance tool described by the authors as VAC0 and a modified VAE surveillance tool as VACMP

— in paediatric traumatic brain injury patients. The VACMP used a modification of VAC/VAE criteria

for a PEEP value greater than or equal to 2cmH2O, sustained for more than or equal to one day, and

retained other parameters for IVAC, and PVAP (VAC0) defined in the same way as the new VAE

surveillance tool. Previously they assessed 119 children using the PNU2/VAP surveillance tool and

reported that 39 patients met the VAP criteria. Nine patients met the new VAE surveillance tool

(VAC0) tier and 22 patients met the modified VAE surveillance tool (VACMP). Despite high

specificity of both VAE surveillance tools (VAC0 and VACMP), low sensitivity was demonstrated in

comparison to PNU2/VAP surveillance tools. Furthermore, patients who experienced pulmonary

diagnosis in VAE or VAP using PNU2/VAP tools had significantly worse outcomes compared to the

group who were without respiratory complications.

What are the potential challenges in the application of the VAE surveillance tool in paediatric

clinical practise?

The principal challenge in the application of the VAE surveillance tool in the paediatric population

relates to unique paediatric physiology and the resulting differences in ventilation modalities

clinically required (Cocoros et al., 2016). The new VAE surveillance tool excludes all patients on

high-frequency oscillatory ventilation (HFOV) or extracorporeal life support (Centers for Disease


Furthermore, during periods of time while the patient is on airway pressure release ventilation, the

VAC should be determined by the changes in FiO2 only (Centers for Disease Control and Prevention

(CDC) & National Healthcare Safety Network (NHSN), 2015b).

One of the benefits highlighted in the adult literature is that the tool of VAE enables automated data

extraction which reduces time spent on surveillance and minimises human bias (Klein Klouwenberg

et al., 2014). Only Phongjitsiri et al. (2015) reported a locally developed and supported system that

enabled automatic data extraction from electronic medical records for later analysis and which had

minimal workforce implications. Beardsley et al. (2016) identified mechanical episodes in eligible

patients using the Virtual PICU Systems from electronic medical records; however, the data were

limited to demographic characteristics, Paediatric Risk of Mortality, and PICU outcomes, such as

duration of mechanical ventilation, PICU length of stay, and PICU mortality. While Beardsley et al.

(2016) briefly explained the data retrieval for their study, other researchers used data from electronic

medical records without automated data retrieval (Cirulis et al., 2016; Cocoros et al., 2016; Iosifidis

32

et al., 2016; Narayanan et al., 2016; Taylor et al., 2014). Thus, challenges remain regarding the

feasibility and reliability of both automated and manual collection and documentation of clinical data

(Magill et al., 2014).

DISCUSSION

Surveillance tools for assessing VAP and other associated adverse outcomes have existed since 1988.

Each new iteration builds on previous models, yet none have been designed exclusively for

paediatrics. This review explored the literature comparing the current VAE tool with previous

iterations in paediatrics. Only one study undertook sensitivity and specificity testing between the two

tools; it found that although there was high specificity, the low sensitivity score indicated that

underreporting of VAE may occur with the new surveillance tool (Cirulis et al., 2016). Several other

studies compared calculated incidence rates across two tools, and these authors concluded that there

was little agreement between the two tools, although there was consistency in reporting (Beardsley

et al., 2016; Iosifidis et al., 2016; Narayanan et al., 2016; Taylor et al., 2014). This has significant

ramifications for paediatric settings as the number of VAE cases meeting the VAE surveillance tool

in children seems to be higher than those in adults. Of 1209 adult medical and surgical patients, 67

met the VAC tier, and of those, 34 met the IVAC tier with an incidence rate of 7.0 and 3.6 per 1000

ventilator days respectively (Boyer et al., 2015). In contrast, the PICU study by Phongjitsiri et al.

(2015), reported an incidence rate of 20.9 and 12.9 episodes per 1000 ventilator days respectively.

Surveillance tools act not only as a means of determining the quality of care delivered and measuring

patient outcomes but also as a benchmark to compare outcomes across units and countries (Haustein

et al., 2011; Klompas, 2013a).

Innovation in care delivery and effectiveness in preventative strategies can be measured based on

surveillance data, but if the data are uncertain, we should question if they are adequately robust to

draw conclusions. Substantial variation exists in incidence rates, with more VAE identified in a study

conducted by Iosifidis et al. (2016), (11.2 episodes per 1000 ventilator days), compared with a

paediatric study that was published in the same year by Cocoros et al. (2016), (2.9 to 3.2 episodes per

1000 ventilator days). Variation in case mix provides a possible explanation for this range,

particularly with a broader group of patients (infant and paediatric) and inclusion of all types of ICUs

by Cocoros et al. (2016). Adult multicentre ICU studies report similar outcomes (Bouadma et al.,

2015; Stevens et al., 2014). Consistent results were reported in the three included studies which

adopted the new VAE tool (Narayanan et al., 2016; Phongjitsiri et al., 2015; Taylor et al., 2014),

compared with two studies where modifications were made to the criteria of the VAE surveillance

tool (Beardsley et al., 2016; Cirulis et al., 2016).

33

The inclusion of positive microbiological cultures of endotracheal aspirate in PNU1/VAP by some

researchers is questionable, as these may not reflect true infection (Chang & Schibler, 2016). There

was consistency regarding the number of PVAP-VAP cases meeting the criteria, 12 versus 13

children using the VAE surveillance tool and the PNU/VAP surveillance tool, respectively; however,

the VAE surveillance tool failed to identify eight patients with positive tracheal cultures (Iosifidis et

al., 2016). A similar result was demonstrated in a comparison study of the traditional PNU/VAP

versus VAE surveillance tool in adult patients. The VAE surveillance tool revealed the incidence of

10.0 episodes per 1000 ventilator days versus 8.0 episodes per 1000 ventilator days using the

traditional PNU/VAP surveillance tool; however, the VAE surveillance tool discovered 32% more

patients with VAP because the tool signalled other causes such as fluid overload (Klein Klouwenberg

et al., 2014). The historical PNU/VAP surveillance tools relied heavily on radiological findings and

the subjective interpretation of respiratory signs and symptoms. However, the new VAE surveillance

tool replaces these criteria with objective parameter tools such as FiO2 and PEEP, thus minimising

subjectivity and potentially reducing ambiguity in the diagnosis of VAP and improving both internal

and external validity (Klompas, 2010, 2012).

Another challenge unique to paediatric critical care clinicians is using adult-focused tools and

mechanisms to assess the prevalence of iatrogenic adverse events. The review of the current evidence

illustrates that this is the case with diagnosing VAEs. This suggests the merit of the new VAE

surveillance tool, which has broader capture of VAE in the paediatric population and opportunities

to examine clinical impact and later, the specific preventative strategies (Muscedere et al., 2013;

Septimus et al., 2015). Both tools have merit in identification of ventilator-associated complications,

but the new VAE surveillance provides other explanations for non-infectious complications that may

exist apart from VAP in mechanically ventilated patients. A recent paediatric study examined the

traits of VAE, finding 44% were also due to non-infectious conditions such as atelectasis and

pulmonary oedema and shock (Phongjitsiri et al., 2015) (compared with pneumonia, pulmonary

oedema, and acute respiratory distress syndrome in adults) (Boyer et al., 2015; Hayashi et al., 2013;

Klein Klouwenberg et al., 2014; Klein Klouwenberg et al., 2013).

The inclusion and exclusion of modality of ventilation and antibiotic treatment for VAE surveillance

tools in paediatrics appears somewhat uninformed. Perhaps, in the paediatric context, the difference

in ventilator treatment modalities and variation in antibiotic prescribing may not be as profound as

that which is evident in adult settings (Beardsley et al., 2016; Cocoros et al., 2016). However, omitting

HFOV risks excluding very sick children as this modality is one of the recommendations in children

with acute respiratory failure (Santschi, Randolph, Rimensberger, & Jouvet, 2013). Cocoros et al.

34

(2016), argued for the need to include patients on HFOV, considering that the usage of HFOV in

paediatric patients is more frequent than in adult units, while other studies did not specify their

ventilation inclusion and exclusion criteria (Beardsley et al., 2016; Cirulis et al., 2016; Iosifidis et al.,

2016; Narayanan et al., 2016; Taylor et al., 2014). The modification threshold of PEEP to 2 cmH2O

was also applied, and an adjustment period of stability to 24h was also tested (Beardsley et al., 2016;

Cirulis et al., 2016). However, the evidence of these modifications is limited to three studies.

The value of automated data extraction using the adult VAE surveillance tool is also worthy of further

consideration in paediatric settings. In an adult study, the automated data extraction was shown to be

not only efficient but also to increase reliability and objectivity (Stevens et al., 2014). The potential

benefit of this is also acknowledged in paediatric studies (Phongjitsiri et al., 2015; Taylor et al., 2014).

A recent adult study confirmed that automated data extraction is feasible with 100% sensitivity and

accuracy when compared with the manual method (Hebert, Flaherty, Smyer, Ding, & Mangino,

2017). Collaboration between clinicians and experts in medical information and systems technology

may result in an innovative data extraction platform (Magill et al., 2013).

IMPLICATIONS FOR FUTURE RESEARCH

The studies identified in this review are largely from the United States where VAP and VAE

surveillance is a key clinical performance indicator. Thus, it may not be surprising that to date, there

is limited research related to the application of the new VAE surveillance in paediatrics in other

countries. However, discrepant VAP rates reported across the globe in adults and children may be

due in part to a lack of objectivity in the existing VAP surveillance tool, (Klompas, 2010) and further

research in investigating VAE in paediatrics is warranted. Although there is promising evidence of

the benefits of using the new adult VAE surveillance tool (Magill et al., 2014; Muscedere et al., 2013),

there is an urgent need to conduct more studies to achieve a paediatric version of the VAE surveillance

tool.

LIMITATIONS

The review was restricted to English language literature, and grey literature was not included in the

search strategy. This may have introduced selection and publication biases.

CONCLUSION

This is the first review of the application of the VAE surveillance tool compared with historical

surveillance data in paediatrics. The strength of evidence is currently of a low level. There is

substantial variation cited across studies and a lack of agreement between the old and new tools when

35

applied to clinical data. This suggests that the current paediatric surveillance tool does not fully

capture the prevalence of VAE in paediatrics, although it is adequate for monitoring. We caution

against comparing the current monitoring results with historical VAP data. Although limited to only

seven studies, this review provides insights into published literature related to the application of the

new VAE surveillance tool and the potential implementation challenges in the paediatric population.

SUMMARY

This chapter shows that the VAE surveillance tool for paediatric patients is currently being developed.

Unlike in adult centres, using this tool is not mandated. A possible reason for this is that the

surveillance tool needs further refinement to suit the paediatric population (Cocoros et al., 2016). It

is also necessary to consider the complexities of the pathophysiology and variations of the underlying

problems in children who require additional attention before the decision on whether to adapt and/or

adopt the criteria currently used in adults can be made (Aelami et al., 2014; Cocoros, Priebe, Gray,

et al., 2017; Cocoros, Priebe, Logan, et al., 2017).

Published data pertaining to adults demonstrated that the VAE surveillance tool showed promising

results in the ability of the surveillance tool to identify other ventilator-associated complications,

improving internal and external validity and enabling/facilitating automated clinical data extraction

(Boyer et al., 2015; Klein Klouwenberg et al., 2014; Klein Klouwenberg et al., 2013; Magill et al.,

2013; Stevens et al., 2014). Despite being accepted in the case of adult ventilated patients, limited

information is known about the applicability of the VAE surveillance tool in children (Lutmer &

Brilli, 2016) and more studies are warranted. Currently, there is no available information regarding

VAE for paediatric patients in the Australian context.

Summary

This chapter has demonstrated that data describing the epidemiology of VAP and associated risk

factors vary globally. The impact of VAP is considerable and challenges healthcare providers. The

lack of paediatric epidemiological data for VAE is evident, particularly in the Australian context.

Little is known about the pathogenesis of VAE or the risk factors for VAP, in particular the modifiable

risk factors. There is limited evidence of the application of the new VAE surveillance tool in children.

Only one study has attempted to evaluate the sensitivity and the specificity of VAE in a paediatric

setting. Thus, more research is required to verify the applicability of the VAE tool on the paediatric

population.

36

The next chapter describes the review of literature relating to preventative strategies, compliance

issues and VAP education.

37

Literature Review: Preventative strategies, compliance and VAP education

Introduction

This chapter will present the review of literature for preventative strategies (VAP and VAE) in

paediatric patients and the challenges with VAP prevention compliance for healthcare workers. This

chapter also includes current information for VAP education and the role of parents and nursing staff,

particularly concerning ‘Speaking up for hand hygiene’.

Preventative strategies for VAP

VAP preventative strategies, also known as ‘VAP bundles’, are a group of evidence-based

interventions designed to create better patient outcomes and are implemented as a set of interventions

rather than on an individual intervention basis (Resar et al., 2014; Resar et al., 2005). This concept

was introduced by the Institute for Healthcare Improvement (IHI) in 2002 in the USA and was

followed in 2004 by the “The 100,000 Lives Campaign” which included ventilator bundles in adult

ICUs. This bundle consisted of four preventative strategies: (1) head of the bed (HOB) elevation 30º-

45º; (2) peptic ulcer disease (PUD) or gastrointestinal (GI) prophylaxis; (3) daily sedation vacation

and assessment of readiness to extubate; and (4) deep vein thrombosis (DVT) prophylaxis (American

Thoracic & Infectious Diseases Society, 2005; Gandra & Ellison, 2014). Extensive research has been

carried out in the adult population on the effectiveness of the VAP bundle. The evidence has

supported the use of the VAP bundle with modifications over time. For example, oral care with

chlorhexidine 0.12% was added in 2010 (Munro & Ruggiero, 2014).

Research into the effectiveness of VAP bundles in paediatrics was first published in 2007 (Cooper &

Haut, 2013). The IHI outlined a supplement for VAP bundles in children in 2005. This consists of

four preventative strategies which are a modification of the adult VAP bundle: (1) HOB to 15º-30º for

neonates, 30º-45º for infants or above; (2) daily assessment of readiness to extubate (daily sedation

interruption is not recommended due to high risk of unplanned extubation); (3) PUD or GI

prophylaxis (only as appropriate for the age and condition of the child); and (4) deep vein thrombosis

(DVT) prophylaxis (unless contraindicated, and as appropriate for the age and condition of the child)

(Resar et al., 2014). In addition to these four preventative strategies, three other preventative strategies

were also proposed, as detailed in Table 3.1.

38

Table 3.1: Additional preventative strategies to consider for the paediatric VAP bundle

No Preventative strategy Details

1 Oral care 1. Daily comprehensive oral care according to age and

condition of the child

2. Increase the frequency of oral care to two-hourly for

‘high risk’ patients

3. Include the use chlorhexidine for children older than two

months of age

2. Ventilator circuit checks 1. Heated ventilator circuit should be used to reduce the

amount of condensate

2. Accumulated water in the ventilator circuit should be

drained every 2-4 hourly and prior to patients being re-

positioned

3. Ventilator circuits should be changed when visibly

soiled

4. Hand hygiene performed before and after contact with

ventilator circuits

3. Aspiration devices 1. Oral aspiration device (example Y-suction catheter)

should be kept in a clean non-sealed plastic bag when not

in use

2. Single-use suction catheter

3. All suction related equipment should be changed when

it is soiled or otherwise indicated

Even though the IHI has outlined the supplement for the ventilator bundle in paediatric patients, the

evidence is sparse (Cooper & Haut, 2013). Variations exist between hospitals, and adult preventative

strategies are often adopted into paediatric settings without further testing (Coffin et al., 2008; Curley

et al., 2006). Table 3.2 presents the studies undertaken in children which utilise variations of

individual VAP preventative strategies (in a bundle) in their study settings and the subsequent VAP

rates.

39

Table 3.2: Individual VAP preventative strategies used in paediatrics and VAP rates (in order of publication date)

Authors Country

number of

patients

Study design HOB Daily

assess for

extubate

GI/

DVT

prophylaxis

Other strategies

Pre/baseline

to Post VAP

rates*

Brilli et al.

(2008)

USA n =26 Retrospective

matched case-

control study

/ 1. Daily oral care with chlorhexidine 7.8 to 0.5a

Bigham et

al. (2009)

USA n =1782 Pre-post

implementation

design

(30- 450)

/ 1. Hand hygiene before and after contact with

ventilator circuit

2. Oral care every 2-4 hourly

3. Drain ventilator circuit 2-4 hourly and before

repositioning patient (use heated wire circuits to

reduce rainout)

4. Use endotracheal tube with subglottic suction

for children more than 12 years old

5. Change ventilator circuits and in-line suction

catheters only if visibly soiled

7. Store oral suction devices in non-sealed plastic

bag at the bedside when not in use, (rinse devices

after use)

8. Wear a gown before providing care to patients

when soiling from respiratory secretions is

expected

5.6 to 0.3

Brierley et

al. (2012)

UK n= 730 Pre-post

implementation

design (quality

improvement)

(20-300)

(Ranitidine

for those

patients not

on full

feeds/

1. Oral care with antiseptic 4-hourly or 12-hourly

with a toothbrush

2. Clean suctioning equipment daily or once

indicated

3. Routine chest x-ray interpreted by

physiotherapist only

4. Documentation of individual implemented

VAP preventative strategies to be completed

every 4-hours

5.6 to 0.0

40

5. Documentation of indication of VAP

compliance needs to be completed every shift

Rosenthal,

Alvarez-

Moreno,

et al.

(2012)

Colombia,

Philippines,

India, El

Salvador,

Turkey n=

4339

Pre-post

implementation

design

(30- 450)

/ 1. Hand hygiene

2. Minimising duration of mechanical ventilation

by use of non-invasive ventilation

3. Preference of orotracheal tube over the

nasotracheal tube

4. Maintenance of ETT cuff pressure of at least

20cm H2O

5. Removal of condensate from ventilator circuits,

keeping the ventilator circuit closed during

condensate removal

6. Changing of ventilator circuit only when

visibly soiled

7. Avoid gastric over-distension

8. Avoidance of histamine-receptor 2 –blocking

and proton pump inhibitor

9. Use sterile water to rinse reusable respiratory

equipment

11.7 to 8.1

Obeid,

Naous,

Naja, and

Naja

(2014)

Lebanon n=

107

Pre-post-

implementation

design

(15- 300)

/ 1. Hand hygiene

2. Oral hygiene with antiseptic solution

3. Oro-gastric residual volume measurement

before feeding

4. Closed suction system

52.6 to 6

cases/100

patients

De

Cristofano

et al.

(2016)

Argentina

n=713

Quasi-

experimental

uninterrupted

time series

(every six

months for 2

years)

(> 300)

/ 1. Oral hygiene with chlorhexidine 0.12% six-

eight hourly

2. Daily sedation interruption

3. Clean and dry ventilator circuits

6.3, 5.7, 3.2,

1.8 to 0.0

*= /1000 ventilator days) (pre/baseline to post); a=control, case

41

Evidence of individual preventative strategies within the VAP bundle

Variations in VAP bundles exist between institutions (Cooper & Haut, 2013; Shmilev & Yankov,

2012). The following section further explains data for individual elements that are commonly

included in ventilator/VAP bundle.

Hand Hygiene

Hand hygiene is the least costly and most effective measure in the prevention of HAIs across

healthcare settings (Kozlowski, 2012; World Health Organization (WHO), 2009b). With the recent

spread of multi-resistant organisms in hospitals, hand hygiene has become significant for researchers

and healthcare workers alike (Rabelo et al., 2014). This is because poor hand hygiene may initiate

bacterial cross-contamination, contributing to HAIs and VAP (Craven, 2006; World Health

Organization (WHO), 2009a). Study have shown that common VAP causative agents such as

Staphylococcus aureus and other gram-negative bacilli organisms cross transmitted to patients

through hand contact of healthcare workers (Sachdev et al., 2013; Safdar Crnich & Maki, 2005).

In 2005, the WHO initiated a campaign entitled, “Save Lives: Clean Your Hands” which outlined the

five key instances of hand hygiene for healthcare workers. This approach recommends healthcare

workers clean their hands in the following instances:

(1) before touching a patient;

(2) before cleaning/aseptic procedures;

(3) after body fluid exposure;

(4) after touching a patient; and

(5) after touching patient surroundings (World Health Organization (WHO), 2009b).

From the perspective of infection control, hand hygiene is considered as general prevention (Gandra

& Ellison, 2014) and often not included in adult ventilator bundles (Resar et al., 2014). Some studies

have recommended incorporation of hand hygiene into the ventilator bundle (Bouadma, Mourvillier,

Deiler, Le Corre, et al., 2010; Tolentino-DelosReyes, Ruppert, & Shiao, 2007). In paediatric and

neonatal settings, hand hygiene becomes instrumental in the prevention of infection (Azab et al.,

2015; Obeid et al., 2014), as children’s immature host defence makes them more susceptible to

infection compared to adults (Chhapola & Brar, 2015). For instance, two paediatric pre-post

implementation study designs incorporating hand hygiene into their ventilator bundle by Bigham et

al., (2009) and multicentred study by Rosenthal, Alvarez-Moreno, et al. (2012) revealed a reduction

of VAP incidence from 5.6 to 0.3 and 11.7 to 8.1 per 1000 ventilator day. More recent findings Obeid

et al., (2014) reported reduction from 53 cases to six cases/100 patients.

42

In PICU, hand hygiene is identified as a key target for quality improvement efforts (Harris et al.,

2011). Some studies have shown that hand hygiene supports the reduction of VAP rates. For example,

Koff, Corwin, Beach, Surgenor, and Loftus (2011) showed that the new hand hygiene initiative

directly resulted in a reduction of VAP from 6.9 to 3.7 per 1000 ventilator days. Similarly, studies in

paediatrics and neonatal settings (with hand hygiene as one of their preventative strategies) showed

the VAP rate significantly decreased from 11.7 to 0.3 per 1000 ventilator days (Azab et al., 2015;

Bigham et al., 2009; Rosenthal, Alvarez-Moreno, et al., 2012). Some studies have shown that the

VAP rate reduced to 0 per 1000 ventilator days (Brierley et al., 2012; De Cristofano et al., 2016).

Therefore, hand hygiene is the most important element in paediatric VAP preventative strategies

Oral Hygiene

Poor oral hygiene is associated with bacterial colonisation and dental plaque formation in the oral

cavity and may place patients at higher risk of VAP (Fourrier et al., 2005; Klompas, Branson, et al.,

2014; Shmilev & Yankov, 2012; Tablan et al., 2004). Inadequate oral hygiene leads to bacterial

plaque formation and oral biofilms that potentially contribute to VAP (Munro et al., 2006; Paju &

Scannapieco, 2007).

A randomised controlled trial by Berry, Davidson, Masters, Rolls, and Ollerton (2011) in adult ICUs

compared two oral care strategies to test the effects of three regimes on dental plaque colonisation

and the incidence of VAP (group A: two-hourly oral rinse with sterile water (control); group B:

sodium bicarbonate mouth wash two-hourly, and Group C: twice daily irrigations with

chlorohexidine 0.2% aqueous oral rinse and two-hourly irrigations with sterile water). All regimes

involved cleaning with a toothbrush and non-foaming toothpaste. The study suggested that

standardised oral hygiene protocols may improve outcomes in critically ill patients although it did

not establish a significant difference between groups (Berry, Davidson, Masters, et al., 2011).

Oral hygiene requires age appropriate standardisation to ensure maximum benefit. This includes oral

assessments prior to oral care to determine the frequency of oral hygiene performance and the type

of cleaning solution used (Oral Care Guideline/Protocol) (Bigham et al., 2009; Brierley et al., 2012;

Johnstone, Spence, & Koziol-McClain, 2010). A critical appraisal of 14 relevant literature sources of

oral hygiene in children by Johnstone et al. (2010) produced PICU oral care guidelines. The

guidelines are shown in Table 3.3.

43

Table 3.3: Oral hygiene protocol for mechanically ventilated children

Age categories Oral hygiene protocol; frequency of performance

Neonates and infants with no

teeth

(a) Moisten mouth with swabs soaked in physiological saline; 2-hourly

(b) Coat lips with petroleum jelly; 2-hourly

Infants and children < 6 years

with teeth

(a) Brush teeth with small, soft toothbrush and fluoride toothpaste; suction out

excess toothpaste, but do not rinse out mouth; 12-hourly

(b) Moisten mouth with swabs soaked in physiological saline; 2-hourly

(c) Coat lips with petroleum jelly; 2-hourly and as needed

Children ≥ 6 years with teeth (a) Brush teeth with small, soft toothbrush and fluoride toothpaste; suction out

excess toothpaste, but do not rinse out mouth; 12-hourly

(b) Rinse mouth with 0.1% chlorhexidine: irrigate with a syringe or wipe oral

mucosa with a swab; suction excess solution, but do not rinse out mouth with

water; use at least 30 minutes after brushing teeth; 12-hourly

(c) Moisten mouth with swabs soaked in clean water or physiological saline;

2-hourly

(d) Coat lips with petroleum jelly; 2-hourly

A standardised oral hygiene protocol inclusive of oral assessment is strongly recommended. A

systematic review by Gibson et al. (2010) evaluating oral assessment tools found that the most

effective tool in paediatric intensive care is the Oral Assessment Guide (OAG) (Eilers, Berger, &

Petersen, 1988). This tool detects changes in oral status for clinical assessment and guides nursing

interventions, in particular to the selection of solutions to be used for oral hygiene. Evidence supports

the use of a soft, small toothbrush rather than foam swabs to remove oral plaque (Munro et al., 2006;

Pearson & Hutton, 2002) and advises against the use of tap water for mouth rinsing due to the

potential presence of pathogenic bacteria (Berry, Davidson, Masters, & Rolls, 2007). An example of

an oral hygiene protocol introduced in a paediatric study by Brierley et al. (2012) consisted of an

initial oral assessment and four-hourly oral care using sterile water, chlorhexidine, and twelve-hourly

toothbrush and toothpaste, based on patient age. In this study, the VAP rate reduced from 5.6 to 0.0

per 1000 ventilator days after the VAP bundle implementation.

Use of chlorhexidine 0.12% for oral care for the prevention of VAP has been previously advocated

in the adult literature (Fourrier et al., 2005), but a recent adult study by Klompas, Li, Kleinman,

Szumita, and Massaro (2016) contradicted this finding. In this observational study, the researchers

found that oral hygiene with 0.12% chlorhexidine was associated with an increased hazard of

ventilator mortality; hazard ratio (HR), 1.63; 95% CI, 1.15-2.31; p= 0.006.

44

In paediatrics, two randomised controlled trials found that the use of chlorhexidine 0.12% for oral

care did not reduce the incidence of VAP (Jácomo, Carmona, Matsuno, Manso, & Carlotti, 2011;

Kusahara, Peterlini, & Pedreira, 2012). In a prospective, randomised, double-blind, placebo-

controlled trial of 160 children undergoing surgery for congenital heart disease, participants were

randomised into two groups: experimental group n=87 received 0.12% chlorhexidine, and the control

group n=73 received a placebo (Jácomo et al., 2011). Each child received their respective oral care

solution preoperatively and twice daily after surgery until PICU discharge or death. No significant

difference in VAP rates was observed (p=0.57). A prospective randomised controlled and double

blinded study by Kusahara et al. (2012), was undertaken among 96 children. The intervention group

(n=46) received chlorhexidine 0.12% with a toothbrush and an antiseptic gel twice daily. The placebo

group (n=50) received oral care with a toothbrush and non-antiseptic gel twice daily. Both groups

were comparable to each other with no difference in VAP rates (p=0.95).

The concentration of chlorhexidine potentially needs to be tailored to the critically ill child’s need;

however, to date no randomised controlled trial has been carried out to test this hypothesis. In

summary, recent evidence shows that the use of 0.12% chlorhexidine does not seem to impact VAP

rates in children (Jácomo et al., 2011; Kusahara et al. (2012).

Endotracheal Suctioning

The purpose of endotracheal suctioning is to maintain airway patency by removal of secretions

(Morrow & Argent, 2008; Volsko, 2013). Endotracheal suctioning with the assistance of

humidification of inspired gas in PICU patients remains the main intervention for secretion

management (Evans, Syddall, Butt, & Kinney, 2014). A review of the indications for endotracheal

suctioning in paediatrics recommends endotracheal suctioning to improve respiratory mechanics and

that it should be performed as indicated by the presence of secretions (Morrow & Argent, 2008). In

a qualitative study, Davies, Monterosso, and Leslie (2011), identified five top indications for

performance of endotracheal suctioning, namely; (1) suspected ETT obstruction due to secretions,

(2) audible or visible secretions, (3) decreased oxygen saturations, (4) suspected aspiration and (5)

dyspnoea or signs of respiratory distress.

When the endotracheal suctioning procedure is required, attention must also be given to the use of

aseptic techniques to prevent contamination while handling suctioning equipment (Tolentino-

DelosReyes et al., 2007). One study provided supportive evidence for reuse of suction catheters in

children. A randomised controlled trial compared the incidence of VAP in patients who were

suctioned using the same catheter in all suctioning episodes within 24 hours (intervention n=241) and

45

patients who were suctioned using a new catheter for each suction episode (control group n=245)

(Scoble, Copnell, Taylor, Kinney, & Shann, 2001). No difference of VAP rates were found; 14

patients developed VAP in the intervention group and 12 patients in the control group. This study

supported reusing the catheter for 24 hours as a cost saving measure.

A comprehensive review of literature by Tume and Copnell (2015) concluded that limited evidence

exists regarding suctioning practise in paediatrics, especially through adequately powered studies to

compare closed and open suction methods in children and VAP occurrence. A prospective

observational study in ventilated infants and children by Morrow, Mowzer, Pitcher, and Argent

(2012) assessed the frequency of VAP on closed versus open systems and was undertaken with 263

PICU admissions. The frequency of VAP for patients on closed versus open systems was 20.3% and

23.3% respectively, with no significant difference between the two methods (p=0.60). Studies in

adults reached similar conclusions; no significant difference was found between the two methods

(Lorente et al., 2005; Topeli, Harmanci, Cetinkaya, Akdeniz, & Unal, 2004).

In terms of the effectiveness of secretion removal using the two suction systems, a study conducted

using an animal model found that the closed system was less effective compared to open system

regardless of ventilator mode (conventional or high frequency ventilation) (Copnell et al., 2007). In

addition, the nature of a closed suction system does not require circuit disconnection from the patient

that may allow for condensate water/fluid from the circuit to accumulate, and this may promote

bacterial colonisation compared to an open suctioning system (Shmilev & Yankov, 2012).

A prospective study by Owen et al. (2016) examined adverse events associated with saline instillation

during ETT suctioning. The results demonstrated hemodynamic instability, bronchospasm and

oxygen desaturation were the adverse events most reported (p<0.001) and three of the 62 patients

were diagnosed with VAP (4.8 cases/100 mechanically ventilated patients). The study suggested

cautious use of saline during ETT suctioning in paediatric patients. An integrative review by Schults,

Mitchell, Cooke, and Schibler (2018), concluded that the instillation of saline during ETT suctioning

was not associated with the development of VAP in children.

Available evidence demonstrates no significant difference between open suctioning and closed

suctioning systems in regards to VAP occurence. To date no specific recommendations from the CDC

have been made on the closed suctioning system (Klompas, Branson, et al., 2014). According to

Tume and Copnell (2015), a closed suction system should be used after an individual patient

46

assessment is performed. Regardless, the maintaining of aseptic technique while performing ETT

suctioning is still advocated as a VAP preventative strategy.

Head of the bed (HOB) Elevation

Systematic reviews in adult patients are inconclusive in their support for the clinical benefits of HOB

elevation and the importance of the degree of elevation, despite this being an IHI recommended

inclusion in the ventilator bundle (Niel-Weise et al., 2011; Resar et al., 2014). Nevertheless, the

practise of elevating the HOB to 30-45 degrees has been a standard practise in nursing for many

years, except when clinically contraindicated (Munro & Ruggiero, 2014; Tablan et al., 2004; Wip &

Napolitano, 2009). In the systematic review by Niel-Weise et al. (2011), the recommendation for

HOB elevation was 20-45 degrees. This is supported by earlier observational and randomised

controlled trials which demonstrated that the supine position during 24 hours of mechanical

ventilation was an independent risk factor for VAP (adjusted OR=2.9; 95% CI, 1.3 to 6.8; p=0.013)

(Cook & Kollef, 1998) and that HOB elevation was associated with a reduction in the risk of

aspiration (Drakulovic et al., 1999).

Recommendations for the degree of HOB elevation are more complicated in infants and children.

This is due to the significant challenge in maintaining the correct position in small children,

particularly if lightly sedated (Foglia et al., 2007). Paediatric studies suggest that the HOB should be

kept at a minimum of 15-45 degrees (Bigham et al., 2009; Brierley et al., 2012; De Cristofano et al.,

2016; Obeid et al., 2014; Rosenthal, Alvarez-Moreno, et al., 2012).

Despite the low level of evidence supporting the rationale and degree of HOB elevation in paediatric

ventilated patients, this procedure is considered clinically important (Foglia et al., 2007; Juneja et al.,

2011). HOB elevation also offers benefits by minimising the risk of atelectasis by improving lung

expansion (Niel-Weise et al., 2011) and helps to reduce the severity of gastrointestinal reflux, hence

minimising the possibility of micro-aspirations that may lead to VAP (Shmilev & Yankov, 2012).

Endotracheal tube (ETT) and cuff pressure checks

The intubation procedure can compromise the natural barrier between the oropharynx and the trachea

and may promote colonisation and the migration of pathogenic organisms into the lower respiratory

tract (Berry, Davidson, Nicholson, Pasqualotto, & Rolls, 2011; Scannapieco et al., 2009). Intubation

with cuffed endotracheal tubes has become routine practise over the last two decades in paediatric

patients less than eight years of age (Eschertzhuber et al., 2010). Advancements in cuff technology

(microcuffs) have improved the safety of this type of ETT in infants and young children

47

(Eschertzhuber et al., 2010; Tobias, Schwartz, Rice, Jatana, & Kang, 2012; Weiss & Dullenkopf,

2007). Air leakage above the microcuff is an important factor in minimising potential microaspiration

of pathogenic secretion into the lungs (Dave, Frotzler, Madjdpour, Koepfer, & Weiss, 2011). Hence,

an optimal seal at minimal pressure is required to protect the airway and minimise VAP potential.

A literature review by Bhardwaj (2013) concluded that an ETT with a cuff pressure of ≤15cm H2O

in children ensures an adequate seal, while Dullenkopf, Bernet‐Buettiker, Maino, and Weiss (2006)

suggested keeping a maximum pressure of 20cm H2O. Rosenthal, Alvarez-Moreno, et al. (2012) in

their study involving five developing countries including Colombia, Philippines, India, El Salvador,

and Turkey suggested keeping ETT cuff pressure to a minimum of 20cm H2O in children.

Weiss et al. (2009) studied 2,246 children (aged from birth to five years old) with cuffed and uncuffed

ETTs in a prospective randomised controlled trial. They found that the use of cuffed ETTs in children

provided a reliably sealed airway at cuff pressures of ≤ 20cm H2O, reducing accidental extubations

and minimising the risk of post-extubation stridor. The study also suggested that the minimum cuff

pressure required to seal the trachea was 10.6cm H2O (Weiss et al., 2009).

No specific study has evaluated the frequency of ETT cuff monitoring that best suits children.

However, a systematic review in adults in Queensland hospitals revealed that monitoring of ETT cuff

pressure is routine practise in ICUs (Talekar, Udy, Boots, Lipman, & Cook, 2014), and there is strong

evidence that monitoring is crucial to avoid tracheal injuries (Jaber et al., 2006; Talekar et al., 2014).

In adult-focused literature, eight-hourly or once per-shift is the frequency adopted in practise (Labeau

et al., 2009; Rello, Lode, Cornaglia, Masterton, & Contributors, 2010). However, more recent

evidence by a prospective observational study suggests that continuous monitoring is favourable due

to the large variation of cuff pressure between patients and within patients (Memela & Gopalan,

2014). It is unclear in the paediatric context what the overall agreement is in regard to routine cuff

pressure monitoring (Bhardwaj, 2013; Tobias et al., 2012).

Ventilator circuit checks

Regularly changing the ventilator circuit prevents bacterial colonisation (Resar et al., 2014). Removal

of condensate from the ventilator is highly recommended by CDC guidelines (Klompas, Branson, et

al., 2014) as is the use of heat and moisture exchangers (HME) (Auxiliadora-Martins et al., 2012).

There are two randomised controlled trials conducted in PICUs which examine the frequency of

changing the circuit, its effects on VAP rates and cost implications. The incidence of VAP was 11.5

per 1000 ventilator days in a group of ventilated children assigned to seven-day circuit changes,

48

compared to 13.9 per 1000 ventilator days in a group assigned circuit changes every three days (p=

0.60) (Samransamruajkit et al., 2010). This randomised controlled trial also showed that alteration of

practise from three days to seven days may save up to US$22,000 per annum and decrease overall

workload.

One study by Chu et al. (2015) reported similar findings in the reduction of costs in their Neonatal

ICU. According to this study, there is no significant difference in VAP rates between changing the

ventilator circuit either every second day or weekly (8.2 versus 9.5 per 1000 ventilator days, p-

value=0.44), but less frequent changes contributed to a yearly cost saving of US$29,350. These trials

therefore support the need for ventilator circuit checks and changing at least weekly as outlined in

most paediatric VAP prevention bundles (Bigham et al., 2009; De Cristofano et al., 2016; Resar et

al., 2014; Rosenthal, Alvarez-Moreno, et al., 2012).

Sedation interruptions

Sedation in mechanically ventilated patients is routine practise to minimise patient discomfort and to

improve synchronisation between patient and ventilator (Ostermann, Keenan, Seiferling, & Sibbald,

2000). Nevertheless, sedation also increases the duration of mechanical ventilation, and hence is

associated with VAP development (Awasthi et al., 2013). In paediatrics, evidence of the effect of

daily sedation interruptions on the prevalence of VAP is limited and somewhat conflicting. A

randomised controlled trial by Gupta, Gupta, Jayashree, and Singhi (2012) compared an intervention

of daily sedation interruption midazolam bolus of 0.1mg/kg, followed by infusion, n= 46) versus a

control group of continuous infusion of midazolam; n=56 (control group). Patients in the intervention

group had daily interruption at 8.00 am, until they became responsive to verbal commands or were

agitated/uncomfortable to the extent that prompted restarting the midazolam infusion. When

recommenced, the dose of infusion was reduced by 50%. The study showed that patients with

interrupted sedation had a significantly shorter average duration of mechanical ventilation than the

patients under the continuous sedation protocol; 7.0 SD ± 4.8 days versus 10.3 ±SD 8.4 days

respectively (p=0.021). The patients in the interrupted sedation group also stayed for a shorter time

in PICU than the patients in the continuous sedation group; median 10.7 days versus 14.0 days

respectively (p=0.048) (Gupta et al., 2012).

A prospective randomised controlled trial (n=30) found that it is feasible to implement daily sedation

interruption in mechanically ventilated children (Hoog et al., 2014). In this study the intervention

group (n=15) received midazolam and morphine infusions which were stopped daily at 1 p.m. and

restarted when the COMFORT behaviour scale was ≥17. The control group (n=15) received standard

49

care of midazolam and morphine infusion and, if signs of agitation were present, bolus doses of

sedative were administered (Hoog et al., 2014). The duration of mechanical ventilation was

significantly shorter in the intervention group compared with the control group: median four days

(IQR 3.0–8.0) and nine days (IQR 4.0–10.0) respectively (p=0.03). Similarly, PICU stays were

shorter in the intervention group compared to the control group: median six days (IQR 4.0–9.0) and

10 days (IQR 7.0–15.0) respectively (p=0.010) (Hoog et al., 2014).

However, a recent multicentre randomised controlled paediatric trial comparing daily interruption

plus protocolised sedation (n=66) against protocolised sedation only (n= 63) by Vet et al. (2016)

found results that contradicted the above studies. Daily sedation interruption made no difference in

terms of the number of ventilator-free days in the daily interruption plus protocolised sedation group

(24.0 days (IQR 21.6–25.8) versus protocolised sedation only 24.0 days (IQR 20.6–26.0). There was

also no difference in median PICU length of stay with daily interruption plus protocolised sedation;

6.9 days (IQR 5.2–11.0) versus protocolised sedation only 7.4 days (IQR 5.3–12.8), p=0.47. The

length of hospital stays for daily interruption plus protocolised sedation was 13.3 days (IQR 8.6–

26.7) versus protocolised sedation only 15.7 days (IQR 9.3–33.2), p=0.19. Surprisingly, despite no

significant difference between the groups at baseline, mortality at 30 days was higher in the daily

interruption plus protocolised sedation group than in the protocolised sedation only group (6/66

versus 0/63, p=0.030) (Vet et al., 2016).

In summary, single-centred feasibility studies by Gupta et al. (2012) and Hoog et al. (2014) have

shown that the daily interruption of sedation is beneficial for critically ill children in PICU. However,

in the multicentre study, the opposite findings were obtained (Vet et al., 2016). Therefore, controversy

remains regarding the adoption of daily sedation interruption as a paediatric VAP preventative

strategy.

Early enteral feeding commencement

The role of enteral nutrition on the development of VAP is important through the prevention of

bacteria colonisation by decreasing gastric pH and ulcer occurrences (Kallet & Quinn, 2005). A meta-

analysis of data from intubated adults (n=6) demonstrated a statistically significant reduction in

pneumonia attributable to the provision of early feeding (OR=0.31, CI 0.12–0.78 p=0.010) (Doig,

Heighes, Simpson, Sweetman, & Davies, 2009).

Multiple studies recommend early commencement of enteral feeding within 24–48 hours of ICU

admission assuming that no contraindications to feeding exist (Barr, Hecht, Flavin, Khorana, &

50

Gould, 2004; Heyland, Dhaliwal, Day, Jain, & Drover, 2004). These recommendations are based on

the understanding of the positive role of early nutrition in promoting tissue repair and improving the

metabolism of the body, and consequent reduction in complications such as infection.

There is scarce evidence of the relationship between early feeding commencement and VAP

development in paediatrics. A recent randomised controlled trial involving 120 children in PICU

investigated initiation of enteral feeding — early (started within 6–24 hours) (n=60) compared with

late (started after 24 hours) (n=60) — examining the length of mechanical ventilation, PICU stay and

incidence of VAP. The study found no difference in VAP rates between patients assigned to early or

late initiation of feedings, p=0.44 (Prakash, Parameswaran, & Biswal, 2016). In an observational

study evaluating enteral nutrition initiation within the first 48 hours in 592 ventilated PICU patients

(60.0%), no association with VAP was identified (Albert et al., 2016). Overall, current evidence

shows that early feeding initiation in mechanically ventilated paediatric patients has minimal impact

in relation to the development of VAP.

Gastrointestinal (GI) prophylaxis

The effect of GI prophylaxis in prevention of VAP in children is unclear because of the low quality

of evidence and it is therefore not recommended (Klompas, Branson, et al., 2014). Despite this

recommendation, it is common practise in most PICUs to administer proton-pump inhibitors (PPIs)

or histamine-2 receptor antagonists (H2RAs) in the prevention of GI bleeding (Duffett et al., 2017;

Spirt, 2003). In a prospective observational study of 398 children from five PICUs in Brazil, 78% of

children received prophylaxis (Araujo, Vieira, & Carvalho, 2010).

A prospective cohort study by Albert et al. (2016), involving 59 PICUs from 15 countries, revealed

that the use of acid-suppressive medications (PPIs and H2RAs) in 763 patients (61.0%) increased the

likelihood of developing VAP (OR 2.0, 95% CI: 1.2-3.6, p=0.011). According to the authors, the

possible impact of acid-suppressive medications on the microbiome of the gastrointestinal tract may

contribute to this finding (Albert et al., 2016), and they suggest further examination of the rationale

for prescription of acid-suppressive drugs in PICUs.

An earlier study indicated that the use of sucralfate did not decrease the incidence of VAP in 53

children who were prescribed the sucralfate compared to 48 children who were not prescribed any

form of GI prophylaxis (Lopriore, Markhorst, & Gemke, 2002). Similarly, a prospective study by

Yildizdas, Yapicioglu, and Yilmaz (2002), revealed no difference in the incidence rate of VAP among

51

children prescribed either ranitidine, sucralfate, or omeprazole, compared with no GI prophylaxis

(p=0.96, CI= 0.95-0.96). In summary, the evidence demonstrates that the use of GI prophylaxis in

paediatric care has little impact or may even increase the risk of VAP incidence.

Summary

The implementation of the VAP prevention bundle in children has so far shown positive outcomes,

such as a reduction in VAP rates. Researchers still debate whether any individual preventative

strategy in the bundle has contributed to this reduction (Cooper & Haut, 2013; Klompas et al., 2016).

Unlike the adult VAP bundle where there are four to six well established individual preventive

strategies, the paediatric VAP bundle has individual preventative strategies which are varied and

understudied. This is likely due to lack of data available for appraising the individual VAP

preventative strategies (Cooper & Haut, 2013).

Most researchers agree that it is difficult to demonstrate high level research evidence for the ventilator

bundle with paediatrics using a randomised controlled trial (RCT) methodology (Duffett et al., 2013).

This may be partly due to feasibility issues. Some studies only analyse practises at a protocol level

due to recruitment challenges, or premature withdrawal of patients from studies subsequent to adverse

outcomes or patient deterioration (Duffett et al., 2017; Duffett et al., 2013; Vet et al., 2016).

Irrespective of these limitations, the individual VAP preventative strategies included in a bundle

should be tailored to individual patients (Klompas et al., 2016; Wip & Napolitano, 2009). This is

crucial to accommodate changes in epidemiology, treatment, diagnosis and prevention of VAP (Nair

& Niederman, 2015).

Organisational and clinician compliance with VAP preventative strategies

The implementation of VAP preventative strategies in clinical practise is hampered by an unclear

compliance benchmark. According to IHI, compliance with the bundle is generally calculated using

an all-or-none measurement rule with an aim for 95% compliance or more (Resar et al., 2014). This

means that adherence is counted either as ‘yes’ or ‘no’ for each individual preventative strategy, and

if any of the individual preventative strategies are absent, compliance is considered as incomplete

(Resar et al., 2014). A paediatric study by Bigham et al. (2009), described overall compliance for

each of the individual preventative strategies as 95% or greater, consistent with the IHI tool. However,

some researchers measure overall compliance categorically. In the latest publication by Tabaeian,

Yazdannik, and Abbasi (2017), there are four categories of compliance: (1) unacceptable compliance

at 0–25%; (2) average compliance 25–50%; (3) relatively acceptable compliance 50–75%; and 4)

acceptable compliance 75–100%.

52

Moreover, details of the level of compliance of individual VAP preventative strategies are often not

reported in publications. This may have implications on the calculation of overall compliance as a

firm compliance benchmark concerning the individual preventative strategies in children’s care is not

well defined (Bouadma, Mourvillier, Deiler, Le Corre, et al., 2010; Klompas et al., 2016; Resar et al.,

2014).

Nevertheless, there are a small number of paediatric studies, such as Bigham et al. (2009) that report

compliance of individual preventive strategies. Interestingly, they reported baseline compliance with

hand hygiene, oral hygiene, hand hygiene before and after contact with ventilator circuit, oral suction

device stored in unsealed plastic bag, in-line suction catheter changed when soiled, condensate

drained every two to four hours and when turning, ventilator circuit inspected and changed only when

soiled all at 60%. HOB elevation compliance was 57%. Following an educational program and

implementation of a paediatric VAP bundle, they reported the compliance increased to 100% for

every element. To establish if these changes were sustained they reaudited 22 months later. There

were improvements from baseline for each element with most compliance rates being 85% (Bigham

et al., 2009).

Compliance of healthcare workers to the ventilator bundle can prove to be a challenge in practise,

with poor to modest compliance being reported (Bouadma, Mourvillier, Deiler, Le Corre, et al., 2010;

Cason et al., 2007; Nair & Niederman, 2015). A recent multicentre cohort study involving five adult

ICUs reported the overall compliance with the VAP prevention bundle (inclusive of hand hygiene,

changing ventilator circuits, sedation interruption, ETT cuff pressure control, and oral care) was less

than 30.0%, with the lowest compliance being hand hygiene at 19.0% (Rello et al., 2013). Brierley et

al. (2012) reported challenges in VAP prevention bundle compliance in their PICU; however, they

managed to increase compliance from 50.0% to 90.0% after strict compliance monitoring with

monthly reporting.

Hand hygiene compliance for healthcare workers is an ongoing challenge in healthcare settings

(Allegranzi et al., 2013; Smiddy et al., 2015; World Health Organization (WHO), 2009a). The World

Health Organization (WHO) (2009b) defined non-compliance of hand hygiene as when the number

of opportunities exceeded the number of actions performed. The WHO does not provide a range of

hand hygiene compliance recommendations for patients’ families. Sickbert-Bennett et al. (2016)

classified hand hygiene compliance among healthcare workers at baseline as high level (>80.0%) or

higher level (>95.0%). The Australian Hand Hygiene benchmark for hand hygiene compliance among

healthcare workers from 2017 onwards is more than 80.0% (Hand Hygiene Australia, 2017b).

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There are few recently published studies which evaluate hand hygiene compliance of healthcare

workers in PICUs in relation to VAP prevalence. In 2002, an interventional randomised cohort study

was conducted in a PICU/Neonatal ICU to evaluate the impact of introducing an alcohol-based hand

gel on hand hygiene compliance (Harbarth et al., 2002). This study revealed that the overall adherence

to hand hygiene was 32.0% at baseline and following the introduction of hand gel the compliance

increased to 37.0%. In two other studies, at baseline the reported hand hygiene compliance of nurses

and medical practitioners in Neonatal ICUs was only at 46% and 65% before a hand hygiene

education program was implemented and increased to 69% and 88% after the program respectively

(Chhapola & Brar, 2015; Helder, Brug, Looman, van Goudoever, & Kornelisse, 2010).

It has been noted that challenges exist in defining individual VAP preventative strategy compliance

in paediatrics, thus contributing to variation in reported compliance rates. Overall compliance

amongst healthcare workers is low to modest, with limited compliance rates reported for the

individual VAP preventative strategies. This indicates that appropriate attention needs to be given to

address these challenges and improve global compliance for all healthcare workers.

Improving compliance with VAP preventative strategies via VAP education

Since VAP and VAE are associated with poor outcomes, it is important to ensure incidence is

minimised. In addition to and consistent with VAP surveillance (Khosim et al., 2015; Marcia Regina

Eches et al., 2015), a two-pronged way of minimising VAP incidence is by VAP education

complemented by strict monitoring of the compliance (Rosenthal, Alvarez-Moreno, et al., 2012;

Smiddy et al., 2015). Current strategies include using multimodal approaches, which include

education and compliance auditing (Flodgren et al., 2013; Klompas, Branson, et al., 2014).

VAP Education

Education remains a key strategy in the prevention of infection in hospital settings (Rello et al., 2010).

A systematic review by Flodgren et al. (2013) assessed eight adult ICU studies and found that

education plays a significant role in improving patient safety. The findings of this review emphasised

the importance of active implementation of procedures via repeated lectures and VAP surveillance.

A systematic review by Borgert, Goossens, and Dongelmans (2015) ranked education (86%),

reminders (71%), and combined audits with feedback (63%) as the top three strategies for effective

implementation of VAP preventative strategies in ICUs. However, these two systematic reviews only

considered adult ICU settings.

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In contrast, very few studies have been conducted in the paediatric setting specifically assessing the

impact of education on VAP rates (Cooper & Haut, 2013). Table 3.4 describes some important studies

in paediatric settings which acknowledge the need for updated VAP education among healthcare

workers. All of the studies mention educational approaches and interventions with Bigham et al.

(2009) and Brierley et al. (2012) presenting paediatric VAP preventative strategies in the USA and

UK respectively. These studies have been repeatedly used by other researchers as the benchmark for

VAP preventative strategies in children. Another three studies, Gupta et al. (2014), Obeid et al.

(2014), and De Cristofano et al. (2016), are more recent and strengthen the evidence on VAP

prevention and education delivery. These studies are consistent with the current medium of

information delivery (e-learning) and may encourage staff engagement with VAP education (Labeau

et al., 2016; Reime, Harris, Aksnes, & Mikkelsen, 2008). All studies demonstrate a positive

association between VAP education and the reduction of VAP rates in PICU (Table 3.4).

A challenge in ensuring compliance with individual VAP preventative strategies is maintaining active

practise over time (Kollef, 2011). Education is essential to maintain a high level of overall compliance

with a VAP prevention bundle (Bigham et al., 2009; Brierley et al., 2012; De Cristofano et al., 2016;

Rello et al., 2013). A quasi-experimental study in a neonatal setting revealed the positive impact of

an education intervention on hand hygiene compliance among healthcare workers indicating that

education is paramount in addressing compliance issues (Chhapola & Brar, 2015). The education

included training sessions, reminders and auditing and feedback. After implementation of these

programs, compliance of hand hygiene increased from 46% to 69% (Chhapola & Brar, 2015). An

earlier study by Helder et al. (2010) also demonstrated an increase in hand hygiene compliance

amongst nurses and other healthcare workers from 65% to 88% after the implementation of education

programs and feedback.

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Table 3.4: Paediatric studies involving VAP education and VAP preventative strategy implementation

Authors/country Design/participants Intervention/ approach Main outcome

measures

Results

Bigham et al.

(2009)/USA

Pre- post

implementation

design; Process-

Improvement

Initiative/ PICU

healthcare workers

(i) VAP bundle education and implementation of

paediatric-VAP bundle (ii) New mouthcare product

(iii) Compliance auditing, (iv) Modify policy and (v)

Advertising latest VAP rates via posters

(i) VAP rate

(ii) PICU

length of stay,

duration of

ventilation,

(iii) Mortality

(i)The VAP rates reduced from 5.6 at

baseline to 0.3 infections per 1000

ventilator days

ii) A significant association found

between VAP and length of stay:

VAP 19.5 days SD ± 15.0 vs non-

VAP 7.5 days ± 9.2, p < 0.001,

duration on ventilator: VAP 16.3 days

SD ± 14.7 vs non-VAP 5.3 days SD ±

8.4, p < .001

(iii) Mortality: VAP 19.1% vs non-

VAP 7.2%, p= 0.010)

Brierley et al.

(2012)/UK

Pre- post

implementation

design; Quality

improvement

study/healthcare

workers

A nurse-led VAP surveillance programme involved (i)

Multiple training opportunity, (ii) VAP education as a

routine part of staff induction, (iii) Compliance

monitoring, added to existing implementation of VAP

bundle and surveillance in the unit

(i)VAP rate

(ii)Compliance

to VAP bundle

(i) The VAP rates reduced from 5.6

to 0.3 per 1000 ventilator days

(ii) Compliance to VAP preventative

strategies progressively increased

Gupta et al.

(2014)/India

Prospective

cohort/nursing staff

and resident doctors

Education program delivered through lectures on (i)

Introduction to HAIs, hand hygiene, standard

precautions, (ii) Standard operating procedure for

sample collection, (iii) Pathophysiology of VAP and

VAP prevention strategies, sterilisation and

disinfection of respiratory equipment, aseptic

procedures for suctioning of ventilated patients.

Education materials displayed in the unit (poster of ‘5

moments of hand hygiene’), added to the existing VAP

bundle implementation in the unit

(i) Incidence

of VAP

(ii) Mortality

(i) The incidence density of VAP

was reduced by 28%

(ii) Pre-intervention=20.2 and post

intervention=14.6 per 1,000

ventilator days, p= 0.21)

(iii) A statistically significant

reduction in mortality among patients

who received mechanical ventilation

for ≥ 48 hours in the post

intervention period (49.3%

vs 31.4%: p= 0.029

56

Obeid et al.

(2014)/Lebanon

Pre- post-

interventional trial

/PICU healthcare

workers

(i) Education on VAP via presentations and discussion

on VAP elements, (ii) Development of a VAP bundle

checklist, (iii) Compliance auditing daily with

feedback

(i) VAP rate

(ii) duration of

mechanical

ventilation

(i) 52 to 6 per 100 ventilator days

(ii) Patient with VAP spent longer

duration on ventilator mean 11.42

days versus 5.18 days (p< 0.0001)

De Cristofano et

al. (2016)/

Argentina

Quasi-experimental

uninterrupted time

series/PICU

healthcare workers

(i) Launched a VAP prevention program. Staff notified

via email and daily presentations by the PICU

leadership team. (ii) Developed VAP education

material including text documents, slide presentations,

posters, and videos. (iii) Displayed educational

material in the PICU virtual campus highlighting the

VAP rate.

(i) VAP

incidence

VAP rate reduction from 6.3, 5.7,

3.2, 1.8 and to 0.0

57

The evidence indicates that VAP education is essential to not only help maximise the compliance of

VAP preventative strategies but also to reduce VAP incidence rates (Haut, 2015; Klompas, Branson,

et al., 2014; Singh, Kumar, Sundaram, Kanjilal, & Nair, 2012). VAP education delivered through a

multimodal approach helps to engage healthcare workers in the PICU environment.

Despite the lack of evidence concerning which educational interventions are most effective to foster

compliance with VAP preventative strategies, Flodgren et al. (2013) suggest in their systematic

review that multiple educational interventions that are periodically implemented in the unit will best

increase adherence amongst healthcare workers. This review also identified that VAP education

exclusively targeting healthcare workers often ignores the potential for educating parents and family

members in hand hygiene promotion and practise (World Health Organization (WHO), 2009a).

The role of parents in VAP prevention and parental education on hand hygiene

The presence or involvement of parents as part of the overall healthcare team is supported (Leape et

al., 2009; Piper, 2011); it is associated with an increase in family and parental satisfaction (Voos &

Park, 2014). Parents have a strong desire to be acknowledged and actively involved in the care of

their child (Meert, Clark & Eggly., 2013). Flexible visiting hours in PICU support parental

availability at the bedside and increase the potential for parent/patient contact and parent/healthcare

worker encounters (Bellissimo-Rodrigues et al., 2016). In PICU perspective, parents’ involvement

is very limited given the complexities of care that often involve complicated medical advancement

and the venerability of children receiving care (Stickney, Ziniel, Brett, & Truog., 2014). In VAP

preventative strategies implementation, they presumably are not handling ventilator tubing,

participating in endotracheal suctioning and oral hygiene. However, directly or indirectly, parents are

well positioned to interact with their child (physical contact i.e. touching and caressing) (Bellissimo-

Rodrigues et al., 2016) and become an observer to healthcare workers’ practises for example

ventilator care bundle implementation.

Hand hygiene stands out as the primary method in breaking the spread of infection (World Health

Organisation (WHO), 2009b; Kozlowski, 2012). In the context of VAP, the cross transmission of

VAP causative organisms to the patients often associated with the issue of contamination, bacterial

colonisation through the direct contact from healthcare providers, partly due to poor hand hygiene

practice (Safdar et al., 2005; Craven, 2006). This could be due to constant challenges in hand hygiene

compliance among healthcare workers (Belela-Anacleto et al., 2018; Erasmus et al., 2010). It is also

a challenging situation where the expectation for parents and visitors to perform good hand hygiene

practice in healthcare settings as this is the primary measures to combat with HCAIs (Anthony et al.

58

(2013); World Health Organisation (WHO), 2009b.). Yet little is known about educating parents and

families in PICUs, particularly on hand hygiene.

Education on the importance of hand hygiene in PICU is also vital not only to healthcare workers,

but also for parents and visitors (Belela-Anacleto et al., 2018; World Health Organisation, 2009a).

Wu et al. (2013) showed that patients/family members who had experience with HCAIs were more

likely to remind healthcare workers to perform hand hygiene (78.4%). Chen and Chiang (2007)

evaluated the effectiveness of a hand hygiene teaching program for families of children in a PICU via

a quasi-experimental time series. The experiment group received an introduction to hand hygiene

from nursing staff. The parents were taught by nursing staff and through watching a video about how

and when to perform hand hygiene. Families in the control group also received the education by

nursing staff and had a reference poster. The results revealed that families in the experimental group

had a higher compliance level compared to families in the control group.

Another paper in a Neonatal ICU, Anthony et al. (2013), reports on practise guidelines and parental

inclusion in hand hygiene practise to reduce Gram-negative bacterial infections. Attention was given

to educating parents on good hand hygiene practise. A more recent quality improvement study, by

Chandonnet et al. (2017), examined hand hygiene compliance among parents and family members in

a Neonatal ICU. The project was initiated due to low compliance with hand hygiene amongst these

visitors and aimed to achieve 100% compliance. The educational materials consisted of (1)

educational sheets about hand hygiene in multiple languages; (2) hand hygiene posters and stickers;

(3) real-time feedback, visual reminders of compliance reports and availability of supplies for hand

hygiene (hand rub, soap etc.). The compliance with proper hand hygiene that was observed among

parents and family members after the education program increased to 89% from 71% at baseline.

In this study, incorporating hand hygiene through parents’ participation to prevent VAP was to ensure

they have cleaned their hands (five moments) before in contact with their ventilated child, also parents

act as hand hygiene promoter when they are observing healthcare workers performing ventilator care

bundle to prevent the VAP.

Perceptions of ‘Speaking up for hand hygiene’ among healthcare workers and parents

The concept of speaking up for patient safety is an emerging area of interest and synonymous with

prevention of medication errors and promotion of hand hygiene practise in healthcare settings

(Daniels et al., 2012; World Health Organization (WHO), 2009a). The expectation of this initiative

is to provide immediate feedback to prevent human errors before harm occurs (Okuyama, Wagner,

59

& Bijnen, 2014). Despite the potential benefits in error prevention, issues arise as to what extent

healthcare workers, patients and families/parents engage with and respond to this initiative (Bsharat

& Drach-Zahavy, 2017).

Perceptions of speaking up may vary, based on: (1) the context of ‘Speak Up’™ (i.e., medication

error, hand hygiene), (2) the roles (i.e., healthcare workers, patients, families/parents), and (3) the

settings (i.e., adult, paediatric/neonatal). These factors could become barriers for collaboration

(Bellissimo-Rodrigues et al., 2016; Bsharat & Drach-Zahavy, 2017). A study that explored the

perception of patients and their involvement in speaking up for safety found that patients had a

positive experience. The healthcare workers respected the patients’ involvement in the prevention of

medication errors; however, they objected to reminders about hand hygiene (Schwappach, Frank, &

Davis, 2013). According to a systematic review by (Okuyama et al., 2014) hesitation to speak up

among healthcare workers can be a main factor contributing to communication errors.

When the ‘Speak Up’™ initiative was first introduced in 2002, the target of the initiative was the

patient themselves, emphasising their role in promoting their own safety (The Joint Commission,

2018). It is an initiative that uses easily understood materials such as leaflets and videos on evidence-

based clinical practises (e.g. hand hygiene; ‘Speak Up: prevent errors’). Later, a similar approach was

extended to family/caregivers of the patients. Evidence of the impact of the extended speak up

initiative that the research lacks rigour (Bsharat & Drach-Zahavy, 2017).

A survey in an adult hospital revealed that 75% of patients/families (n=334) were willing to remind

healthcare workers to clean their hands. In the same survey only 31% of nurses and 26% of medical

practitioners would welcome reminders from patients/families (Kim et al., 2015). The families of

patients hospitalised in the paediatric department were more reluctant to remind healthcare workers

about hand hygiene (OR 1.95; 95% CI: 0.99-3.83, p=0.053) but agreed that they could help to remind

healthcare workers about hand hygiene practise (96.5%; 333/345) (Pan et al., 2013). The intention of

patients/families to remind healthcare workers to perform hand hygiene only rated at 67.2% (232/345)

(Pan et al., 2013). An interesting finding by Wu et al. (2013) showed that patients/family members

who had experience with HCAIs were more likely to remind healthcare workers to perform hand

hygiene (78.4%). If the patient/family felt comfortable, they were increasingly willing to ask the

nurses and doctors to clean their hands (nurse: from 50.8% to 76.3%, p<0.001; doctor: from 48.9%

to 74.6% p<0.001).

60

In a large study in a tertiary hospital in Taiwan, 63% (553/880) of healthcare workers were willing to

remind patients/families about hand hygiene (Pan et al., 2013). This survey included 345

patients/families (115 patients, 220 family members and 10 attendants) and 880 healthcare workers

(241 medical practitioner, 505 nurses, 69 medical/nursing students and 65 technicians). The survey

also found that healthcare workers would feel ashamed if they were reminded by the patients/families

to practise hand hygiene. This study recommended that a mutual communication method should be

developed between staff, patients and families on hand hygiene to empower patients and families.

Illiterate families are more reluctant to remind healthcare workers to perform hand hygiene (OR, 1.79;

95% CI: 1.08-2.94, p=0.025) (Pan et al., 2013). Hierarchies within the various healthcare professions

also influence confidence levels in prompting colleagues to perform hand hygiene. For example,

junior staff reminding their senior work colleagues to perform hand hygiene is frowned upon in many

settings (Kobayashi et al., 2006; Samuel et al., 2012).

The role of patients and their families in speaking up is subtly different when the patient is a child

and the family members are parents. A systematic review by Bellissimo-Rodrigues et al. (2016)

examined 11 papers on the role of parents in the promotion of hand hygiene in paediatric centres. The

results suggest that parents understand the importance of hand hygiene to prevent infection, but they

lacked knowledge on hand hygiene procedures.

According to Coyne, Murphy, Costello, O’Neill, and Donnellan (2013) and Smith, Swallow, and

Coyne (2015), parents/family members are highly concerned about the attitudes of healthcare workers

towards their involvement with safety issues. Most parents and healthcare workers are aware that

hand hygiene is important for the prevention of infection in hospital (Bellissimo-Rodrigues et al.,

2016; Wu et al., 2013), but the willingness to remind each other of hand hygiene in practise varies

considerably. Similar research by Ciofi degli Atti et al. (2011) found that 56% of parents did not

believe that they should remind healthcare workers about hand hygiene. For their part, many

healthcare workers perceived that a reminder from parents to perform hand hygiene was unnecessary

(48.9%) (Ciofi degli Atti et al., 2011).

The literature demonstrates that the perception of ‘Speaking up for hand hygiene’ is equally valued

by parents and healthcare workers. Both parties agree that the initiative is important and helps prevent

infection, but participants were not always confident or comfortable in reminding each other, with

more healthcare workers preferring minimal participation from parents/family members. There is

minimal study on ‘Speaking up for hand hygiene’ specifically in the VAP prevention among parents

in PICU. Hand hygiene compliance monitoring amongst parents and visitors is not mandatory in most

61

institutions, unlike hand hygiene compliance among healthcare workers (Hand Hygiene Australia,

2017a; World Health Organization (WHO), 2009a). This lack of surveillance may underestimate the

demand for education on hand hygiene for parents and visitors (Giannini et al., 2016).

VAE and its preventative strategies

VAP preventative strategies and the challenges in implementation have been comprehensively

discussed in this chapter. For VAE, however, little is known about the specific preventative strategies

in paediatric and adult settings. Available evidence in adult populations suggests that VAE

preventative strategies are based on associations with pneumonia, fluid overload, atelectasis and

ARDS (Hayashi et al., 2013; Klompas et al., 2015). Thus, avoiding intubation, sedation interruption,

minimising the use of sedation (Lewis et al., 2014), paired daily spontaneous awakening and

breathing trials (Muscedere et al., 2013), and low tidal volume ventilation (Neto et al., 2015) are

among the VAE preventative strategies recommended. In paediatric literature, there are no studies

which examine VAE preventative strategies.

Summary

This chapter describes VAP preventative strategies that when combined are referred to as a VAP

bundle. The variation of individual VAP preventative strategies in a bundle in paediatrics is noted.

This review indicates that some individual VAP preventative strategies in adult VAP bundles are

applicable to paediatrics, with specific modification of strategies such as HOB elevation and cuff

pressure value. There is less evidence to support the use of GI prophylaxis and sedation interruptions.

The challenges, especially with compliance with VAP preventative strategy implementation, continue

in clinical settings. The review also indicates that hand hygiene is a crucial element/individual

preventative strategy, and this highlights the necessity of updating VAP education among PICU staff.

This review also acknowledges the parental role in a clinical setting and the value of educating parents

on ‘Speaking up for hand hygiene’ which may add new insight to VAP prevention in PICU.

The next chapter describes the methodology of this study.

62

Research Methodology

Introduction

This chapter outlines the approaches used in the research described in this thesis. There were three

phases to this work: Phase 1: Retrospective study; Phase 2: VAP education with VAP preventative

strategies compliance auditing and cross-sectional surveys; and Phase 3: Prospective study (Figure

4.1). This study utilised quantitative approaches with a small qualitative component in the Phase 2

cross-sectional surveys.

Figure 4:1: Study timeframe with respective research activities undertaken

Study setting

The study was carried out in the paediatric intensive care unit (PICU) of Queensland Children’s

Hospital (QCH) formerly known as Lady Cilento Children’s Hospital (LCCH). The change of name

to QCH was effective from 21st September 2018. This metropolitan hospital is a large and modern

dedicated paediatric facility in Australia with a capacity of 35 ICU beds (Children's Health

Queensland, 2016).

Study design

An epidemiological approach was adopted for early phases of the research described in this thesis.

Epidemiology is “the study of the distribution and the determinants of health-related states or events

in specified populations and the application of this study to control health problems” (Porta et al.,

2014, p. 13). This study involved two major epidemiological study designs: descriptive or

Phase 1:

Retrospective data collection

Mid-Nov 2016 to early Mar 2017

Phase 2:

VAP Education, VAP preventative

strategies' compliance auditing

and, Surveys

Mar to May 2017

i) VAP Education (PICU staff and Parents)

ii) VAP preventative strategies' compliance auditing with feedback

iii) Parental and Nurses surveys

Phase 3:

Prospective data collection

June to Dec 2017

63

observational and interventional (Woodward, 2014). The descriptive study design allows

identification of the status of the problem over time, which permits an analytical process to focus on

the possible risk factors associated with the disease occurrence. The interventional study design

involves testing the preventative measures or evaluation of programs/strategies that have been

implemented (Webb, Bain, & Page, 2017).

Phase 1: Retrospective study was a descriptive study which aims to summarise the prevalence of

VAP and VAE at baseline. Phase 2: VAP education used analytical study designs with quantitative

and qualitative methods and includes compliance auditing with interim feedback and a cross-sectional

survey of both parents and PICU staff. To determine the influence of VAP education and compliance

auditing with feedback, Phase 3: Prospective study used an interventional study design.

The prevalence of VAP and VAE and compliance with VAP preventative strategies was assessed in

Phase 1. An updated VAP education program and VAP compliance auditing inclusive of feedback

were introduced in Phase 2 and the impact of these were evaluated in Phase 3. These approaches

enabled the research questions to be adequately examined in this thesis.

Phase 1: Retrospective study

The purpose of the retrospective study was to assess the current status of VAP and VAE in a paediatric

population using the PNU1/VAP surveillance tool and the VAE surveillance tool. Retrospective

studies are widely used in epidemiological studies (Jansen et al., 2005) for evaluation of quality

improvement studies (Allison et al., 2000) and assessment of inpatient care (Ashton, Del Junco,

Souchek, Wray, & Mansyur, 1997). Retrospective studies allow analysis of a large dataset with less

cost (Clark, 2008) and are able to provide robust, naturalistic data to inform the evaluation of

treatment patterns and clinical outcomes and safety (Stein, Bassel, & Payne, 2014). The design is

indeed useful in analytical techniques for patient safety studies (Weinger, Slagle, Jain, & Ordonez,

2003).

In the retrospective study there were four research questions to be addressed:

1. What was the incidence and prevalence of VAP and VAE in QCH PICU in 2015?

2. What was the sensitivity and specificity of the VAE surveillance tool compared to the PNU1/

VAP tool?

3. What were the risk factors and compliance with VAP preventative strategies in QCH PICU

in 2015?

64

4. What were the risk factors of VAP and VAE and preventative strategies associated with a

diagnosis of VAP and VAE in QCH PICU in 2015?

The specific approaches employed in the methodology for this phase respond directly to the research

questions above.

Population and sample

All patients admitted to QCH PICU requiring invasive mechanical ventilation for greater than or

equal to 48 hours from 1 January 2015 to 31 December 2015 were included in this phase. The

surveillance involved all admissions to QCH PICU.

The inclusion criteria were;

1. age 0 to 18 years old;

2. invasive mechanically ventilated for ≥48 hours;

3. intubated with an endotracheal tube (ETT).

The exclusion criteria were:

1. non-invasive ventilation;

2. ventilated for <48 hours;

3. admission with existing tracheostomy intubation.

Data collection

The data were obtained from the Centre for Children’s Health Research at South Brisbane, through

the Children’s Health Queensland servers between mid-November 2016 and early March 2017. Data

was entered into a Microsoft Excel spreadsheet. The electronic repositories involved were Metavision

(iMDsoft®), Enterprise Picture Archive and Communication System (PACS), AUSLAB (Pathology

Queensland) and Hospital Based Corporate Information System (HBCIS). Monthly hand hygiene

compliance data of PICU nurses was obtained from Patient Safety and Quality Service, Children’s

Health Queensland (Children’s Health Queensland Hospital and Health Service, 2016). The data

derived from audit process undertaken monthly involving trained observers watch for opportunities

(5 moments) from a sample of nurses in PICU. A pilot study was undertaken to maximise the

efficiency of data retrieval and confirmation validity of data using sets of dummy data combined with

frequent communication with other researchers who had undertaken similar work. Appendix A was

the data collection sheet used in the Phase 1 study.

65

VAP and VAE surveillance tools

The PNU1/VAP surveillance tool

This tool was previously described in Chapter 2 (see Table 2.2).

The VAE surveillance tool

The VAE surveillance tool was previously described in Chapter 2 (see Table 2.3).

Demographic characteristics and admission-related variables

The choice of demographic characteristics was based on a review of the literature and the guidance

provided by clinical colleagues working in the area. Each of the variables collected were defined in

Appendix A, including their units of measurement for continuous and categorical variables.

Potential risk factors

A review of the literature was undertaken to identify potential risk factors for both VAP and VAE in

the paediatric population. These include the most frequently reported risk factors found to be

associated with VAP development in paediatrics such as reintubation, the presence of paralytic

agents, sedation level, nasogastric tube, absence of gastrointestinal prophylaxis and routes of

intubation (Casado et al., 2011; Gautam et al., 2012; Kusahara et al., 2014; Liu et al., 2013). Each of

the risk factors was defined in Appendix A.


The PICU at QCH had pre-existing documented procedures in place for VAP preventative strategies,

known as the VAP bundle. The bundle consisted of seven preventative strategies: hand hygiene, oral

hygiene, endotracheal suctioning (open suction), head of bed elevation, cuff pressure checks,

ventilator circuit checks and initiation of enteral feeding within 24 hours of PICU admission

(Queensland Children's Hospital Paediatric Intensive Care Unit, 2016). The VAP bundle was

developed at the Mater Children’s Hospital and transitioned to its existing form at QCH in early 2015.

The frequency of each VAP preventative strategy performance within a 24-hour period was recorded

and the variables were defined in Appendix A. The hand hygiene data derived from audit process

undertaken monthly involving trained observers watch for opportunities (5 moments) from a sample

of nurses in PICU. This validated hand hygiene data was derived from Patient Safety and Quality

Service, Children’s Health Queensland (Children’s Health Queensland Hospital and Health Service,

2016).

66

Data analysis

Data were analysed using the Statistical Package for the Social Sciences software IBM version 24,

(IBM, 2016) and a general-purpose statistical software, STATA® version 14 for multivariate analysis

(STATA 14, StatCorp, College Station, TX). The data in Excel format were checked and exported

into Statistical Package for the Social Sciences software. Data checking, and cleaning processes were

performed. Data were checked and cleaned by running frequencies, calculating maximum, minimum,

mean, standard deviation (SD), median, interquartile range (IQR) and using contingency tables. This

ensured that the data were free from errors and anomalies, thus permitting analysis of the correct data

to answer the research questions (IBM Knowledge Center, 2011). Univariate analysis of demographic

data, risk factors and preventative strategies required use of the Student t-test or the Mann-Whitney

U test for non-normally distributed continuous variables, Chi-squared test or Fisher’s exact test where

more than 20% of the expected counts are less than 5 for categorical variables. The significance level

used was 0.05.

The experimental unit was defined as episodes of mechanical ventilation; however, data are

summarised by patient and admission where appropriate, and clearly indicated as such. Results are

presented as frequency and percentages for categorical data, and means and SD for normally

distributed continuous variables, and medians and IQR for non-normally distributed continuous

variables.

4.3.1.7.1 Incidence of VAP and VAE

The outcome of interest was a binary event and the calculation of the incidences of VAP and VAE

were undertaken separately. Firstly, VAP events were identified after fulfilment of the PNU1/VAP

surveillance tool and confirmed by a clinician from the unit and research supervisor. VAE events

were identified after fulfilment of the VAE surveillance tool and classification was then confirmed

using the VAE Calculator Version 4.0 from the CDC and NHSN website (Centers for Disease Control

and Prevention (CDC), 2016b).

The first incidence rate was calculated using the CDC formula which sums all ventilation days within

the study period.

The following formula was used:

𝐼𝑛𝑐𝑖𝑑𝑒𝑛𝑐𝑒 𝑟𝑎𝑡𝑒 =𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑛𝑒𝑤 𝑉𝐴𝑃 𝑜𝑟 𝑉𝐴𝐸 𝑑𝑖𝑎𝑔𝑛𝑜𝑠𝑒𝑑 𝑑𝑢𝑟𝑖𝑛𝑔 𝑡ℎ𝑒 𝑠𝑡𝑢𝑑𝑦 𝑝𝑒𝑟𝑖𝑜𝑑

𝑆𝑢𝑚 𝑜𝑓 𝑜𝑏𝑠𝑒𝑟𝑣𝑒𝑑 𝑣𝑒𝑛𝑡𝑖𝑙𝑎𝑡𝑖𝑜𝑛 𝑑𝑎𝑦𝑠 𝑑𝑢𝑟𝑖𝑛𝑔 𝑡ℎ𝑒 𝑠𝑡𝑢𝑑𝑦 𝑝𝑒𝑟𝑖𝑜𝑑

67

The second incidence rate was calculated to adjust for time at risk for developing VAP/VAE, which

is not taken into consideration within the CDC calculation. The endpoint for observed ventilation

days were defined as either:

• until ventilation is ceased in the absence of the development of VAP or VAE;

• until diagnoses of VAP or VAE; or

• death.

The incidence of VAP or VAE was then expressed per 1000 ventilation days.

4.3.1.7.2 Diagnostic accuracy of the VAE surveillance tool

The diagnostic accuracy of the VAE surveillance tool compared to the PNU1/ VAP tool was

determined using the following formulae:

a) 𝑆𝑒𝑛𝑠𝑖𝑡𝑖𝑣𝑖𝑡𝑦 =𝑡𝑟𝑢𝑒 𝑝𝑜𝑠𝑖𝑡𝑖𝑣𝑒

𝑡𝑟𝑢𝑒 𝑝𝑜𝑠𝑖𝑡𝑖𝑣𝑒 +𝑓𝑎𝑙𝑠𝑒 𝑛𝑒𝑔𝑎𝑡𝑖𝑣𝑒

b) 𝑆𝑝𝑒𝑐𝑖𝑓𝑖𝑐𝑖𝑡𝑦 =𝑡𝑟𝑢𝑒 𝑛𝑒𝑔𝑎𝑡𝑖𝑣𝑒

𝑓𝑎𝑙𝑠𝑒 𝑝𝑜𝑠𝑖𝑡𝑖𝑣𝑒 + 𝑡𝑟𝑢𝑒 𝑛𝑒𝑔𝑎𝑡𝑖𝑣𝑒

c) 𝑃𝑜𝑠𝑖𝑡𝑖𝑣𝑒 𝑃𝑟𝑒𝑑𝑖𝑐𝑡𝑖𝑣𝑒 𝑣𝑎𝑙𝑢𝑒 =𝑡𝑟𝑢𝑒 𝑝𝑜𝑠𝑖𝑡𝑖𝑣𝑒

𝑡𝑟𝑢𝑒 𝑝𝑜𝑠𝑖𝑡𝑖𝑣𝑒+𝑓𝑎𝑙𝑠𝑒 𝑝𝑜𝑠𝑖𝑡𝑖𝑣𝑒

d) 𝑁𝑒𝑔𝑎𝑡𝑖𝑣𝑒 𝑃𝑟𝑒𝑑𝑖𝑐𝑡𝑖𝑣𝑒 𝑣𝑎𝑙𝑢𝑒 =𝑡𝑟𝑢𝑒 𝑛𝑒𝑔𝑎𝑡𝑖𝑣𝑒

𝑓𝑎𝑙𝑠𝑒 𝑛𝑒𝑔𝑎𝑡𝑖𝑣𝑒+𝑡𝑟𝑢𝑒 𝑛𝑒𝑔𝑎𝑡𝑖𝑣𝑒

Values were calculated by hand and then entered into the online calculator:

https://www.medcalc.org/calc/diagnostic_test.php to calculate the 95% confidence intervals

(Altman & Bland, 1994; MEDCALC easy-to-use statistical software, 2017).

4.3.1.7.3 Assessment of potential risk factors and preventative strategies for VAP and VAE

Assessment of potential risk factors and preventative strategies in this study employed a multivariate

analytical approach using Poisson and Negative Binominal Regression models. All of the final

models were run in STATA (STATA 14, StatCorp, College Station, TX).

Variables used in the multivariable modelling

Response variables

1. Ventilator-associated pneumonia (VAP): Yes or No during a single episode of mechanical

ventilation.

2. Ventilator-associated event (VAE): Yes (defined as VAC, IVAC or PVAP) or No during a

single episode of mechanical ventilation.

Exposure variables

Hours of at risk was defined by case classification as:

68

1. For those cases that were classified as having VAP: time of first x-ray found to be positive

(≥48 hours) minus time mechanical ventilation commenced.

2. For those cases that were not classified as having VAP: time mechanical ventilation

ceased/patient died minus time mechanical ventilation commenced.

3. For those cases that were classified as having VAE: the time of worsening oxygenation (≥48

hours/2 calendar days) minus time mechanical ventilation commenced.

4. For those cases that were not classified as having VAE: time mechanical ventilation

ceased/patient died minus time mechanical ventilation commenced.

Potential explanatory variables

• Gender: (male, female)

• Age: (months)

• Weight: (kg)

• Reintubation episodes (yes, no)

• Underlying disease (categorical: trauma/injury, cardiovascular, neurological, respiratory,

renal, gastrointestinal, infection and miscellaneous)

• Paralytic agent (yes, no)

• Gastrointestinal prophylaxis (yes, no)

• Nasogastric tube presence (yes, no)

• Routes of intubation: (categorical: nasal, oral)

• Sedation level: (categorical: deep sedation, light sedation, agitated)

• Percentage of compliance in month of hand hygiene (continuous)

• Average of frequency oral hygiene performed per total mechanical ventilation days

(continuous)

• Average of frequency endotracheal suctioning performed (open suction)/total mechanical

ventilation days (continuous)

• Average of frequency head of bed elevation performed/total mechanical ventilation days

(continuous)

• Average of frequency cuff pressure checks performed/total mechanical ventilation days

(continuous)

• Average of frequency ventilator circuits checks performed/total mechanical ventilation days

(continuous).

69

The Poisson regression was run initially as it allows assessment of the time that patients were at risk

for VAP and VAE, where the patients are followed over a variable length of time. This accounts for

the adjustment required to exclude children that had already developed VAP/VAE. These children

were no longer at risk for developing VAP/VAE so were then not included in further at-risk

calculations.

With a very low VAP and VAE event, logistic regression was not appropriate as it did not meet the

assumptions; the patients were not at risk for the same time period and the event rate was less than

10%, which would result in an underestimation of the probability of the rare events (King & Zeng,

2001). Since the study outcome is in binary form, a robust error variance procedure called sandwich

estimation was required to correct for overestimation of the error for the estimate parameter in the

Poisson regression model (Zou, 2004). This type of Poisson model is referred to as a modified Poisson

model.

The modified Poisson model has the following probability distribution:

𝑓(𝑦; 𝜇) =𝜇 𝑦𝑒−𝜇

𝑦!, 𝑦 = 0,1

Where:

y is the number of VAP or VAE (yes/no)

𝜇 is the average rate of VAP or VAE per hour of ventilation.

The present study used the mechanical ventilation episode as the experimental unit and each

mechanical ventilation had a minimum duration of 48 hours. The VAP/VAE event is recorded for

each mechanical ventilation. The dataset also counted mechanical ventilation episodes within

admissions, and each admission is nested within patients, but the effect of correlation present between

mechanical ventilation within an admission is unknown. Despite this, Elward et al. (2002) used

mechanical ventilation as the experimental unit in their study. To examine the effect of correlation

between mechanical ventilation within an admission, a mixed effects Poisson regression model was

carried out using the three-level, random-intercept Poisson model described as:

log(𝜇𝑖𝑗𝑘) = log(expected𝑖𝑗𝑘) + 𝛽0 + 𝛽1X𝑖𝑗𝑘 … . +𝑢𝑘 + 𝑣𝑗𝑘

Where mechanical ventilation within an admission is j, subjects k, and mechanical ventilation

episodes i, X is an explanatory variable. 𝛽0 is the intercept estimate, 𝛽1is the estimate for a predictor,

70

𝑢𝑘 is random patient effect and 𝑣𝑗𝑘 is the random mechanical ventilation within an admission effect

nested within the patient. The model includes the offset term for time at risk, to obtain incidence rate

ratio per hour of ventilation. A sandwich estimator was again applied. The likelihood ratio test is used

to examine whether the mixed effects model better explains the data than the modified Poisson.

When the Poisson models are over dispersed, it means that the assumption of modified Poisson

regression is not met (the mean does not equal the variance). An alternative is the Negative Binomial

regression models which were performed using STATA version 14 (STATA 14, StatCorp, College

Station, TX). An offset term for time at risk was also examined. To correct the underestimate, the

standard errors of estimates, a gamma-Poisson distribution in addition to the dispersion parameter

relaxes the strict assumption of the Poisson model by accounting for heterogeneity. These, in theory,

should perform similarly with a sandwich estimator as per the modified Poisson model since to the

best of our knowledge, no other study that we could find has used a Negative Binominal with a binary

outcome.

A Negative Binomial model has the following probability distribution:

𝑓(𝑦; 𝑟, 𝑝) = (𝑦 + 𝑟 − 1

𝑦) 𝑝𝑦(1 − 𝑝)𝑟, 𝑦 = 0,1

Where:

y is VAP/VAE (yes or no)

r is the number of cases without VAP/VAE

p is the probability of VAP/VAE.

A three-level random-intercept negative binominal model is as per the three-level random-intercept

Poisson model except it contains the additional dispersion parameter.

Steps to the univariate and multivariate analysis:

Step 1: Understand the variables under consideration. From a clinical perspective, is it

biologically plausible that they could be a predictor of VAP or VAE? What are the potential

relationships between risk factors and between risk factors and demographics? What form of

each variable would be most interpretable?

Step 2: Examine at the number of events.

Step 3: Conduct univariate analysis to explore the presence of an association between each

potential risk factor and the VAP and VAE response variables (described above), taking note of

small cell frequencies and empty cells.

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Step 4: Conduct univariate analysis for each risk factor with other risk factors to assess for

collinearity.

Step 5: Run age- and gender-adjusted Poisson model with robust estimator for one predictor at

a time and report the adjusted incidence risk ratio.

Step 6: For those variables with a p-value of less than or equal to 0.15 in the age- and sex adjusted

Poisson models, step-wise backwards selection was used to identify the final predictors in the

model with p-value≤0.05.

Step 7: Conduct diagnostics of model to ensure model fits assumptions [over-dispersion=square

root (Pearson statistic/df, linearity of continuous variable on the logit using squared terms and

Box-Tidwell transformation), examine overall fit (Deviance goodness-of-fit and Pearson

goodness-of-fit, AIC, BIC, log-likelihood) and influence of any outliers (Pearson and Deviance

residuals)].

Step 8: Repeat analysis for the negative binomial model and the mixed effects Poisson and

Negative Binomial models.

Assessment of compliance of VAP preventative strategies

Data relating to preventative strategies were further analysed using descriptive and univariate analysis

with comparison to the compliance standards in the PICU VAP guidelines (Table 4.1).

Table 4.1: Compliance standard for VAP preventative strategies according to PICU and national

standard for hand hygiene

VAP Preventative Strategies PICU/ national standard

1. Hand hygiene > 80%

2. Oral hygiene 6 times/24 hours

Adhered to 12-hourly oral health

assessment

Twice/24 hours

Adhered to age-appropriate oral

hygiene guideline

i) Child under 6 months old without teeth

Moistening (4 hourly or 6 times)

Pink swab with sterile water (0800 & 2000; 1200 & 2400; 0400 & 1600)

ii) Above 6 months with teeth

Tooth brush (twice) - Tooth paste (0800 & 2000)

Mouth rinse (twice) - Chlorhexidine (1200 & 2400)

Moistening (twice) - Pink swab with sterile water (0400 & 1600)

3. Endotracheal suctioning (open

suction)

4 times/ 24 hours

4. Head of bed elevation 24 times/24 hours

72

5. Cuff pressure checks Twice/24 hours

Adhered to 12 hourly cuff pressure

checks

Maintained cuff pressure readings

within the limit

Min 10cmH20 to max 20cmH20

6. Ventilator circuits checks 24 times/24 hours

7. Enteral feeding commencement

within 24 hours of PICU

admission

Started within 24 hours of admission if not contraindicated

Ethical considerations

The retrospective study received ethical approval from the Human Research Ethical Committee

(HREC) (Appendix B), Site-Specific Assessments (SSA) from the Governance Office of Queensland

Health (Appendix C), Public Health Act (PHA) 2005 (Appendix D) and the University of Queensland

(UQ) Ethical approval (Appendix E). Data were collected from the electronic systems in a de-

identified format with each individual having a unique identifier. The desktop computer used was

password protected and records were stored securely.

Phase 2: VAP education, VAP preventative strategies compliance auditing and surveys

The second phase involved multiple components of research as illustrated in Figure 4.2. However, data

were derived only from auditing compliance of VAP preventative strategies and the perception of the

‘Speaking up for hand hygiene’ initiative via surveys. Two research questions were addressed:

1. What was the compliance with VAP preventative strategies in the QCH PICU between March and

May 2017?

2. What was the perception of the ‘Speaking up for hand hygiene’ initiative amongst parents and

nurses in QCH PICU?

Firstly, in section 4.3.2.1, VAP education for PICU staff and parent were discussed followed by their

engagement with VAP education. Then, in section 4.3.2.2 the VAP preventative strategies

compliance auditing were explained. Finally, surveys on ‘Speaking up for hand hygiene’ initiative

involving parents and PICU nursing staff were discussed in section 4.3.2.3 and 4.3.2.4 respectively.

73

Mar 2017 May 2017

PICU

Staff

Researcher’s strategies on VAP education:

• Approached the PICU educators to reinforce the PICU staff on updated VAP education

package accessible through TEACH-Q platform since August 2016.

Compliance auditing

• Assessed the compliance of seven VAP preventative strategies.

• Provided feedback from compliance auditing of VAP preventative strategies on three

occasions: after 2 weeks of compliance auditing, end of April, and 7 May.

Conducted surveys on ‘Speaking up for hand hygiene’.

Parents

in PICU

Researcher’s strategies on VAP education:

• Provided face-to-face education on hand hygiene and pamphlet, ‘VAP: How I Can Help my

Child in PICU’ was given to parents.

Compliance auditing:

• Assessed the compliance of hand hygiene practises.

Figure 4:2: The research components involved in Phase 2 of the study

VAP education and education engagement

VAP education packages existed at both the Royal Children’s and the Mater Children’s Hospitals prior

to merging as QCH. However, the move, in November 2014, brought about challenges in maintaining

the pre-existing documented practises of VAP preventative strategies as described in Section 4.3.1.6

due to adaptation to the new working environment and systems (Chang, personal communication,

September 2015). The researcher’s role with the updated VAP education package was to update the

existing VAP education based on recent evidence. These findings provided a greater understanding

of the current preventative strategies applied to paediatrics (Cooper & Haut, 2013). Serial meetings

were undertaken with PICU Nurse Educators, and the updated VAP education package was produced

in May 2016. Completion of the VAP education package is compulsory for PICU nursing staff. It is

not compulsory learning for medical practitioners and allied health staff; however, they were

encouraged to enrol.

PICU staff

1. Updated VAP education

The updated education package (Appendix F) was re-launched in August 2016 and involved two

components:

74

1) Ventilator-Associated Pneumonia Prevention: Nursing Interventions with VAP Preventive

strategies.

This is a 32-slide PowerPoint presentation, delivered to PICU staff in the unit via the TEACHQ

platform — an online training system available within the hospital network. The package was the

updated VAP education package, which consists of the content outlined in the table below:

Table 4.2: The content of updated VAP education in PICU

What is VAP and what is the VAP tool?

Outlined in the PNU/VAP tool.

How is VAP diagnosed?

A case presentation of how VAP is diagnosed based on the VAP criteria outlined in the

PNU/VAP.

Focused on the PICU staff’s role in VAP assessment and the VAP surveillance team.

The challenges with the VAP tool

The new ventilator-associated complication tool

An example of study that applied the new ventilator-associated complication to the paediatric population.

Risk factors for VAP

Non-invasive ventilation strategies

Weaning sedation: State Behaviour Scale (SBS)

What is the SBS and the classifications – deep sedation, light sedation and agitation?

Emphasised on the interventions related to SBS scores and the documentation in Metavision

(iMDsoft®).

VAP preventative strategies (bundle)

Emphasised on seven preventative strategies in a poster.

Vigorous hand hygiene

Emphasised on this simple action – remains as primary measure to reduce.

Oral hygiene

Reinforce the mouth care protocol (4-hourly oral hygiene), 12-hourly oral assessment and

documentation.

Cuff pressure checks

PICU guidelines – 12-hourly cuff pressure check, maintain minimum cuff pressure at 10 to 20 cm H2O.

Suction and VAP

Ventilator circuits checks

Head of bed elevation

Early enteral nutrition

Strategies to improve adherence to VAP preventative strategies (bundle)

75

2) VAP Preventive Strategies poster

This is a poster presented on the wall of the patients’ rooms in PICU. The poster was also available

in the PowerPoint slides described earlier. The poster consists of seven VAP preventative strategies

with the images and the expected practises within 24 hours (Table 4.3).

Table 4.3: The content of VAP preventative strategies poster

1. Hand hygiene

Adhere to the 5 Moments for Hand Hygiene.

Always use gloves when: performing suction, disconnecting ETT and breaking ventilator circuit.

2. Oral hygiene

Four-hourly oral hygiene: under six months without teeth – 4-hourly moistening of mouth with sterile

water; above six months – 12-hourly 0.2% Chlorhexidine for patients with teeth and 12-hourly brushing

teeth with toothpaste.

3. Suctioning

ETT – aseptic non-touch technique (ANTT) (open suction)

Oropharynx – sterile bore Y-suction catheter. Use new catheter and suction prior to repositioning;

single-use yankaeur if required.

Equipment – change all suction related equipment 24-hourly.

Saline – syringe of saline single episode use only.

4. Cuff pressure checks

12-hourly cuff pressure checks.

Maintain cuff pressure 10–20cm H2O.

Only deflate cuff fully upon extubation or if excessive swelling occurs.

5. Ventilator circuits

Drain condensate away from patient or expel onto disposable cloth.

Change ventilator circuit at 14 days or if visibly soiled.

Change expiratory filter daily (label with date).

Discard circuit within 24 hours of disconnection and reset ventilator.

6. Head of bed elevation

Keep head of bed 15–30o unless contraindicated.

7. Enteral nutrition

Start enteral nutrition within 24 hours of admission

The expected frequency of performance of each of the VAP preventative strategies in 24 hours was

described in the PICU guidelines. For example, the expected frequency performance of cuff pressure

checks is twice in 24 hours. The majority were stated in the VAP preventative strategies poster and

VAP education in the PowerPoint slides. Otherwise they were mentioned in separate guidelines such

76

as the national standard of hand hygiene compliance set by Hand Hygiene Australia which is more

than 80%, 12-hourly oral health assessment in PICU Oral Hygiene Care Guideline and twice per shift

for ETT suctioning, documented through Metavision (Chang & O'Leary, 2016; Queensland

Children’s Hospital Paediatric Intensive Care Unit, 2015).

2. Provision of feedback from compliance auditing of VAP preventative strategies.

The provision of feedback from compliance auditing of VAP preventative strategies was provided on

three occasions. The first feedback was held at two weeks after commencement (mid-March 2017),

when a presentation was requested in the PICU Patient Safety and Quality Monthly Meeting. The

oral presentation with PowerPoint slides was delivered to PICU staff. The majority of attendees were

nurses. A copy of the presentation was included in the meeting minutes. The second feedback was

delivered through a poster presentation disseminated via the Electronic Information Board. In

addition, daily immediate bedside feedback was provided to PICU staff, particularly for hand hygiene

and for endotracheal suctioning. The final feedback was in the form of a Portable Document Format

(PDF) of slides and circulated by the Nurse Educator to staff email addresses.

Parents

The role of parents in minimising the incidence of VAP is an innovative inclusion to this study.

Educational material for parents was designed that aligned with the Children’s Health Queensland’s

“Speak Up for Safety” initiative. A bi-fold pamphlet, ‘VAP: How I Can Help my Child in PICU’

(Appendix G) was developed and distributed describing simple measures that parents could perform

such as hand hygiene. Parents of children in PICU were provided with face-to-face education with

emphasis on hand hygiene and oral hygiene in PICU.

The development of the pamphlet, ‘VAP: How I Can Help my Child in PICU’, began in mid-April

2016 with a meeting with LCCH PICU clinicians, Lead Nurse of Paediatric Critical Care Research

Group (PCCRG) and a Nurse Educator from the education unit in the PICU. The meeting was a

brainstorming session, sharing information around VAP prevention implementation in the PICU. The

fruitful discussion proposed parental involvement in VAP prevention concerning hand hygiene and

‘Speaking up for hand hygiene’, consistent with the unit interest to empower parents in patient safety.

Subsequently, a series of meetings was undertaken with the Nurse Educator and research supervisors

to finalise a list of VAP preventative strategies which were practical for parents in the PICU, and

education strategies which were suitable for transmitting information. Reliable information was

retrieved from the World Health Organisation (WHO), the Australian Commission on Safety and

Quality in Health Care and QCH PICU Oral Hygiene Guideline and existing VAP education materials

77

available in the unit to draft the content of the pamphlet (Australian Commission on Safety and Quality

in Health Care, 2013; Chang & O'Leary, 2016; World Health Organization (WHO), 2009a). The

content of the pamphlet was revised through five validation rounds involving different panels (refer to

Table 4.4).

Table 4.4: The summary of content validation for bi-fold pamphlet, ‘VAP: How I Can Help my Child

in PICU’

Date Panel members Recommendations/changes

End of May 2016 Two research supervisors, a PICU

clinician and a nurse educator

1. Language should be simple and the

information succinct.

Mid-June Two research supervisors, a PICU

clinician, a nurse educator, a social

worker and two PICU nursing staff

(representing the PICU Safety and

Quality Unit)

1. To change the title of the pamphlet,

simplification and removal of unnecessary

information and images.

July 2016 Two research supervisors, a PICU


worker, two PICU nursing staff


Quality Unit) and two parents

1. The language needs to be in line with the

lowest adult health literacy levels

(Australian Bureau of Statistics, 2009).

2. To condense the information to only one

page and add images of hand rub and hand

hygiene using soap.

End of August

2016

Two research supervisors, a PICU


worker, two PICU nursing staff


Quality Unit) and two parents

1. Panel approved the pamphlet

2. Final review required from a PICU social

worker.

December 2016 PICU social worker Approved the pamphlet.

February 2017 A PICU clinician and PICU Director 1. Reword the parents’ contribution to care

section “encourages to speak up” to “it is OK

to check if I washed my hands”

March 2017 - Finalised and approval obtained.

Engagement of VAP education

1. PICU staff

A two-fold approach was undertaken for PICU staff education: 1) an update of the VAP education

package and 2) VAP preventative strategies compliance interim feedback (during auditing). These

approaches to VAP education have been previously shown by researchers to be associated with a

reduction of VAP rates (Bigham et al., 2009; Brierley et al., 2012; Flodgren et al., 2013).

The education package was accessed via a compulsory online training platform and education

development program. These were the usual avenues at this hospital and the PICU Nurse Educators

had access to the analytics describing completion rates. The online learning platform is beneficial, as

78

it provides flexibility in access, fitting in with PICU staff needs and shift work (Choules, 2007;

Labeau et al., 2016). Furthermore, staff were provided with a copy of parental pamphlet. This ensured

consistency of information between PICU staff and parents. The majority of staff welcomed this input

and verbalised that they were good reminders for their daily practise.

During compliance auditing, there were also proactive measures from the PICU Patient Safety and

Quality unit. They involved actively promoting ‘Speaking up for hand hygiene’ by performing video

recordings to PICU staff holding a sign, “It is OK to ask me to clean my hands”. The videos were

available around strategic PICU areas (PICU entrances, airlock between two wings of PICUs, pantries

and toilets). Colourful visual reminders such as hands full of germs also posted in those strategic areas

added to the existing posters in addition to monthly hand hygiene compliance conducted by hospital

staff.

Feedback during the compliance auditing occurred via a group presentation, a poster disseminated

via the electronic information board and face to face on the wards. The advantages of presenting at

unit monthly meetings meant that the researcher was able to emphasise the importance of VAP

prevention strategies to various PICU staff and, at the same time, remind them to revisit the education

package on VAP that had been relaunched in August 2016. A soft copy of the presentation was made

available via staff emails as part of their meeting minutes. Staff asked questions concerning their hand

hygiene practise during the presentation, and the researcher provided appropriate answers; mostly

these concerned missed hand hygiene moments. In addition, the researcher also received feedback

from a few staff members who welcomed the auditing and, since the researcher was from the unit it

was easier for them to voice any concerns.

2. Parents

Parents were given the pamphlet, ‘VAP: How I Can Help my Child in PICU’, and face-to-face

education. Parents appeared to be receptive and welcomed the information given. They seemed to

understand the information in the pamphlet and had a few questions regarding the hand hygiene

resources for those who are allergic to the soap or gel provided in the PICU. The VAP education

engagement in PICU is illustrated in Table 4.5.

79

Table 4.5: The VAP education engagement in PICU at Phase 2

Timeline 6 Mar 2017 20 Mar 2017 28 Apr 2017

7 May 2017

Researcher to

PICU staff

1) Reinforcement of updated VAP education by Nurse Educators in TEACHQ platform

Researcher engaged with the PICU staff by:

a) Supplied the bi-fold pamphlet – ‘VAP: How I Can Help my Child in PICU’ designed for parents to align with the Children’s Health

Queensland’s ‘Speak Up for Safety’ initiative through hand hygiene via electronic and printed copies. 2) VAP preventative strategies’ compliance auditing

Researcher engaged with the PICU staff by providing the VAP preventative strategies’ compliance provision of interim feedbacks at three

occasions:

1st VAP compliance auditing’

feedback

via oral presentation in the PICU

Patients Safety Monthly Meeting.

2nd VAP compliance auditing’

feedback via poster presentation

electronic information board and

daily bedside one-to-one

feedback.

3rd VAP compliance auditing’

feedback via PDF slides

circulated to staff email

addresses.

Researcher to

parents

1) VAP education via bi-fold pamphlet and face-to-face education

Patients’ Safety

and Quality Unit

to PICU staff and

parents

1) Promoted ‘Speaking up for hand hygiene’ via video recordings

2) Colourful visual hand hygiene reminders

3) Monthly hand hygiene compliance

80

Compliance auditing


Participants included in hand hygiene compliance auditing were those PICU staff who were caring for

eligible screened patients, including nurses, medical practitioners, allied health clinicians and parents.

Other VAP preventative strategies compliance auditing only involved nurses.

Sample size

Compliance auditing used convenience sampling and aimed to obtain compliance data minimally from

30 to 40 patients based on the sample size calculation. The sample size was determined using EpiInfo

(Centers for Disease Control and Prevention (CDC), 2016a) with the following parameters: 95%

confidence interval, population size, degree of accuracy and 50% of the time the standard will be met

(University Hospitals Bristol NHS Foundation Trust, 2009).

Potential patients were screened for inclusion in auditing prior to recruitment by logging into the

Report Server via QCH Queue Manager and accessing the Patients Summary Report. The patient list

was confirmed with the PICU Nurse Researcher before auditing could commence. This two-stage

screening ensured that only appropriate families were approached for recruitment. For example,

unstable or terminally ill children or those with complex family dynamics were not approached for

recruitment. Patients were followed in PICU from the day of intubation until the day of extubation,

or deceased, or at the audit end date, whichever came first.

Following screening, the applied inclusion criteria were:

• intubated with endotracheal tube (ETT);

• receiving invasive mechanical ventilation.

The exclusion criterion was:

• receiving non-invasive mechanical ventilation.

Audit tools

The VAP preventative strategies checklist from the Dominican Hospital, Santa Cruz, the USA,

published by Healthcare Improvement (IHI) (Institute for Healthcare Improvement (IHI), 2015) was

adapted and a revised version of the VAP audit tool based on the QCH PICU VAP preventative

strategies was produced. The ‘5 Moments for Hand Hygiene’ data collection tool was used to collect

the hand hygiene compliance data (Hand Hygiene Australia, 2017a).

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The audit tools were piloted in February 2017 to assess practicality and feasibility through two

simulation sessions. The researcher also took note of the common times most of the preventative

strategies were carried out in the unit. The researcher then made changes by adding further strategies:

1) adhered to aseptic non-touch technique (ANTT); 2) adhered to using single suction catheter; and

3) adhered to the use of new normal saline for instillation for every new episode of suctioning.

Data collection

Auditing was carried out in the PICU from the 6th of March until the 6th of May 2017, with

compliance feedback provided in this period (Hand Hygiene Australia, 2017). Two data collection

methods were used: 1) data retrieval from electronic documentation Metavision (iMDsoft®); and 2)

bedside observation. Data for the frequency of oral hygiene performance in 24 hours and the

adherence to the cuff pressure measurements are obtained from Metavision (iMDsoft®), while

adherence to aseptic non-touch technique during ETT suctioning was obtained through bedside

observation (Table 4.6). Auditing was undertaken on four weekdays (Monday to Thursday; excluding

public holidays) morning and/or afternoon (8.00–10.00 am and/or 2.00–4.00 pm).

The researcher determined in consultation with bedside nurses whether any VAP preventative

strategies were due within the next two hours and then returned to conduct the observation. For ETT

suctioning the researcher liaised with the physiotherapist on a daily basis to maximise the opportunity

for suctioning observations. Observations took place either in the patient’s room or just outside the

room. Twenty-minute periods of observation of hand hygiene were carried out to examine compliance

among PICU staff and parents.

Data analysis

Statistical Package for the Social Sciences software IBM version 24 was used to analyse the auditing

data (IBM, 2016). Data were summarised as frequency and percentage, mean and standard deviation,

or median and interquartile range.


Permission for auditing was granted by HREC and the Governance of the hospital as part of quality

improvement in the unit. All participating PICU staff and parents were coded with a unique

identifying number.

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Table 4.6: VAP compliance data auditing

Participants VAP

preventative

strategies

Elements evaluated Measurements Source of data Remarks

Bedside

observation

Metavision

(iMDsoft®)

1. Nurses

2. Medical

practitioner

3. Allied

health

4. Parents

1. Hand hygiene 1. Five moments of hand hygiene

% compliance

(continuous)

Nurses 2. Oral hygiene

(OH)

1. Frequency of performance in 24 hours Continuous

If any chance to observe

the OH performance –

recorded the frequency

of observation

2. Adherence to 12 OH hourly

assessment

Yes/No

3. Age appropriate oral hygiene

cleansing material used.

Yes/No

1. Nurses

2. Allied

health

3. ETT

suctioning


Arrangement with

respective staff (bedside

nurse/physio required in

advance e.g. diverse

time of suctioning from

one patient to another)

2. Adherence to aseptic non-touch

technique (ANTT)

Yes/No

Participants VAP

preventative

strategies

Elements evaluated Measurements Source of

data

Remarks

83

Bedside

observation

Metavision

(iMDsoft®)

3. Single suctioning catheter used Yes/No

4. New posiflush saline used every new

episode of suctioning

Yes/No

5. Connected to filtered test lung after

disconnection of ETT and the ventilator

circuit

Yes/No

6. Drain the condensate away from

patient or expel onto disposable cloth

prior to re-connection to ETT

Yes/No

Nurses 4. Head of bed

elevation (HOB)


Bedside observation

also performed, and

degree of HOB

compared with the

Metavision (iMDsoft®)

2. Adherence to the degree of HOB Yes/No

Nurses 5. ETT cuff

pressure checks

1. Frequency of performance in 24 hours

(patients who were with cuffed ETT

only)

Continuous

If any chance to observe

the cuff pressure checks

performance – recorded

the frequency of

observation

Participants VAP

preventative

strategies

Elements evaluated Measurements Source of

data

Remarks

Bedside

observation

Metavision

(iMDsoft®)

2. Adherence to 12-hourly cuff pressure

checks

Yes/No

84

3. Maintaining the cuff pressure within

the limit

Yes/No

Nurses 6. Ventilator

circuits checks


2. Change expiratory filter every 24

hours

Yes/No

Medical

practitioner

7. Enteral

nutrition

commencement

1. Enteral nutrition commencement

within 24 hours of admission if no

contraindication

Yes/No

85

Survey for parents

The parental survey examined perceptions of VAP prevention following face-to-face education

regarding hand hygiene and oral hygiene in the pamphlet called ‘VAP: How I Can Help my Child in

PICU’.


Parents or primary caregivers of children admitted to PICU during the data collection period were

invited to complete the survey.

Sample size

The total number of participants was based on a sample size calculation performed using the EpiTool

epidemiological calculator (Sergeant, 2017). The latest prevalence of paediatric VAP in Australia

was estimated to be 6.7% (Gautam et al., 2012) and was entered as 0.67 in the calculator as an estimate

of true proportion. The population size of 100 parents was entered in the calculator based on the

estimated number of admissions of children requiring invasive mechanical ventilation to PICU, at

QCH within a three-month period. The Z value was 1.96 and e was 0.05 as desired precision entered

into the calculator respectively. The formula applied was:

𝑛 =Z2 × P(1 – P)

e2

where Z=value from standard normal distribution corresponding to desired confidence level [Z=1.96

for 95% confidence interval (CI)]. P is expected true proportion, e is desired precision (half desired

CI width). The calculated sample size for parents was 78.

The potential parents or primary caregivers for the survey were identified via the Metavision

(iMDsoft®) platform, using a similar screening process to that undertaken for compliance auditing.

Following the screening the applied inclusion criteria were:

• Parent or primary caregiver of a child receiving invasive mechanical ventilation.

• Able to read and understand the English language.


• Parent or primary caregiver who did not agreed to participate in the study.

86

Instrument (Survey questionnaire)

The questionnaire used in this study was adapted from publications by Chang, Easterbrook, Hancock,

Johnson, & Davidson, (2010), Kim et al., (2015), Samuel et al., (2012), World Health Organization

(WHO), (2017) and Wu et al., (2013). The questionnaire consisted of three sections: Section A:

Demographic information; Section B: General perception on information provided in the pamphlet:

‘VAP: How I Can Help my Child in PICU’ and Section C: Perceptions of parents about the ‘Speaking

up for hand hygiene’ initiative (Appendix H). Table 4.7 gives a summary of the survey; sections,

number of questions, measurements/scoring and final measurements after the data analysis was

conducted.

The research supervisors evaluated the content validity of the survey questions. The face validity and

overall understanding of the survey questions were tested with five parents in February 2017. Parents

made suggestions and comments, and these were included in the final version of the questionnaire.

These pilot responses were not included in the results.

Data collection

The eligible parents or primary caregivers were identified through a PICU Nurse Researcher before

the education and survey commenced. Following this, one parent or primary caregiver was recruited

to participate in the survey. An explanation regarding the study was given, and face-to-face education

was provided, together with a pamphlet given to the parents. Parents were allowed to ask any

questions and express any concerns. Parents were invited to complete the survey either using the self-

administered questionnaire or an online questionnaire (via Qualtrics™).

Data analysis

The responses from the self-administered questionnaire were manually entered into Statistical

Package for the Social Sciences software (IBM, 2016). Quantitative data were summarised as

frequency and percentage, mean and standard deviation or median and interquartile range. The free

text responses in survey studies were analysed using content analysis (Hsieh & Shannon, 2005). The

responses were highlighted to capture key concepts. Then, these were sorted into categories based on

how different codes were related and linked (Hsieh & Shannon, 2005).

Ethical consideration

Several ethical issues were anticipated. Of most concern was when to approach the parents of

critically ill children. The researcher understood the sensitivity of the situation and the PICU nurse

researchers were approached prior to attending the parents/caregivers or bedside nurses. Additionally,

87

the researcher was educated about referring the parent or primary caregiver to social workers in the

unit if necessary. Informed consent for the survey was important. Survey participants were provided

with explicit information regarding the project, the voluntary obligation of participation, risk and

benefits, confidentiality and the opportunity to express any concerns. This information was included

in the participant information sheet (Appendix I). A response to the online surveys was deemed to

constitute consent of the participant. The survey had approval from the respective ethical bodies

following amendments which included adding the paper version of the survey questionnaire for the

parents.

88

Table 4.7: Elements in parents’ survey

Section Number of questions/statements

Measurement/scoring Final measurement

A: Demographic

information

Six:

• Age

• Gender

• Education

• Working in healthcare field or not

• History of child admission to PICU

• History of their child who received mechanical

ventilation via ventilator in PICU

• Tick in the designated boxes

(Categorical)

• Age was collapsed into 2

categories from 3

Less than 30 years old and more

than 31 years old

• Education level was collapsed

into 2 categories from 5

Non-formal qualification

Formal qualification

B: General

perception on

information

provided in the

pamphlet: ‘VAP:

How I Can Help

my Child in

PICU.”

Ten:

• One question about whether the parent ever

heard about VAP before

• One question about the method they routinely

use for hand hygiene in PICU

• Eight statements referred to the level of

agreement with the information stated in the

pamphlet


Categorical: yes, no, unsure

• Hand gel, hand wash,

combination

• 5-point Likert Scale

[1=strongly disagree,

5=strongly agree]

• 5-point Likert Scale was

collapsed into disagree (1, 2, 3)

and agree (4, 5).

C: General

perception on

information

provided in the

pamphlet:

‘Speaking up for

hand hygiene’

Nine:

• Six statements referred to the level of

agreement with the information stated in the

pamphlet

• Two questions on the possible reason parents

would stop to remind nurses and other PICU

staff if the parents saw that they did not

perform hand hygiene

• One open-ended question for suggestions or

comments to improve the hand hygiene

practise in the unit.



5=strongly agree]


Categorical: four options and

other reason with free text

response

• Free text response


collapsed into disagree (1, 2, 3)

and agree (4, 5).

89

Surveys for nurses

Nursing staff within the unit were surveyed to establish the priority they placed on their perception of

the ‘Speaking up for hand hygiene’ initiative.


All PICU nurses were invited to participate in the study.

Sample size

The total number of participants was based on a sample size calculation using the EpiTool

epidemiological calculator (Sergeant, 2017). The prevalence of paediatric VAP in Australia was

estimated to be 6.7% (Gautam et al., 2012) and this was entered as 0.67 in the calculator as estimated

true proportion. The population size of 150 nurses was entered in the calculator based on the estimated

number of nurses employed in PICU. Z value was 1.96 and e was 0.05 as desired precision entered

into the calculator respectively. The formula applied was:

𝑛 =Z2 × P(1 – P)

e2

where Z=value from standard normal distribution corresponding to desired confidence level [Z=1.96

for 95% conficence interval (CI)]. P is expected true proportion, e is desired precision (half desired

CI width). The calculated sample size for nurses was 105.

The inclusion and exclusion criteria

The inclusion criterion was:

• PICU nursing staff.


• Nurses who have not agreed to participate in the study.

Instrument (Surveys questionnaire)

The questionnaire used for data collection was adapted from Kim et al., (2015), Samuel et al., (2012),

World Health Organization (WHO), (2017) and Wu et al., (2013). The questionnaire consisted of two

sections: Section A: Demographic information, and Section B: Perception of nurses on the ‘Speaking

up for hand hygiene’ initiative (Appendix J). Table 4.8 gives a summary of the sections of the

questionnaire, number of questions, measurements, and final measurements after the data analysis

90

was conducted. The questionnaire was initially available online (via Qualtrics™) and subsequently

made available in hard-copy form. The online questionnaire was distributed via a link to PICU

nursing staff members’ email addresses.

Data collection

The online survey invitation via the Qualtrics™ platform was sent to all nurses through the PICU

Nurse Researcher as advised by the Lead Nurse of PCCRG (Qualtrics, 2016). The first invitation was

sent on the 1st of April 2017, and the researcher gave verbal reminders to the nurses while conducting

the audit. In early May 2017, a reminder email was sent by the Lead Nurse of PCCRG. A hard-copy

version was also distributed to increase the response rate. The survey period was from the 1st of April

to the 6th of June 2017. The researcher went to each PICU nursing staff and asked did he/she had

attempted to participate the online version before. Those who did not participate in online version, an

explanation regarding the study was given. The nurses’ information sheet and hard copies of survey

were given. Hard copies were then collected from the designated survey boxes in PICU, every day in

the afternoon on the following day.

Data analysis

All online responses were recorded in Qualtrics™ (Qualtrics, 2016) and the self-administered

questionnaires were manually entered into Statistical Package for the Social Sciences software (IBM,

2016). The free text responses in survey studies were analysed using content analysis where the

responses were highlighted and categorised (Hsieh & Shannon, 2005). Quantitative data were

summarised as frequency and percentage, mean and standard deviation or median and interquartile

range.


Nurses were also provided with the nurses’ information sheet which provided explicit information

regarding the study, the voluntary obligations of participation, risks and benefits, confidentiality and

the opportunity to express any concerns. A response to the online survey constituted informed consent

by the participant.

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Table 4.8: Elements in nurses’ survey

Section Number of questions/statements

Measures Final measurement

A: Demographic

information

Three

• Gender

• Length of working experience in PICU

• The method nurses routinely use for hand

hygiene in PICU


(Categorical)


• Categorical: yes, no, unsure;

hand gel, hand wash,

combination

• Hand hygiene method nurses

used was collapsed from 3

categories into 2 categories; a

single method only or

combination.

B: General

perception on

‘Speaking up for

hand hygiene’

Nine

• Six statements referred to the level of

agreement of ‘Speaking up for hand hygiene’

• Two questions on the possible reason nurses

would stop to remind parents and other PICU

staff if the nurses saw they did not perform hand

hygiene

• One open-ended question for suggestions or

comments to improve the hand hygiene practise

in the unit.



5=strongly agree]


Categorical: three options and

other reasons with free text

response



collapsed into disagree (1,2,3)

and agree (4,5)

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Phase 3: Prospective study

In this final phase, the incidence of VAP and VAE was examined. Four research questions were

addressed:

1. What was the incidence of VAP and VAE in QCH PICU from the 12th of June until the 12th

of December 2017?

2. What was the compliance with VAP preventative strategies in QCH PICU from the 12th of

June until the 12th of December 2017?

3. Did VAP education and compliance preventative strategies including auditing with interim

feedback reduce VAP and VAE status as defined by the PNU1/VAP surveillance and the VAE

surveillance tool?

4. Was there any improvement in VAP preventative strategies compliance after the VAP

education and compliance preventative strategies auditing feedback?


All children admitted to QCH PICU requiring invasive mechanical ventilation for greater than or

equal to 48 hours during the period from 12 June 2017 to 12 December 2017 were screened. The

prospective surveillance involved all admissions to QCH PICU during this time period.

The inclusion criteria were:

• age 0 to 18 years old

• invasively mechanically ventilated for ≥ 48 hours

• intubated with an ETT.

The exclusion criteria were:

• non-invasive ventilation

• ventilated for < 48 hours

• admission with existing tracheostomy intubation.

Data collection

The recruitment was based on intubation admission reports that were screened daily to determine

eligible patients. The reports were available within Children’s Health Queensland servers at Children

Health Research Centre. Parents of eligible patients were approached for informed consent. The

eligible patients were followed over time from intubation until the patients were extubated, died, or

93

data collection ceased. Daily data collection ended on the 12th of December 2017 at 00:00 hours. The

data collection via the electronic repositories mentioned in 4.3.1.2 were again utilised and entered

into a Microsoft Excel spreadsheet.

VAP and VAE surveillance tools

The study utilised the criteria from the PNU1/VAP and the VAE surveillance tools described in

4.3.1.3.

The demographic characteristics, possible risk factors, and preventative strategies mirrored to the

retrospective study were also included in this phase. VAE risk factors such as steroid and blood product

administration were added in this phase based on recently published literature (Cocoros, Priebe, Gray

et al., 2017) (Appendix K).

Data analysis

Data were analysed using the Statistical Package for the Social Sciences software IBM version 24,

(IBM, 2016). Process for data checking, exporting, analyses and presentation were similar to the

process used in the retrospective study previously described in section 4.3.1.7. In the prospective

study, the incidence of VAP and VAE and the compliance of VAP preventative strategies were

additionally compared with the retrospective study findings, but only at univariate analysis level.


Parents were provided with general information about the research topic, the research objectives,

duration of the study and the instruments used to collect the data. Parents were also informed about

potential risks and benefits, confidentiality, voluntary basis of participation and the opportunity to

express any concerns related to the study. This information was provided in the Parents/Guardians

Information Sheet and Consent Form (Appendix L). The amendment for waiver of consent was

considered since there were a number of admissions with a high probability of being identified with

VAP and VAE, but the child was very ill or deceased before the researcher was able to obtain consent.

In each of these cases it would have been inappropriate to approach parents for consent. Considering

the value of this data the discussion held with the PICU research group and advisory team the potential

to apply for a waiver of consent. Agreement was reached, and an application was sent to respective

ethical bodies. In mid-October 2017, approval for a waiver of consent by HREC was granted

(Appendix M).

94

4.4 Summary

This chapter outlines the methodological approaches used to provide a thorough investigation of VAP

and VAE in critically ill children. Phase 1 provided a picture of VAP/VAE prevalence at baseline.

Phase 2 explored VAP compliance auditing and surveys. In this second phase, various components

were involved: 1) reinforcement of the VAP education package for PICU staff and education for

parents regarding hand hygiene; 2) VAP preventative strategies compliance auditing with feedback,

involving PICU staff, i.e., nurses, medical practitioners, allied health staff, and parents. Surveys to

find perceptions of ‘Speaking up for hand hygiene’ amongst parents and nurses were also undertaken.

Finally, Phase 3 involved a prospective study to assess the effects of the intervention.

The next chapter will highlight the results and discussion for Phase 1: Retrospective study. Chapter

6 presents the results and discussion for Phase 2: VAP preventative strategy compliance auditing and

surveys. Chapter 7 presents the results and discussion for Phase 3: Prospective study.

95

Results and discussion Phase 1: Retrospective study

Introduction

This chapter describes the results and discussion for Phase 1: Retrospective study. The aim of the

retrospective study was to describe the baseline of VAP/VAE incidence and prevalence in the PICU

of the Queensland Children’s Hospital (QCH). This chapter addresses the following research

questions:

1. What was the incidence and prevalence of VAP and VAE in QCH PICU in 2015?

2. What is the sensitivity and specificity of the VAE surveillance tool compared to the PNU1/

VAP surveillance tool?

3. What was the compliance of VAP preventative strategies in QCH PICU in 2015?

4. What were the possible risk factors and preventative strategies associated with the diagnosis

of VAP and VAE in QCH PICU in 2015?

The methodology for this chapter was described in Chapter 4, Section 4.3.1.

Selection of patients with eligible mechanical ventilation episodes

Of the 669 episodes of mechanical ventilation reviewed in the PICU of the QCH, 262 met the required

inclusion and exclusion criteria (Figure 5.1) with an inclusive total of 1713 mechanical ventilation

days, median duration of four days. The PNU1/VAP and the VAE surveillance tool was thus applied

to 262 episodes of mechanical ventilation. For VAP and VAE, the total time until patients were no

longer at risk (i.e., ventilation ceased) or, they were diagnosed with VAP or VAE as per the tool, or

they died, was 1562.27 and 1532.48 mechanical ventilation days respectively.

96

Figure 5:1: 262 episodes of mechanical ventilation met the study criteria

Demographic characteristics of patients in PICU admission

Of the 253 admissions in this study, there were 234 eligible patients. Males accounted for 57.3% of

the eligible patients. More than half the patients were aged less than 1 year (62.5%). The majority

(64.4%) of PICU admissions in 2015 that required mechanical ventilation ≥48 hours were for a

medically-associated condition; 37.0% for an underlying cardiovascular problem and 43.1% from a

direct admission. The median Paediatric Index of Mortality Score 3 (PIMS3) was 1.90 (IQR: 0.70 –

5.50). These indicate that the overall probability of death in this cohort was 1.90% (Table 5.1).

Excluded 22 that receiving invasive

ventilation via tracheostomy

10 mechanical ventilation episodes were

merged into 1, 2, 3 or 4 mechanical

ventilation episodes after re-evaluation

for any breaks between datasets that the

mechanical ventilation was < 24hrs

262 mechanical ventilation

episodes

(234 patients, 253 admissions;

1713 total mechanical ventilation

days)

294 had invasive ventilation

episodes for ≥48 hours

(245 patients)

272 receiving invasive ventilation

via ETT

(234 patients)

669 patients with invasive

ventilation and intubation episodes

in 2015

(252 patients)

Excluded 375 which had intubation

episodes for <48hrs

97

Table 5.1: Demographic characteristics according to patient admission (n=253)

Characteristics n (%)

Gender Male 145 (57.3)

Female 108 (42.7)

Age <1 year 158 (62.5)

1- 12 year 80 (31.6)

13 and above 15 (5.9)

Weight (kg, median (IQR)) 5.8 (3.6- 15.0)

PICU source of admission

OT/ Recovery 70 (27.7)

Emergency

Department

37 (14.6)

Ward (other

inpatient area)

37 (14.6)

Direct admission 109 (43.1)

PICU diagnosis category

Medical 163 (64.4)

Surgical 71 (28.1)

Trauma 19 (7.5)

Underlying disease

Trauma/ Injury 29 (11.5)

Cardiovascular 94 (37.2)

Neurological 21 (8.3)

Respiratory 50 (19.8)

Renal 3 (1.2)

Gastrointestinal 10 (4.0)

Infection 17 (6.7)

Miscellaneous 29 (11.5)

PIMS3 (median, IQR)

PIMS3 1.90 (0.70- 5.50)

OT=Operation Theatre; PIMS3=Paediatric Index of Mortality Score 3; IQR=Interquartile range

Outcome variables according to mechanical ventilation episodes

Table 5.2 shows the outcome variables according to mechanical ventilation episodes. Patients had a

median duration of mechanical ventilation of 4.2 days (IQR: 2.8- 7.5) and stayed in PICU for 7.6

days (median) and 18.9 days (median) in the hospital respectively. Of 234 patients, 85.5% were

discharged to the ward and then home. In the 2015 cohort, 25 patients died.

98

Table 5.2: Outcome variables according to mechanical ventilation episodes (n=262)

Variables n (%)

Duration of mechanical

ventilation

(days, median (IQR))

4.2 (2.8- 7.5)

Length of PICU stay


7.6 (4.8- 13.5)

Length of hospital stay


18.9 (9.8- 34.4)

PICU outcome

Discharge to ward/home 227 (86.6)

Died 26 (9.9)

Transferred to another ICU (includes Neonatal

ICU)

9 (3.4)

Mortality (*n= 234)

Yes 25 (10.7)

No 209 (89.3)

* patient level

VAP and VAE counts according to mechanical ventilation episodes

Of 262 mechanical ventilation episodes, 16 (6.1%) were identified as having VAP using the

PNU1/VAP surveillance tool and 16 (6.1%) were identified as have VAE using the VAE surveillance

tool. All 16 met the VAC tier; four of these met the infection-related ventilator-associated

complication (IVAC) tier, and three met the possible ventilator-associated pneumonia (PVAP) tier.

The majority (14 out of 16) of patients identified as having VAP. Ten out of 16 patients identified

with VAE. All happened during their single admission to PICU with a single mechanical ventilation

episode. Four patients with multiple PICU admissions were identified with VAP or VAE at their first

PICU admission, one for VAP and three for VAE. One patient with a single admission was identified

with both VAP and VAE during the second mechanical ventilation out of three mechanical ventilation

episodes in total.

Incidence and prevalence of VAP in PICU

The incidence rate of VAP was 9.3 per 1000 ventilation days according to the CDC tool (end point

being end of ventilation as the denominator) and 10.2 per 1000 ventilator days until the patients were

no longer at risk of VAP (that is ventilation ceased, they were diagnosed with VAP as per the tool, or

died). There were 16 episodes of mechanical ventilation from 16 patients (6.8%) identified as VAP

using the PNU1/VAP surveillance tool, giving a prevalence of 6.1%. No patients were identified as

having VAP on more than one occasion.

99

Incidence and prevalence of VAE in PICU

The incidence rate of VAE was 9.3 per 1000 ventilator days according to the CDC tool (end point

being end of ventilation as the denominator) and 10.4 per 1000 ventilator days defined by end points

at which the patients are no longer at risk of VAE (that is ventilation ceased, they were diagnosed

with VAE as per the tool, or died). There were 16 mechanical ventilation episodes met the VAE

surveillance tool, a prevalence of 6.1%. Fifteen patients (6.4%) were identified as having VAE with

one patient experiencing two VAC/VAEs on two separate occasions.

The sensitivity and the specificity of the VAE surveillance tool

The sensitivity of the new VAE surveillance tool was 18.8% (95% CI: 4.1–45.7) and its specificity

was 94.7% (95% CI: 91.3–97.2). This indicates that the VAE surveillance tool is a poor surveillance

tool for correctly diagnosing VAP as it has a high number of false negative results. Conversely it is a

very good surveillance tool for correctly identifying patients who test negative for VAP as it has few

false positive results.

The positive predictive value (PPV) was 18.8 (95% CI: 6.8–42.1) and negative predictive (NPV)

value 94.7 (95% CI: 85.8–95.8), indicating that a patient is highly likely not to have the disease given

that the test result is negative. The low PPV reflects the low prevalence of VAP. Hence, the VAE

surveillance tool does not appear to be a useful surveillance tool for detecting VAP, but it is useful

for screening patients who do not have the disease.

A patient who had VAE and VAP in the same mechanical ventilation episode was further classified

as IVAC (using the VAE surveillance tool) while identified as VAP using the PNU1/VAP

surveillance tool. Agreement in the identification of VAP and VAE occurred during three episodes

of mechanical ventilations and the surveillance tools agreed VAP and VAE was not present during

233 episodes of mechanical ventilations (Table 5.3).

Table 5.3: Contingency table of VAE versus VAP

VAP

No Yes Total

VAE No 233 13 246

Yes 13 3 16

Total 246 16 262

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Agreement between the two surveillance tools

Cohen’s κ was run to determine if there was agreement between the two methods in detecting

pneumonia. There was slight agreement between the methods, κ=0.135 (95% CI, 0.055 - 0.325), p=

0.029.

Discussion

Discussion of demographic characteristics of the patients

In this retrospective study, eligible episodes of invasive mechanical ventilation were assessed based

on criteria that have been widely used by previous VAP studies (Elward et al., 2002; Gautam et al.,

2012). This is important to distinguish between healthcare-associated infections (HAIs) and

community-acquired infections. The cut-off point of ≥48 hours was used in line with previous studies

for VAP (Charles et al., 2014; Elward et al., 2002; Kusahara et al., 2014; Roeleveld et al., 2011).

In the present study, the number of patients who were mechanically ventilated for ≥ 48hours in a 35-

bed PICU (234 patients) was lower than the number in a retrospective study of a developed country

(Japan) where 320 patients were observed over one- year period in an eight-bed PICU (Hatachi et al.,

2015). Most of the patients in this study were aged less than 12 months and they were predominantly

male (57.3%), which was consistent with the report of the Australian and New Zealand Paediatric

Intensive Care Registry in 2015 (Australian and New Zealand Intensive Care Society, 2016). The

annual report states that infants aged <12 months constitute 56.1% of admission, with 66.4% aged

less than five years. According to the same report, the overall admission rate to PICU for males was

2.15 per 1000 children compared to females at 1.67 per 1000 children (Australian and New Zealand

Intensive Care Society, 2016). Several studies demonstrate that younger children have a higher risk

for device-associated infections such as VAP (Becerra et al., 2010; Grohskopf et al., 2002; Tang et

al., 2009).

In contrast to the annual report of the Australian and New Zealand Paediatric Intensive Care Registry

in 2015, an underlying disease due to respiratory causes accounted for half (51.5%) of PICU

admissions (Australian and New Zealand Intensive Care Society, 2016). The majority of patients

(64.4%) in this study had an underlying disease due to cardiovascular causes. This may influence the

variability of oxygenation requirement for VAP/VAE diagnosis, for example with congenital

cyanotic heart disease and veno-arterial shunting (Cocoros et al., 2016).

The median PIMS3 value was 1.9%, which is lower than the reported mean for children in Australasia

of 2.9%. In the United Kingdom and Ireland the mean PIMS3 value was at 3.9% (Straney et al.,

101

2013). This difference may be due to the admission threshold, baseline population health status, or

individual patient management (Straney et al., 2013).

Discussion of VAP and VAE in the PICU of the QCH in 2015

The VAP incidence rate of 9.3 per 1000 ventilator days found in this study was within the expected

range for developed countries of 1.8–17.1 per 1000 ventilator days (Hatachi et al., 2015; Ismail et al.,

2012; Muszynski et al., 2013; Roeleveld et al., 2011; Stabouli et al., 2012).

In contrast, the incidence rate of VAP in the present study was higher in comparison to the latest

single setting one-year prospective study in Australia with 7.02 per 1000 ventilator days and a

retrospective study by Iosifidis et al. (2015) which showed 7.7 per 1000 ventilator days. It is, however,

difficult to directly compare the incidence rate to other paediatric studies, due to the diversity of

paediatric demographics, institutional preventative strategies and treatment options (Gautam et al.,

2012; Nair & Niederman, 2015). The incidence rate found in the present study may be due to the

challenges in implementation and monitoring of VAP preventative strategies when the QCH was

moved to a new site in November 2014 and the rotation of new staff/senior doctors, nurses and other

PICU staff that also occurred at that time (Siegel, Rhinehart, Jackson, Chiarello, & Health Care

Infection Control Practises Advisory, 2007).

The VAE incidence rate in this study (9.3 per 1000 ventilator days) is lower compared to two previous

studies which reported 11.2 and 20.9 per 1000 ventilator days respectively (Iosifidis et al., 2016;

Phongjitsiri et al., 2015). However, this incidence rate was higher than three studies that reported

incidence rates ranging from 1.1–4.6 per 1000 (Beardsley et al., 2016; Cocoros et al., 2016;

Narayanan et al., 2016). The higher VAE/VAC identified in this current study may partly be due to

the dominant proportion of patients with underlying cardiac disease, as suggested by Cocoros et al.

(2016), who tested FiO2 threshold and found a higher VAC incidence in their CICU patients. Other

possible explanations may be due to the large diversity of patient characteristics and underlying

diseases included in those studies. For example, Cocoros et al. (2016) included CICU, Neonatal ICU

and PICU patients. Although Narayanan et al. (2016) and Beardsley et al. (2016), conducted their

study in a PICU, one was prospectively conducted for a six-month period and Beardsley et al. (2016),

potentially underestimated the true incidence of VAE by only reporting IVAC. Furthermore, there

were also modifications of the VAE surveillance tool by Cocoros et al. (2016) — they replaced PEEP

with mean airway pressure (MAP) at different thresholds for VAC. In addition, Beardsley et al.

(2016) applied daily minimum PEEP values of at least 2cmH2O instead of 3cmH2O, which may have

contributed to the lower incidence of VAE.

102

The present study revealed equal numbers of episodes of VAE and VAP detected by two surveillance

tools for a total of 16 episodes (in 15 patients for VAE and 16 patients for VAP). This has not been

reported by previous studies. Nevertheless, this result mirrored the findings of a single setting PICU

study by Iosifidis et al. (2016), which identified 12 patients identified as VAE versus 13 patients

identified as VAP.

Other previous studies have reported higher VAE and VAP counts using two surveillance tools (the

VAE (adult) versus PNU/VAP); 41 patients versus nine patients (Phongjitsiri et al., 2015); seven

patients vs. four patients (Narayanan et al., 2016); and 17 patients vs. 15 patients (Taylor et al., 2014).

Conversely, one study reported lower VAE counts as compared to VAP using two surveillance tools

(the VAE versus PNU/VAP); four mechanical ventilation episodes versus five mechanical ventilator

episodes (Beardsley et al., 2016).

This present study found that only four patients met both surveillance tools, with only three

mechanical episodes that matched PNU1/VAP surveillance tool and PVAP tier (VAE surveillance

tool) and this indicates poor agreement between the two surveillance tools. This result was similar to

the previous study by Iosifidis et al. (2016), where five patients out of 25 patients met both

surveillance tools. Only one mechanical ventilation episode out of nine mechanical ventilation

episodes met both surveillance tools in the Beardsley et al. (2016) study, although their study differed

with the application of modified PEEP values of 2cmH2O. Cocoros et al. (2016) also found low

concordance of the VAE surveillance tool in comparison to the PNU/VAP tool. These low agreements

have also been noted in adult studies (Klein Klouwenberg et al., 2013; Stevens et al., 2014).

The sensitivity and specificity result for the VAE surveillance revealed that it is useful for screening

paediatric patients who do not have VAP (high specificity), which may reflect the ability of this tool

to capture other ventilator-associated complications (Hayashi et al., 2013; Klompas, Kleinman, et al.,

2014). Using VAE and surveillance tools in the present study on a single mechanical ventilation

episode in one patient, this tool was able to discriminate the episode as being either IVAC or PVAP,

while using PNU1/VAP, this was classified as VAP. Similarly, in an adult study, using the VAE

surveillance tool, fewer cases of VAP (PVAP) were identified. This reflected the ordinal tiers (VAC

and IVAC) applicable in VAE surveillance tool was able to distinguish VAP (PVAP) (Boyer et al.,

2015). Thus, the introduction of a VAE surveillance tool, with the purpose to capture not only VAP

but also other ventilator-associated complications, may echo those of others who have reported

limitations to the present PNU/VAP surveillance tool in children (Klompas, 2013a; Septimus et al.,

2015).

103

Potential risk factors for VAP and VAE

Table 5.4 describes the potential risk factors encountered in the 262 mechanical ventilation episodes

studied. There were fewer reintubations during the course of mechanical ventilation in the 2015

cohort (74.0%). The majority of patients (78.6%) received no paralytic agent and were less sedated

(94.3%). Over half (53.4%) of mechanical ventilation episodes did not have gastrointestinal

prophylaxis (GI) prescribed. Nasal endotracheal tubes were more common in mechanical ventilation

episodes (64.5%).

Table 5.4: Risk factors according to mechanical ventilation episodes (n=262)

Risk factors n (%)

Reintubation

Yes 68 (26.0)

No 194 (74.0)

Paralytic agent

Yes 56 (21.4)

No 206 (78.6)

Gastrointestinal prophylaxis (GI)

Yes 122 (46.6)

No 140 (53.4)

Nasogastric presence

Yes 259 (98.9)

No 3 (1.1)

Routes of intubation

Nasal 169 (64.5)

Oral 93 (35.5)

Sedation level

Deep sedation 15 (5.7)

Light sedation 247 (94.3)

Compliance of preventative strategies for VAP

Table 5.5 describes the compliance of VAP preventative strategies implemented in 2015. Two VAP

individual preventative strategies which had achieved full compliance were hand hygiene and

performance of endotracheal tube (ETT) suctioning in accordance with the Australian National

Standard and PICU Standard. Oral hygiene was performed regularly (4.9 (SD: 1.0)) with an overall

percentage compliance of 81.6%; however, the frequency of performance did not meet the unit’s Oral

Hygiene Guideline (6 times/day). The head of bed (HOB) elevation and cuff pressure checks were

reported to have a 90.0% compliance rate. The lowest compliance was with ventilator circuit checks

at 70.8%. The overall compliance of VAP preventative strategies (VAP bundle) in the PICU of the

QCH in 2015 was 89.0%.

104

Table 5.5: Comparison between VAP preventative strategies compliance and PICU/national standard

practise

VAP Preventative Strategies Mean (SD)

PICU/ national

standard

% Compliance in

comparison to PICU

/national standard

Hand hygiene 86.4 (12.3) > 80% ≥100%

Oral hygiene 4.9 (1.0) 6 times/24hours 81.6

ETT suctioning 8.6 (2.6) 4 times/24hours ≥100%

HOB elevation (median (IQR)) 22 (19.4-23.4) 24 times/24hours 91.6


(median (IQR))

1.8 (0.9- 3.0) 2 times/24 hours 90.0

Ventilator circuits checks 17 (6.6) 24 times/ 24

hours

70.8

SD=Standard deviation; IQR=Interquartile range

Univariate analysis

The univariate analysis was conducted to assess for associations between possible explanatory

variables and the outcome of either VAP or VAE in the study as the primary outcome.

Association between demographic characteristics and VAP and VAE

Univariate analysis revealed no association between demographic characteristics and development of

VAP/VAE. Underlying respiratory disease was associated with the development of VAE in all

mechanical ventilation episodes (p=0.045) (Table 5.6). Children with either underlying medical or

surgical PICU diagnosis categories were associated with the development of VAP, but this did not

reach statistical significance (p= 0.062).

105

Table 5.6: Univariate analysis for association of demographic characteristics with VAP/VAE (n=262)

Variables VAP p-

value

VAE p-

value

Yes No Yes No

Gender Male 7 (43.8%) 139 (56.5%) 0.44 9 (56.3%) 137 (55.7%) 0.97

Female 9 (56.3%) 107 (43.5%) 7 (43.8%) 109 (44.3%)

Age <1 year 8 (50.0%) 159 (64.4%) 0.34 12 (75%) 155 (63.0%) 0.57

1-12 year 6 (37.5%) 74 (30.1%) 3 (18.8%) 77 (31.3%)

13 and above 2 (12.5%) 13 (5.3%) 1 (6.3%) 14 (5.7%)

Weight 9 (4.7-28.8) 5.5 (3.5-15.0) 0.17 4.8 (3.3-

15.4)

5.8 (3.6- 15.0) 0.71

PICU

Diagnosis

Category

Medical 14 (87.5%) 158 (64.2%) 0.062 12 (75.0%) 160 (65.0%) 0.59

Surgical 2 (12.5%) 88 (35.8%) 4 (25.0%) 86 (35.0%)

PICU

source of

admission

OT/

Recovery

3 (18.8%) 67 (27.2%) 0.64 4(25.0%) 66 (26.8%) 0.22

Emergency

Department

3 (18.8%) 35 (14.2%) 3(18.8%) 35 (14.2%)

Ward (other

inpatient

area)

4 (25.0%) 37 (15.0%) 5(31.3%) 36 (14.6%)

Direct

admission

6 (37.5%) 10.7 (43.5%) 4(25.0%) 109 (44.3%)

Under-

lying

disease

Cardio-

vascular

4 (25.0%) 93 (37.8%) 0.33 10(62.5%) 87 (35.4%) 0.045

Respiratory 2 (12.5%) 48 (19.5%) 0 (0.0%) 50 (20.3%)

Others 10 (62.5%) 105 (42.7%) 6 (37.5%) 109 (44.3%

PIMS3

PIMS3 1.80 (1.30-

6.00)

2.00 (0.70-

6.30)

0.99 2.70 (1.60-

7.80)

1.80 (0.70-

5.30)

0.091

PIMS3= Paediatric Index of Mortality Score 3; IQR= Interquartile range

Association of outcome characteristics with VAP and VAE

There was an association between duration of mechanical ventilation, length of PICU and hospital

stay and VAP and VAE occurrence (p<0.05) (Table 5.7). No association was found between PICU

outcome, mortality, VAP or VAE.

106

Table 5.7: Univariate analysis for association of patient outcome characteristics with VAP and VAE

(n=262)

Association of possible risk factors with VAP and VAE

Reintubation and the presence of GI prophylaxis were associated with the development of VAE (p <

0.05, Table 5.8). Although not statistically significant, there was some evidence to suggest that both

are associated with the development of VAP (p=0.14 and p=0.07). The use of a paralytic agent, route

of intubation and sedation level was not found to be associated with either VAP or VAE.

Variables VAP p-

value

VAE p-

value

Yes No Yes No

PICU

outcomes

Discharge

ward/home &

Trans to

another

ICU/Neonatal

ICU

13 (81.3%) 223 (90.7%) 0.20 13 (81.3%) 223 (90.7%) 0.38

Died in ICU 3 (18.8%) 23 (9.3%) 3 (18.8%) 23 (9.3%)

Mortality

Died

3 (18.8%)

23 (9.3%)

0.20

3 (18.8%)

23 (9.3%)

0.20

Not died 13 (81.3%) 223 (90.7%) 13 (81.3%) 223 (90.7%)

Duration of

mechanical

ventilation

(days, median

(IQR))

11 (5.2-19.6) 4.1 (2.8-6.8) 0.001 13.7 (8.2- 20.5) 4.1(2.8-6.5) 0.001

Length of

PICU stay

(days median

(IQR))

17.8 (10.9-

34.8)

7.2 (4.7-12.8) 0.001 32.8 (26.6- 52.5) 6.9 (4.7- 12.3) 0.001

Length of

hospital stay

(days median

(IQR))

33.1 (17.7-

85.2)

18.7 (9.3- 33.6) 0.007 51.2 (29.7- 64.5) 9.3 (18.1-32.6) 0.001

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Variables VAP p-

value

VAE p-

value

Yes No Yes No

Reintubation Yes 7 (43.8%) 61 (24.8%) 0.14 10 (14.7%) 6 (3.1%) 0.002

No 9 (56.3%) 185 (75.2%) 58 (14.7) 188 (96.9%)

Paralytic agent Yes 4 (25.0%) 52 (21.1%) 0.75 4 (7.1%) 52 (92.7%) 0.75

No 12 (75.0%) 194 (78.9%) 12 (5.8%) 194 (94.2%)

GI prophylaxis Yes 11 (68.8%) 111(45.1%) 0.07 14 (11.5%) 108(88.5%) 0.001

No 5 (31.3%) 135 54.9%) 2 (4.1%) 138 (98.65)

Nasogastric

presence

Yes 16 (100%) 243 (98.8%) 1.00 16 (6.2%) 243 (93.8%) 1.00

No 0 (0%) 3 (13.0%) 0 (0%) 3 (100%)

Routes of

intubation

Nasal 9 (56.3%) 160 (60.0%) 0.48 12 (7.1%) 157 (92.9%) 0.27

Oral 7 (43.8%) 86 (35.0%) 4 (4.3%) 89 (95.7%)

Sedation level Deep

sedation

1 (6.3%) 14 (5.7%) 1.00 0 (0%) 15 (100%) 0.61

Light

sedation

15 (93.8%) 232 (94.3%) 16 (6.5%) 231(93.1%)

Association of preventative strategies with VAP and VAE

Univariate analysis revealed that cuff pressure checks were associated with VAP and VAE occurrence

(p ≤ 0.05). Although no significant association was found, there is some evidence to suggest that oral

hygiene is associated with the development of VAE (p= 0.092) (Table 5.9).

108

Table 5.9: Univariate analysis for association of VAP preventative strategies with VAP/VAE (n=262)

Variables VAP p-

value

VAE p-

value

Yes No Yes No

Hand hygiene

(mean (SD))

88.8 (14.7) 86.2 (12.1) 0.44 85.5 (13.9) 86.5 (12.2) 0.75

Oral hygiene

(mean (SD))

4.8 (0.7) 4.9 (1.0) 0.75 5.6 (1.1) 4.9 (1.0) 0.092

ETT suctioning

(mean (SD))

8.7 (2.2) 8.5 (2.7) 0.86 8.1 (1.7) 8.6 (2.7) 0.45

HOB elevation

(median (IQR))

22.7 (20.3- 23.4) 21.9 (19.4- 23.5) 0.40 21.7(19.8- 23.3) 22.0 (19.4- 23.4) 0.68

Cuff pressure

checks (median

(IQR))

2.9 (1.9- 3.5) 1.7 (0.7- 3.0) 0.041 2.6 (2.1- 3.7) 1.7 (0.7- 3.0) 0.013

Ventilator

circuits checks

(mean (SD))

17.3 (5.2) 17.0 (6.7) 0.88 17.2 (3.8) 17.0 (6.8) 0.94

Summary of the significant explanatory variables found in the study

Table 5.10 illustrates variables in the retrospective study which were found to be significant in

relation to VAP and VAE occurrences. Note that, although underlying disease was found to be

significant at p=0.045, this variable cannot be modelled for VAE as no patients with underlying

respiratory disease were identified as having VAE.

Table 5.10: Explanatory variables with a significant association with VAP or VAE by univariate

analysis

Response variables/ Explanatory variables with a significant p-value (measurements)

VAP VAE

• Duration on mechanical ventilation

(continuous)

• Length of PICU stays (continuous)

• Length of hospital stays (continuous)

• Cuff pressure checks (continuous)

• Underlying disease (cardiovascular, respiratory,

others)

• Duration on mechanical ventilation (continuous)

• Length of PICU stays (continuous)

• Length of hospital stays (continuous)

• Reintubation (yes/no)

• GI prophylaxis (yes/no)

• Cuff pressure checks (continuous)

109

Discussion

Possible risk factors and compliance of VAP preventative strategies

In this study, the reintubation procedure was performed 26.0% (68/262 mechanical ventilation

episode). This was due to planned but failed extubation, accidental extubation or when ETT change

was deemed clinically necessary. This proportion of reintubation procedure occurred was higher

compared to a prospective study by Gautam et al. (2012) who reported 7.1% of 269 patients have

been reintubated. Elward et al., (2002) in their study identifed only 13.7% of 911 patients were

undergone reintubation procedure.

Reintubation increases the likelihood for microaspiration of oropharageal secretion that could lead to

VAP. The majority of patients in this study were nasally intubated, were less sedated and were

administered muscle relaxants during the course of mechanical ventilation. These factors are also

noted in previous studies as factors that could explain the relationships with VAP development

(Coffin et al., 2008; Hellyer et al., 2016; Zolfaghari & Wyncoll, 2011). While almost all patients had

a nasogastic tube while receieving mechanical ventilation, nearly 50% of the patients received GI

prophylaxis, reflecting common practise in PICU patients. This was also reported by previous studies

(Albert et al., 2016; Heyland et al., 2004; Prakash et al., 2016).

The overall compliance to VAP preventive strategies performed by nurses for ventilated patients in

the 2015 cohort was 89%, showing that compliance was at acceptable ranges according to Tabaeian

et al. (2017), but lower than the benchmark (above 95%) set by the IHI (Resar et al., 2014). This

compliance rate is similar to other compliance rates reported in paediatric studies by Brierley et al.

(2012) and Bigham et al. (2009) but lower than rates from De Cristofano et al. (2016) (above 95%).

The overall compliance rate is considered to be within an acceptable range given the challenges in

implementation and monitoring due to the transitioning of two former PICUs into one at QCH. This

data, however, forms the baseline data for the unit (PICU).

Hand hygiene and frequency of endotracheal suctioning met 100% compliance. One possible reason

is the raised awareness of the importance of hand hygiene in healthcare organisations (Bouadma,

Mourvillier, Deiler, Le Corre, et al., 2010). Another possible reason includes the mandatory

monitoring of the effectiveness of the National Hand Hygiene Initiative which is measured monthly

through auditing conducted by hospital staff (Hand Hygiene Australia, 2017b).

The suggested frequency of ETT suctioning is four times per day (see Chapter 4, Table 4.1). This

frequency is based on patient stability and is highly dependent on clinical assessment of need. Given

110

that many children are intubated for an underlying respiratory disease with subsequent increased

secretions it is not surprising that 100% compliance is achieved (Davies et al., 2011; Morrow &

Argent, 2008). Other VAP preventative strategy compliance, such as oral hygiene, cuff pressure

checks and HOB elevation were reported above 80%. This may reflect the standard of nursing care

and baseline knowledge of unit staff.

The lowest compliance reported (70.8%) was for ventilator circuit checks. However, there may be a

gap between performing a task and documentation. All data in this study is derived from documented

procedures as provided by the hospital.

Discussion of the association between study variables and VAP/VAE development at

univariate analysis level

The duration of mechanical ventilation, length of PICU and hospital stays were associated with the

development of VAP and VAE. These findings corroborated other studies (Awasthi et al., 2013;

Becerra et al., 2010; Cocoros et al., 2016; Elward et al., 2002; Hatachi et al., 2015; Iosifidis et al.,

2016; Phongjitsiri et al., 2015; Roeleveld et al., 2011; Tang et al., 2009). This suggests that patients

on mechanical ventilation are exposed to ventilator-associated complications (VAP and VAE), and

that the impact of this increases hospitalisation duration.

However, the development of VAP and VAE were not directly associated with mortality. This is

consistent with some contemporary VAP studies (Almuneef, Memish, Balkhy, Alalem, & Abutaleb,

2004; Elward et al., 2002; Gautam et al., 2012; Iosifidis et al., 2015; Srinivasan et al., 2009). In

contrast to the present study, VAE was found to be associated with hospital mortality, as shown by

Cocoros et al. (2016); Iosifidis et al. (2016); Phongjitsiri et al. (2015). This possibly suggests that

there is no significant association between VAP/VAE incidence and hospital mortality rate, but this

is affected by relatively low VAP and VAE rates. In this study only three patients who met both VAP

and VAE surveillance tools died, but this finding could not claim that the mortality was due to

VAP/VAE.

The present study found that only ETT cuff pressure checks were associated with the development of

VAP in univariate analysis. This may be explained by possible aspiration of pathogenic secretions to

the lower respiratory tract (Dave et al., 2011) due to inadequate cuff pressure. In this study, some

patients clinically required a change from an uncuffed to a cuffed ETT. More than 90% of patients in

the 2015 cohort were mechanically ventilated with a light sedation state which still permits patient

111

movement. This movement may also contribute to cuff leakage and consequently there is the potential

for oropharyngeal secretions’ aspiration to occur (Mietto et al., 2013).

Reintubation, high acuity (PIMS3) score, presence of nasogastric tube and nasogastric feeding,

female gender and post-surgical state have been previously shown to be associated with VAP

development in children (Awasthi et al., 2013; Casado et al., 2011; Elward et al., 2002; Gupta et al.,

2015; Kusahara et al., 2014; Roeleveld et al., 2011). These risk factors were not identified during the

present study. Reintubation was not a risk factor for VAP in the present study, but this may be due to

75% of patients not requiring reintubation. The majority of children were nasally intubated which

could reduce the chance of unplanned extubations and possible reintubations (Gupta & Rosen, 2016).

These subsequently may reduce the potential for microaspiration of pathogenic secretion in to the

lungs that could lead to VAP (Berry, Davidson, Masters, et al., 2011; Dave et al., 2011).

The present study found that reintubation, cuff pressure checks, and the presence of GI prophylaxis

were associated with the occurrence of VAE at univariate analysis (p<0.05). Previous studies have

identified neuromuscular blockage, blood transfusion, positive fluid balance, tracheostomy,

immunocompromised status, chronic respiratory disease, mean peak inspiratory pressure, acute

kidney injury, and trauma as being associated with VAE in children (Beardsley et al., 2016; Cocoros

et al., 2016; Cocoros, Priebe, Gray, et al., 2017; Guess et al., 2018; Phongjitsiri et al., 2015). This is

the first study that has found an association between VAE development and reintubation, cuff

pressure checking and the presence of GI prophylaxis.

For cuff pressure checks and VAE development, this result may be explained by current practises

which dictate the frequency at which ETT cuffs should be checked. Although the compliance to cuff

pressure checking (twice daily) in this cohort was satisfactory (despite no universal accepted range

for frequency of cuff pressure checks), a huge variation in cuff pressures was reported over the

duration of mechanical ventilation in patients with cuffed ETTs (Memela & Gopalan, 2014), possibly

due to air leakage. Optimum cuff pressure for children is unknown, with both under- and overinflated

cuffs exposing the patient to air leakage which may compromise oxygenation and increase the

potential for microaspiration.

The present study found an association of GI prophylaxis and VAE incidence, which is consistent

with the adult study by Klompas et al. (2016) who also examined the PVAP tier in the VAE

subcategories. Although no relationship was found between GI prophylaxis and VAP in the present

112

study (using the PNU1/VAP surveillance tool), the finding suggests that using the new VAE

surveillance tool in children may potentially identify other complications.

Multivariate analysis

Incidence rate ratios per hour of ventilation (IRR) for each individual risk factor/preventative strategy

are presented in Tables 5.11 and 5.12. These are adjusted incidence rates accounting for age and

gender, which is commonly seen in the analysis of VAP and VAE (Klein Klouwenberg et al., 2014;

Klompas, Kleinman, et al., 2014; Muscedere et al., 2013; Patria et al., 2013; Phongjitsiri et al., 2015).

Only the duration of mechanical ventilation is included in the models. Length of PICU stay and length

of hospitalisation are excluded due to collinearity.

VAP models

Age and gender adjusted Poisson and negative binominal models

All risk factors and preventative strategies with a p-value of 0.15 or less were examined. The results

show some large effects, for example 1.40, however the 95% confidence intervals (CIs) in the

modified Poisson model for reintubation episodes, paralytic agent, gastrointestinal prophylaxis,

routes of intubation and oral hygiene are wide, indicating that these IRRs, although large, are not

robust estimates of the ability of these variables to predict the incidence of VAP per hour of

ventilation. The natural log alpha parameter in the negative binominal regression model also reveals

a large degree of dispersion for hand hygiene, oral hygiene and HOB elevation with the 95% CI

include 1, indicating this model may not be a good fit for this data.

Only cuff pressure checks were found to be significant in the modified Poisson and negative

binominal models (p=0.096 and 0.091) based on the criteria for variable selection for the multi-

variable models (p ≤ 0.15). The negative binomial regression appears to be overdispersed as indicated

by the lack of the 95% CI for log alpha (-14.43–11.40). Thus, this preventative strategy is not an

important predictor of the incidence of VAP per hour of ventilation, at the 5% level of significance.

VAE models

Age and gender adjusted Poisson and negative binominal models

All risk factors and preventative strategies were examined in VAE models, except for nasogastric

tube presence and sedation level as there were empty cells identified during the univariate analysis.

Weight was also excluded because weight is correlated with age although weight was identified as a

potentially important predictor of VAE at univariate analysis.

113

The age and gender adjusted in the Poisson regression model appears to have a large effect size (2.15;

1.26; 4.95; 0.74; and 1.84) with a wide 95% CI for reintubation episodes, paralytic agent,

gastrointestinal prophylaxis, routes of intubation and oral hygiene (0.76–6.67; 0.37– 4.31; 1.09–

22.49; 0.20–2.74 and 1.28–2.64). These results indicate that the incidence rate ratios, although large,

are not robust estimates of the ability of these variables to predict the incidence of VAP per hour of

ventilation. The natural log alpha parameter which is a parameter in the negative binominal regression

models was significant for reintubation episodes and head of bed (HOB) elevation (95% CI includes

1), indicating that for these two variables there is overdispersion present and the Poisson model may

not be a good fit for this data.

114

Table 5.11: Age and gender adjusted Poisson and Negative Binominal regression models of risk factors and preventative strategies for incidence

of VAP/hour of ventilation

Modified Poisson Negative Binomial

Explanatory variables N Age and gender

adjusted IRR

(95% CI)

p-value Age and gender

adjusted IRR

(95% CI)

p-value lnalpha

Reintubation episodes (yes) 262 1.16 (0.43 - 3.13) 0.77 1.25 (0.33 - 4.77) 0.75 -0.41 (-7.24 - 6.42)

Paralytic agent (yes) 262 1.40 (0.45 - 4.31) 0.56 1.40 (0.45 - 4.31) 0.56 -9.57 (-34.51 - 15.37)

Gastrointestinal prophylaxis (yes) 262 1.25 (0.44 - 3.54) 0.68 1.29 (0.40 - 4.16) 0.67 -0.82 (-9.19 - 7.54)

Routes of intubation (oral) 262 1.34 (0.41 - 4.35) 0.63 1.34 (0.40 - 4.47) 0.64 -3.46 (-113.50 -106.57)

Sedation level (deep) 262 0.99 (0.12 - 8.45) 0.99 0.99 (0.11 - 8.65) 0.99 -3.00 (-65.22 - 59.23)

Hand hygiene 244 1.02 (0.97 - 1.08) 0.42 1.02 (0.97 - 1.08) 0.43 -12.28 (-15.57 - -9.00)

Oral hygiene 262 0.77 (0.49 - 1.20) 0.25 0.77 (0.49 - 1.20) 0.25 -11.51 (-16.04 - -6.98)

Endotracheal suctioning 262 1.01 (0.85 - 1.22) 0.88 1.01 (0.85 - 1.21) 0.88 -2.54 (-40.57 - 35.48)

Head of bed elevation 262 1.12 (0.95 - 1.31) 0.17 1.12 (0.95 - 1.31) 0.17 -11.80 (-16.96 - -6.65)

Cuff pressure checks 251 1.15 (0.98 - 1.37) 0.096 1.16 (0.98 - 1.37) 0.091 -1.51 (-14.43 - 11.40)

Ventilator circuits checks 262 1.03 (0.95 - 1.12) 0.51 1.03 (0.95 - 1.12) 0.51 -10.40 (-36.36 - 15.55)

IRR=incidence rate ratio/hour of ventilation. CI=confidence interval.

115

Table 5.12: Age and gender adjusted Poisson and Negative Binominal regression models of risk factors and preventative strategies for incidence

of VAE/hour of ventilation

Modified Poisson Negative Binomial

Explanatory variables

N Age and sex adjusted

IRR

(95% CI)

p-value Age and sex adjusted

IRR

(95% CI)

p-value lnalpha

Reintubation episodes (yes) 262 2.15 (0.76 - 6.67) 0.15 3.47 (1.06 - 11.34) 0.039 1.44 (0.22 - 2.66)

Paralytic agent (yes) 262 1.26 (0.37 - 4.31) 0.71 1.42 (0.34 - 6.02) 0.63 1.17 (-0.86 - 3.19)

Gastrointestinal prophylaxis (yes) 262 4.95 (1.09 - 22.49) 0.038 7.00 (1.58 - 31.14) 0.011 1.24 (-0.15 - 2.63)

Routes of intubation (oral) 262 0.74 (0.20 - 2.74) 0.65 0.62 (0.14 - 2.71) 0.52 1.15 (-0.66 - 2.97)

Hand hygiene 244 1.00 (0.96 - 1.05) 0.92 1.00 (0.95 - 1.05) 0.99 1.01 (-0.81 - 2.82)

Oral hygiene 262 1.84 (1.28 - 2.64) 0.001 1.94 (1.38 - 2.73) <0.001 0.82 (-1.17 - 2.82)

Endotracheal suctioning 262 0.91 (0.78 - 1.06) 0.23 0.91 (0.77 - 1.08) 0.30 0.85 (-2.11 - 3.80)

Head of bed elevation 262 1.02 (0.90 - 1.16) 0.72 1.02 (0.90 - 1.17) 0.71 1.04 (0.97 - 3.05)

Cuff pressure checks 251 1.19 (1.03 - 1.36) 0.016 1.23 (1.02 - 1.47) 0.028 1.04 (-0.99 - 3.07)

Ventilator circuits checks 262 1.03 (0.97 - 1.09) 0.40 1.02 (0.96 - 1.09) 0.44 1.01 (-1.13 - 3.15)

IRR=incidence rate ratio/hour of ventilation. CI=confidence interval

116

The final modified Poisson and Negative Binominal models for VAE

Gastrointestinal prophylaxis and oral hygiene were found to be significant predictors of VAE, as

shown in Tables 5.13 and 5.14. The mixed effects Poisson model was not a significant improvement

on the modified Poisson model (likelihood ratio test p=0.06, AIC 134.5 (modified) versus 132.4

(mixed), BIC 152.4 (modified) versus 153.8 (mixed), log-likelihood -62.27 versus -60.18). Both the

modified and mixed effects Poisson models were overdispersed. The negative binomial natural log

alpha value indicates that there was overdispersion present, although this overdispersal disappears

with the mixed effects negative binomial model. The mixed effects negative binomial model was not

an improvement on the negative binomial model (AIC 132.9 versus 132.9 (mixed), BIC 154.3 versus

154.3, log-likelihood -60.44 versus -60.44). The mixed effects Poisson model reported similar

estimates and had a similar fit to the negative binomial models; however, the standard error for

gastrointestinal prophylaxis was very large, which may indicate that the mixed effects Poisson and

negative binomial models are over specified, that is they are too complex for the number of events.

The AIC results favoured the negative binomial model while the BIC favoured the modified Poisson

regression which is conflicting and provides supportive evidence of an over specified model. With

the exception of gastrointestinal prophylaxis, the parameter estimates for all the models are relatively

similar with similar standard errors, p-values and 95% CIs. The model that best fits our data is

therefore the modified Poisson regression model.

Gastrointestinal prophylaxis and oral hygiene were found to be significant predictors of VAE, using

the modified Poisson regression. For every extra oral hygiene given, the incidence of VAE is 2.15

(95% CI 1.27–3.65) times higher per hour of ventilation. For those on GI prophylaxis, the incidence

of VAE is 6.10 (95% CI 1.60–23.21) times higher per hour of ventilation compared to those not

receiving GI prophylaxis. This estimate should be used with caution due to the wide confidence

intervals. This model is not robust due to the low event rate but identifies a risk factor and preventative

strategy which may be influential in the diagnosis of VAE, although this should be re-examined with

a larger study.

117

Table 5.13: Final Poisson models of risk factors and preventative strategies for incidence of VAE/ hour of ventilation

Explanatory variables Modified Poisson Mixed effects Poisson

Beta (SE) IRR (95% CI) p-value Beta (SE) IRR (95% CI) p-value

Gender (female) -0.51 (0.62) 0.60 (0.18 - 2.00) 0.41 -0.57 (0.69) 0.57 (0.15 - 2.19) 0.41

Age (months) -0.00 (0.01) 1.00 (0.99 -1.01) 0.65 -0.00 (0.01) 1.00 (0.98 - 1.01) 0.61

Gastrointestinal prophylaxis (yes) 1.81 (0.68) 6.10 (1.61 - 23.15) 0.008 2.82 (1.23) 16.78 (1.49 - 188.59) 0.022

Oral hygiene 0.77 (0.27) 2.15 (1.27 - 3.65) 0.004 0.87 (0.32) 2.38 (1.27 - 4.43) 0.007

Constant -12.84 (1.46) 0.00 (0.00 - 0.00) <0.001 -15.02 (2.68) 0.00 (0.00 - 0.00) <0.001

Variance attributed to patient n/a 0.00 (0.00) 0

Variance attributed to mechanical ventilation

within an admission n/a 2.52 (2.15) 2.52 (0.47 - 13.43)

IRR=incidence rate ratio/hour of ventilation. CI=confidence interval. n/a=not applicable

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Table 5.14: Final Negative Binominal regression models of risk factors and preventative strategies for incidence of VAE/hour of ventilation

Explanatory variables Negative binomial Mixed effects Negative binomial

Beta (SE) IRR (95% CI) p-value Beta (SE) IRR (95% CI) p-value

Gender (female) -0.72 (0.63) 0.49 (0.14 - 1.68) 0.25 -0.72 (0.68) 0.49 (0.13 - 1.86)) 0.29

Age (months) -0.00 (0.01) 1.00 (0.98 -1.01) 0.75 -0.00 (0.01) 1.00 (098 - 1.01)) 0.72

Gastrointestinal prophylaxis (yes) 2.70 (0.92) 14.84 (2.47 - 89.31) 0.003 2.70 (1.11) 14.85 (1.67 - 130.68) 0.015

Oral hygiene 1.02 (0.24) 2.76 (1.72 - 4.44) <0.001 1.02 (0.36) 2.76 (1.37 - 5.56) 0.004

Constant -14.45 (1.88) 0.00 (0.00 - 0.00) <0.001 -14.46 (2.49) 0.00 (0.00 - 0.00) <0.001

lnalpha 1.30 (0.53) 1.30 (0.27 - 2.34) 1.30 (0.73) 1.30 (-0.13 - 2.74)

Variance attributed to patient n/a 0.00 (0.00)

Variance attributed to mechanical ventilation

within an admission n/a 0.00 (0.00)

IRR=incidence rate ratio per hour of ventilation. CI=confidence interval. n/a=not applicable

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Discussion

Discussion of potential risk factors and VAP preventative strategies and association

with VAP/VAE development by multivariate analysis

In this study, the multivariate analyses examined the ability of possible risk factors and VAP

preventative strategies to predict VAP/VAE. The multivariate analyses undertaken included all

potential risk factors and VAP preventative strategies. Only duration of mechanical ventilation was

taken into the model for incidence rate ratios excluding the length of PICU, length of hospitalisation,

age and weight due to collinearity. This collinearity affects the stability of the data (Weisberg, 2005).

It is understood that these variables correlate with each other.

The majority of previous studies have used logistic regression analysis to examine the possible risk

factors for VAP/VAE development (Casado et al., 2011; Elward et al., 2002; Patria et al., 2013;

Phongjitsiri et al., 2015; Roeleveld et al., 2011; Srinivasan et al., 2009). Moreover, some studies

counted patients as experimental units (Roeleveld et al., 2011; Srinivasan et al., 2009) instead of

mechanical ventilation episodes (Elward et al., 2002; Gautam et al., 2012), and some of the studies

ignore the multiple mechanical ventilation episodes in a person with multiple PICU admissions

(Balasubramanian & Tullu, 2014; Gautam et al., 2012). To our knowledge, none of the statistical

modelling methods used in published VAP research take time at risk into account, which may not

allow for meaningful conclusions in predicting possible risk factors/VAP preventative strategies at

an incidence rate ratio of VAP/VAE per hour of ventilation. Poisson and Negative Binomial mixed

effects models allow for multiple mechanical ventilation episodes and multiple admissions and report

incidence rate ratios, bringing new statistical methodology to the field.

It was found in the present study that an increased frequency of oral hygiene performance was

associated with an increase of VAE of incidence by 2.15 times per hour of ventilation. This finding

corroborates the findings of the adult study, which suggested that oral hygiene using chlorohexidine

was associated with increased mortality (Klompas et al., 2016). This result does need to be interpreted

with caution as a wide confidence interval was reported and with a very low event rate.

Oxygenation deterioration in mechanically ventilated children is more likely to occur compared to

adults because of the risk of airway leakage due to the conical shape of the airway in infants and

children (Khine et al., 1997). Moreover, infants and children are at a higher risk of rapid deterioration

because they expend proportionally more metabolic effort with the increased work of breathing

(Gupta & Rosen, 2016). Given that oral hygiene performance in children is risky (especially in non-

sedated paediatric patients), there is the possibility of worsening oxygenation while performing oral

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hygiene, particularly for oral tubes. Even in critically ill adult patients, the ideal frequency of oral

care is difficult to determine and performing oral hygiene on uncooperative patients may pose a risk

for aspiration which may subsequently compromise oxygenation (Ames, 2011). The method in which

oral care was performed in the study by Klompas et al. (2016) and how this increased the risk of VAE

development was unclear, but a finding from their metanalysis suggested that it may be due to the

aspiration of chlorohexidine which could cause lung injury (Klompas, Speck, Howell, Greene, &

Berenholtz, 2014).

Another finding of this study noted that patients who received GI prophylaxis had a risk rate 6.10

times higher/hour for VAE. Nevertheless, a wide confidence interval with a low event rate was

reported and thus the interpretation should be undertaken cautiously. Similarly to oral hygiene and

VAE, GI prophylaxis was not found to be covered in depth in any current paediatric VAE literature

to date. However, an adult study assessing the VAP bundle component versus VAE surveillance tools

was found and used as a reference in this study. Through this data, it was found that GI prophylaxis

was associated with risk for VAE (PVAP-tier) [hazard ratio, 7.69; (95%CI, 1.44 -41.10; p =0.02)]

(Klompas et al., 2016). Interestingly, the GI prophylaxis previously was found to be significant at

both univariate and multivariate analysis, which may further support the need for further research

regarding the mechanism of action in children (Albert et al., 2016) and the usefulness of VAE

surveillance tool in children.

Summary

In this chapter, Phase 1: Retrospective study provided detailed epidemiological data for VAP and

VAE in the 2015 cohort of PICU patients in the QCH. The results of VAE using the VAE surveillance

tool described incidence rates, possible risk factors, and the existing VAP preventative strategies for

critically ill children. The VAE surveillance tool in this cohort of patients had high specificity, which

led to a broader explanation of other possible ventilator-associated complications. The compliance of

VAP preventative strategies was measured at 89.0%. Modelling of VAP and VAE was completed but

the findings are not robust due to low numbers of VAP and VAE in this study. They do, however,

provide methodology on which to build future work in this field. None of the risk factors or VAP

preventative strategies were found to be predictive of VAP at multivariate analysis. Oral hygiene

performance and the presence of GI prophylaxis were identified as potentially important predictors

of VAE, which mirrors the latest adult study assessing VAP preventative strategies using the new

VAE surveillance tool.

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Chapter 6 presents the results and discussion for Phase 2: VAP preventative strategy compliance

auditing and surveys on ‘Speaking up for hand hygiene’.

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Results and discussion Phase 2: VAP preventative strategy compliance and

surveys

Introduction

This chapter describes and interprets the findings of Phase 2. The aim of this phase was to assess the

compliance auditing of the VAP preventative strategies in the PICU at Queensland Children’s

Hospital. Nursing staff and parents’ opinions of the ‘Speaking up for hand hygiene’ initiative was

also assessed. This chapter addresses the following research questions:

1. What are the current VAP preventative strategies in Queensland Children Hospital PICU?

2. What are the perceptions of parents and nurses in Queensland Children Hospital PICU of the

‘Speaking up for hand hygiene’ component of the VAP education?

The methodology for this phase is described in Chapter 4, Section 4.3.2.

Results of compliance auditing of VAP preventive strategies

Demographic characteristics of participants in VAP preventative strategy compliance

auditing

Compliance auditing was undertaken to describe the current status of VAP preventative strategy

compliance in PICU. The overall compliance of VAP preventative strategies (VAP bundle) was

83.1%. The audit involved a total of 183 individuals who were responsible for the care of 37 patients;

a total of 204 mechanical ventilation days. Of the 183 individuals, 84 were nurses, 50 medical

practitioners, 12 allied health personnel, and 37 parents. Twenty-eight of the patients were male and

nine were female. The median age of these patients was five months (IQR 0.9–36.0) and the median

number of mechanical ventilation days was four (IQR 2.0–7.5).

Hand hygiene

Both PICU staff and parents were audited for hand hygiene compliance. Of the 475 instances of hand

hygiene observation of nurses, 410 hand hygiene observations were compliant, resulting in

compliance rate of 86.3%. Medical practitioner hand hygiene compliance was measured at 87.4%

(97/111 observations), allied health personnel 86.1% (31/36 observations), and parents 64.7% (44/68

observations).

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Oral hygiene

Oral hygiene data from a total of 204 mechanical ventilation days was evaluated. The compliance in

performing 12-hourly oral health assessments was at 84.3% (172/204 days). The adherence to

frequency of oral hygiene performance and age-appropriate oral care practise using a recommended

cleaning solution as per unit guidelines was at 52.9% (108/204 days) (Figure 6.2).

Cuff pressure check

The rate of compliance for 12-hourly cuff pressure checks was 70.9%, with practise compliance found

in 107/151 mechanical ventilation days. Cuff pressure check compliance in terms of maintaining the

cuff pressure within limits was 86.1% (130/151 days).

Endotracheal suctioning

Endotracheal suctioning (open method) was performed mainly by nurses and on some occasions by

physiotherapists. A total of 31 episodes of suctioning were observed. Adherence to aseptic non-touch

techniques during suctioning was 74.2% (23/31). Full compliance (100%) was recorded for the

practise of connecting the filtered test lung to the ventilator circuits, after disconnection of ventilator

circuits from the endotracheal and the use of a single suction catheter while performing endotracheal

suctioning (Figure 6.1). The practise of draining the condensate away from the patient and/or

expelling the condensate onto a disposable cloth before re-connection to endotracheal tube showed a

compliance rate of 22.6% (7/31).

Figure 6:1: Endotracheal suctioning (open method) compliance

100.0%

100.0%

74.2%

22.6%

Single-use catheter during endotraheal tube

suctioning (open method)

Connecting the ventilator circuits to filtered test

lung prior re-connection to endotracheal tube

Aseptic non-touch technique adherence

Draining condensate of ventilator circuit away

from patient or expel onto disposible cloths

before re-connection to endotracheal tube

Endotracheal tube suctioning (open method) compliance

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Head of bed (HOB) elevation

HOB elevation compliance was measured at 86.4%. HOB compliance was reported for a total of 204

mechanical ventilation days.

Ventilator circuits checks

The compliance rate for changing the expiratory bacteria filter every 24 hours recorded during

auditing was 95.2%. The changing of the expiratory filter every 24 hours was observed in 60/63

mechanical ventilation days.

Enteral feeding commencement within 24 hours of admission

Full compliance (100%) was recorded for enteral feeding commencement in 29 patients. Eight

patients were excluded from the analysis because they had either a medical or surgical

contraindication for feeding commencement.

Discussion of compliance of VAP preventative strategies during auditing

The overall compliance rate of VAP preventative strategies (VAP bundle) during the auditing was

83.1%, indicating that compliance was below the expected level (95%) set by the Institute for

Healthcare Improvement (IHI) (Resar et al., 2014). Nevertheless, overall compliance in this phase is

classified as acceptable (75-100%) according to Tabaeian et al. (2017). The inclusion of hand hygiene

within the VAP bundle may explain failure to achieve the IHI benchmark.

The inclusion of hand hygiene in the VAP bundle may lead to results that do not fully represent

compliance because it is not a direct patient intervention (Resar et al., 2014). It appears that when

hand hygiene is included, overall compliance tends to drop below 95%, as cited by Bigham et al.

(2009) and Brierley et al. (2012). De Cristofano et al. (2016) reported compliance above 95% in their

VAP preventative strategies only when excluding hand hygiene compliance assessments. Overall

compliance to the VAP preventative strategies in the present study fits within the acceptable range

since the re-launching of updated VAP education to PICU staff. This is the first time the overall

compliance of VAP preventative strategies and individual VAP preventative strategies was audited

in the unit.

At the level of individual VAP preventative strategies, hand hygiene compliance among PICU staff

(nurses, medical practitioner and allied health staff (physiotherapists)) was reported as being in line

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with the Australian national benchmark (>80%) (Hand Hygiene Australia, 2017b). It is also consistent

with results of monthly compliance hand hygiene auditing conducted by hospital staff in the PICU

achieving 86% compliance (March–April 2017) (Children’s Health Queensland Hospital and Health

Service, 2017). This result was defined as a high level of hand hygiene compliance by Sickbert-

Bennett et al. (2016).

The findings above agree with those from a study by Bigham et al. (2009) where an improvement of

hand hygiene compliance from 60% to 90% was reported, although they specifically evaluated hand

hygiene practise before and after contact with ventilator circuits. Sickbert-Bennett et al. (2016)

reported that the hand hygiene compliance of healthcare workers was 95% in the PICU following the

implementation of their ‘Clean In, Clean Out’ program which asks that all staff perform hand hygiene

every time they enter and exit a patient room. The present study used similar hygiene compliance

assessments as those undertaken in study by Sickbert-Bennett et al. (2016), where ‘5 Moments of

Hand Hygiene’ were assessed. Another study that found incremental increases in hand hygiene from

65% at baseline to 88% in Neonatal ICU staff after a hand education program was implemented

(Helder et al., 2010).

This high level of hand hygiene compliance reported in the present study may be explained by a few

factors including staff engagement with patient safety and ongoing organisational hand hygiene

auditing. Another factor which may have contributed to these rates was the launching of a video called

‘It is OK to ask me to wash my hands’. Previous studies have demonstrated that the compliance of

hand hygiene among healthcare workers may also be influenced by the actions of colleagues and the

effort made by the organisation/unit to promote a positive culture (Boscart, Fernie, Lee, & Jaglal,

2012; Dixit, Hagtvedt, Reay, Ballermann, & Forgie, 2012; Erasmus et al., 2010).

There is also the possibility of the Hawthorne effect, especially in relation to hand hygiene

compliance assessments (Chen et al., 2013; Dhar et al., 2010). The Hawthorne effect refers to the

tendency of an individual who is being observed to alter their behaviour towards expected practise

(McCambridge, Witton, & Elbourne, 2014; Parsons, 1974). The present study minimised this

possibility by performing unobtrusive hand hygiene auditing at random times (Rosenthal, Alvarez-

Moreno, et al., 2012). The monthly hand hygiene compliance audits run by trained hospital staff were

held separately from the study compliance audits. These results (not presented) were similar to those

obtained by the researcher, demonstrating that measurement bias was minimised (Chen et al., 2013).

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A unique aspect of this study was the measuring of hand hygiene compliance by parents. Although

compliance reached above 60%, this result could not be compared to any benchmark of hand hygiene

compliance because there is none in a PICU setting (World Health Organization (WHO), 2009a). One

study found hand hygiene compliance amongst parents and family members in a Neonatal ICU to be

on average 71%. This was not considered an acceptable compliance rate by the Prevention Committee

(IPC) of the hospital (Chandonnet et al., 2017). These findings highlight that parents, as a target group

to enhance hand hygiene compliance in the prevention of hospital-associated infections (HAIs), need

a good standard of education for hand hygiene (Anthony et al., 2013; Chandonnet et al., 2017; World

Health Organization (WHO), 2009a).

Two elements of oral hygiene during auditing reported a compliance gap. These are: compliance with

12-hourly oral hygiene assessment, which was 84%; and frequency of age appropriate oral hygiene

practise compliance, which was 50%. Theoretically, the assessment of oral hygiene should be

followed with compliance with age-appropriate oral care practise (Bigham et al., 2009; Brierley et

al., 2012; Johnstone et al., 2010). In QCH, four-hourly oral hygiene is expected in mechanically

ventilated children. However, this oral hygiene compliance was consistent with a study by Bigham et

al. (2009), which observed the practise at a baseline of 60%. Other possible reasons that have an

impact on the quality of oral hygiene undertaken in ICU are:

(1) inadequate time

(2) prioritising of other tasks over oral hygiene

(3) perception that oral hygiene is unpleasant

(3) lack of knowledge of oral care for intubated patients (Allen Furr, Binkley, McCurren, & Carrico,

2004).

The ETT cuff pressure monitoring measured the compliance rate of maintaining cuff pressure within

limits set by the unit and results were found to be in line with the study by Bigham et al. (2009). The

cuff pressure was set to a minimum 10 cmH2O, and maximum 20 cmH2O by the study setting. This

is in line with the parameters used by Weiss et al. (2009) and Rosenthal, Alvarez-Moreno, et al.

(2012). This pressure is believed to be able to provide an adequate seal to avoid aspiration of

pathogenic secretions into the lower respiratory tract (Dave et al., 2011; Bhardwaj, 2013).

Full compliance of frequency of ETT suctioning was found. This result is expected, as the frequency

of ETT suctioning varies across patients and relies on clinical indicators (Morrow & Argent, 2008).

The Hawthorne effect could be one of the factors contributing to this result. Compliance of aseptic

non-touch technique for endotracheal suctioning, and the practise of draining the condensate

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ventilator circuit away from patients was 74% and 23% respectively. These findings may suggest

potential for contamination to occur which may in turn facilitate VAP occurrence (Coffin et al., 2008;

Kollef, 2004; Tolentino-DelosReyes et al., 2007). This discrepancy is likely to be related to practise

variations, although a sound knowledge of aseptic technique by nurses has been reported (Leong et

al., 2017). Full compliance was achieved for the practise of using single-use catheters during ETT

suctioning and connecting the ventilator circuits to a filtered test lung. Full compliance in these

elements may help minimise the risk of cross-infections (Tolentino-DelosReyes et al., 2007).

The compliance to HOB elevation was 86%. In this study, HOB was set at 15–30 degrees (Queensland

Children's Hospital Paediatric Intensive Care Unit, 2016), which is similar to a previous study, which

used a range of 20–30 degrees (Brierley et al., 2012). A compliance rate of 85% was also reported in

a study by Bigham et al. (2009), where the elevation was set at 30–45 degrees for paediatric patients.

More than 95% compliance was reported for ventilator circuit checks, measured by the change of

expiratory bacteria filter every 24 hours. This was higher than the 85% compliance rate reported in a

previous study (Bigham et al., 2009). The possible reason for the high compliance found in the present

study could be the requirement to change the filter every 24 hours either by the in-charge nurse or

respiratory therapist scheduled before 4.00pm every day. This preventative measure helps to

minimise bacterial contamination (Klompas, Branson, et al., 2014; Resar et al., 2014).

Full compliance for early commencement of enteral feeding within 24 hours of admission (in cases

with no contraindication) was reported during auditing. This compliance was anticipated because it

is routinely assessed after PICU admission and reviewed regularly thereafter during patient rounding

in this study setting.

Parental survey: ‘Speaking up for hand hygiene’

Response rate

VAP education was delivered to 30 parents during the data collection period. Each parent opted for

a hard copy of the survey as opposed to an online version. One parent was excluded due to a language

barrier. There were 11 losses to follow up. Of those, five patients were discharged home without the

parents returning the survey, two parents felt hesitant to continue the survey and decided not to

participate, two children died, and two children had a deteriorating condition while in treatment. A

total of 19 surveys was returned, constituting a 63.3% response rate.

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Demographic characteristics of parents and their child’s admission history

A total of 19 parents returned the survey, however some of them did not filled three demographic

characteristics. This was (i) education level of parents (2/19), (ii) history of child their being admitted

to PICU (1/19) and (iii) history of their child experiencing/receiving mechanical ventilation (1/19).

Majority of parents who participated in the survey were female 15 (78.9%). Most parents (12; 63.2%),

were 31 years old or above. Of the 17 parents who responded to the survey, there was an equal

proportion who had formal qualifications (nine; 52.9%), and those who did not (eight; 47.1%). Most

parents were not employed in the healthcare field (14; 73.7%). Of 18 parents, only two (11.1%)

reported that their child had a previous history of a PICU admission and 14 (77.8%) had no prior

experience of their child receiving mechanical ventilation. Eleven (57.9%) parents reported that they

had heard about VAP. Most of the parents preferred to perform hand hygiene using either hand gel

or by hand washing (13; 68.3%), while four (21.1%) used hand wash only, and two (10.5%) used

hand gel only.

Perceptions of parents on VAP education

Hand hygiene was perceived by parents as important in the prevention of infection in hospitals,

including VAP in PICU. All parents felt hand hygiene was important for nurses and other PICU staff

providing care to their child. Most parents agreed that nurses (18; 94.7%) and other PICU staff (17;

89.5%) wash their hands enough in PICU. Of 19 parents, 10 (52.6%) agreed that the pamphlet, ‘VAP:

How I Can Help my Child in PICU’ was easy to understand. Of the 19 parents, 10 (52.6%) disagreed

that the information in the pamphlet made them concerned and nine (47.4%) parents perceived that

the information was upsetting.

Parental perceptions on willingness to remind and to be reminded by nurses and other

PICU staff to perform hand hygiene

Most parents reported that they would be willing to remind nurses (13; 68.4%), and other PICU staff

(doctor, physiotherapist, dietitian, occupational therapist) (15; 78.9%) to perform hand hygiene when

necessary. Most parents (18; 94.7%) agreed that they were willing to be reminded of hand hygiene

by nurses. Parents agreed that the ‘Speaking up for hand hygiene’ initiative would increase hand

hygiene practises amongst nurses (15; 78.9%) and other PICU staff (14; 73.7%).

Reasons parents would be reluctant to prompt nursing staff regarding hand hygiene

Parents identified several reasons that would make them reluctant to prompt nursing staff regarding

hand hygiene. Eight (38.1%) responses from parents felt that it was not their place to remind the

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nurses to perform hand hygiene, with one parent (4.8%) in a free written response highlighting their

concern that if they remind the nurses, the attitude of nurses might change. Five (23.8%) responses

from parents noted that they worried that if they reminded nurses, it would affect the care of their

child and they did not want to interrupt nurses by reminding them to perform hand hygiene. Two

parents reported that they would be too embarrassed to remind the nurses (9.5%).

Reasons parents would be reluctant to remind other PICU staff regarding hand

hygiene

Parents provided several responses as to why they would be reluctant to remind other PICU staff of

hand hygiene. Ten (43.5%) responses indicated that they felt it was not their place to remind other

PICU staff to perform hand hygiene with one (4.3%) worried about changing the attitude of PICU

staff if parents elected to remind them of hand hygiene. Four (17.4%) responses respectively

represented parents feeling worried that if they reminded other PICU staff, it would affect the care of

their child, or that they did not want to interrupt other PICU staff by reminding them to perform hand

hygiene and would be too embarrassed to remind the other PICU staff.

Suggestions or comments to improve hand hygiene practise in the unit

Eight of the 19 parents made suggestions and comments to improve hand hygiene within the unit.

The majority of these suggestions focussed on clear communication to convey good hand hygiene

practise. Suggested communication included verbal reminders directly to the nurses and other PICU

staff before coming into contact with their child. They suggested that nurses and other PICU staff

should strictly enforce hand hygiene with parents and visitors. Parents also suggested that more effort

should be made by the unit to make parents feel comfortable to remind the staff to perform hand

hygiene. Visual reminders were also suggested, with examples such as signs with images of germs

and additional floor signs visible upon entry into a room in case wall signs are not seen.

Discussion of parental perceptions on ‘Speaking up for hand hygiene’

The survey response rate from parents was 63.3%. The parents’ response rate is quite similar to that

reported in other surveys involving family members, with response rates of 63.8% and 64.7% by Pan

et al. (2013) and Wu et al. (2013) respectively. However, these two studies were conducted across

multiple sites compared to a single hospital unit involved in the present study. Due to the time

constraints of having only three months for the survey (Phase 2), the invitation for the survey was

terminated although the target number of participants was not achieved, based on the initial sample

size calculation (78 parents). However, measures have been done to increase the response rate. For

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example, five parents were followed up when they were not returning the survey after discharged

home. In these cases, online version was offered, yet no response received. Two parents that their

children were discharged to ward also were followed up daily and arrangement with ward staff nurse

also done to collect the survey when they completed the survey. Despite that, they felt hesitant to

continue the survey.

Most participants were mothers, congruent with other studies, such as that by Buser, Fisher, Shea,

and Coffin (2013), who reported 80% of their participants as mothers. Parents used the combination

hand hygiene (hand gel and hand wash) in the PICU, which reflects the results of Ciofi degli Atti et

al. (2011). A small fraction of parents preferred hand wash over the use of an alcohol-based rub, a

finding consistent with another study involving general healthcare workers. This preference may be

influenced by a number of factors, including knowledge regarding the benefits of this method or other

factors preventing use, such as those with allergies (Karaaslan et al., 2014). This finding signals the

importance of making educational resources and hand hygiene resources (both alcohol-based rub and

soaps) available in intensive care units.

Parents perceived VAP education delivered through the pamphlet ‘VAP: How I Can Help my Child

in PICU’ as easy to understand. Education to promote hand hygiene among parents and patients

requires information to be presented in a way that enhances understanding. This includes a range of

resources and careful consideration with language and formatting that is suitable for the lay audience.

A similar approach is noted by Davis, Parand, Pinto, and Buetow (2015) and Chandonnet et al.

(2017); they used leaflets, information sheets, posters and videos to convey information. In this study,

it was found that the information in the pamphlet provided to parents was easy to understand given

the language used was simple and it was created with input from PICU staff (Australian Bureau of

Statistics, 2009). The pamphlet had been extensively revised by different panels during five validation

rounds before being printed and distributed to ensure the language level and content were appropriate

(see Chapter 4, Table 4.4).

Parents reported that the information about VAP in the pamphlet was important, but it did make them

feel concerned about hand hygiene. Factors which could explain this observation may include that

the parents are in a state of fear and ongoing stress, and hence their concern gravitates more towards

their child’s wellbeing/stability rather than the information related to hand hygiene (Bellissimo-

Rodrigues et al., 2016; Ciofi degli Atti et al., 2011; Uhl, Fisher, Docherty, & Brandon, 2013).

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Most parents agreed that hand hygiene is important in VAP prevention in PICU. This is in line with

the previous studies where Buser et al. (2013) found that the majority (78%) of parents perceived

hand hygiene as the most important practise needed to prevent hospital infection. Parents agreed that

hand hygiene of nurses and other PICU staff is important while providing care to their child and the

majority agreed that nurses and other PICU staff wash their hands sufficiently while caring for their

child in PICU. This result accords with the earlier study by Pan et al. (2013) which reported that

77.1% of healthcare workers wash their hands adequately according to hand hygiene standards.

Almost all parents in the present study (94.5%) were willing to be reminded by the nurses and other

PICU staff to perform hand hygiene when necessary, but only 68.4% (14/19) of parents were willing

to remind the nurses (14/19) and other PICU staff 78.9% (15/19) to perform hand hygiene. This

difference was also noted in another study by Wu et al. (2013) where 50.8% (425/836) and 48.9%

(410/839) of families were willing to remind nurses and doctors to perform hand hygiene respectively.

The majority of families agreed (96.5%) that they should help remind healthcare workers to perform

hand hygiene, but only 67.2% of them were actually willing to remind the healthcare workers (Pan et

al., 2013). The level of parents’ willingness to remind nurses to wash their hands could be influenced

by social barriers caused by the healthcare workers’ professional status (McGuckin, Storr, Longtin,

Allegranzi, & Pittet, 2011). This is also mirrored in the study by Kim et al. (2015), which found that

70% of families believed that it is not their role to remind healthcare workers to perform hand hygiene.

Parents (78.9% and 73.7%) agreed that ‘Speaking up for hand hygiene’ initiative would increase hand

hygiene practise among nurses and other PICU staff respectively. Despite this, many of the parents

who reported this also said that they would be reluctant to remind nurses and other PICU staff to

perform hand hygiene because they feel it is not their position to question nurses and other PICU

staff. This finding was similar to several studies where parents/families felt uncomfortable about

reminding doctors and nurses to perform hand hygiene, due to the perceived authority of the medical

staff (Ciofi degli Atti et al., 2011; Dixit et al., 2012; Kim et al., 2015; Longtin, Sax, Allegranzi,

Hugonnet, & Pittet, 2009). It seems that there is an issue of power imbalance, ineffective

communication, professional expectations, and relationship problems with healthcare workers that

prevents parents voicing their concerns regarding their child to healthcare workers (Bellissimo-

Rodrigues et al., 2016; Corlett & Twycross, 2006).

Parents’ suggestions to improve hand hygiene practise in PICU overwhelmingly focused on the need

for clearer communication, with suggestions that the unit should increase efforts to help them feel

more able to remind staff to perform hand hygiene. This was consistent with the previous systematic

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review by Bellissimo-Rodrigues et al. (2016) and Buser et al. (2013), and is also in line with patient-

centred, family-centred care (Kuo et al., 2012; Muething et al., 2012; Rosen, Stenger, Bochkoris,

Hannon, & Kwoh, 2009). Parents/family members are concerned with how healthcare workers might

treat them or their loved one if they were to voice a safety issue with healthcare workers (Coyne et

al., 2013; Smith et al., 2015). Parents agreed with suggestions to include more visual reminders such

as larger graphics to indicate the risks associated with poor hand hygiene in the PICU. The use of a

visual reminder is one of the strategies to promote hand hygiene among patients to healthcare workers

that may also be applicable to parents (Fitzpatrick et al., 2011; Pittet et al., 2011).

Nursing staff survey

Response rate

The survey was available online and self-administered to 150 nurses in PICU during the data

collection period. Twenty-four nurses responded via the online version and 10 nurses responded via

hard copy, resulting in 34 nurse participants completing the survey. The total response rate was

22.6%.

Demographic characteristics of nursing staff participants

All survey participants were female nurses with the median PICU experience of 5.3 years. The

participants routinely used a combination of both hand gel and hand washing in PICU (31; 91.2%).

Nurses’ perceptions of their willingness to remind and be reminded by parents and

other PICU staff to perform hand hygiene

Most nurses agreed they would remind parents and other PICU staff to perform hand hygiene if

necessary and they were willing to be reminded by parents if they themselves did not perform hand

hygiene (30; 88.2%). Only two (5.9%) nurses disagreed concerning reminders if they came from other

PICU staff. The majority of nurses agreed that ‘Speaking up for hand hygiene’ would increase hand

hygiene compliance amongst parents (31; 91.2%) and other PICU staff (29; 85.3%).

Reasons nurses would be reluctant to prompt parents regarding hand hygiene

Thirty responses were recorded for reasons as to why nurses would be reluctant to remind parents to

perform hand hygiene in PICU. More than half of the respondents (20; 66.7%) provided a response

in the ‘other reasons’ free response option, rather than agreeing with one of three fixed responses,

and identified being concerned about parents’ attributes and behaviour as a contributing factor. This

included potential instances when parents are distressed (e.g. emotionally disturbed or aggressive)

133

and in highly sensitive moments, such as after receiving distressing information. Nurses were also

reluctant to remind parents if the parents were known to have been confronting, defensive or

unwilling to engage in the past, and the nurses feared causing offence. In addition, 5 (16.6%)

respondents noted that they simply did not want to interrupt the parents with their child 3 (10.0%)

nurses felt that it would be too embarrassing to remind parents to perform hand hygiene, and 4

(13.3%) felt that it was not their place to question parents.

Reasons nurses would be reluctant to prompt other PICU staff regarding hand hygiene

Nurses provided 28 responses, 13 (46.4%) of which provided the ‘other reason’ free response. These

showed that nurses were reluctant to remind PICU staff about hand hygiene for reasons such as

finding staff unapproachable, irritated or aggressive, and therefore they perceived a lack of

willingness from them to accept reminders. One response highlighted the issue of medical hierarchies

and seniority in the unit; junior staff felt unable to remind seniors, and some felt that senior staff were

not leading by example. There were also responses that suggested nurses did not remind other PICU

staff because they had missed the opportunity at the time and forgot to do so afterwards. Furthermore,

9 (32.1%) responses found that nurses would be too embarrassed to remind other PICU staff to

perform hand hygiene. Nurses also felt that they did not want to interrupt other staff and felt that it

was not their place to question other staff (3; 10.7%).

Suggestions or comments to improve hand hygiene practise in the unit

Fourteen suggestions or comments were received from 34 nurses to improve hand hygiene practise

in PICU. Overall, there was a perceived need for PICU staff to maintain active involvement in hand

hygiene promotion. More feedback from auditing was also welcomed. Nurses highlighted the

importance of being proactive and vigilant with hand hygiene education not only for patient safety

but also staff and visitors’ protection. Other suggestions were to reintroduce mini hand gel bottles

that could clip to nurses’ uniforms for easy access, and to offer rewards for consistent good practise

at a unit level. Continuity of existing hand hygiene promotion in PICU is supported, with suggestions

to include more reminders, such as large graphics to educate those in the unit about the spread of

disease caused by a lack of hand hygiene.

Discussion of nurses’ perceptions on ‘Speaking up for hand hygiene’

The nurses’ response rate was lower compared to the previous study by Kim et al. (2015), where the

response rate was 84%. In the nurses’ survey, more than 90% agreed that ‘Speaking up for hand

hygiene’ would increase hand hygiene among parents and more than 80% among other PICU staff.

134

Eighty-eight percent of nurses surveyed reported a positive perception of the parents’ role in their

child’s health, and more than 90% were willing to be reminded to perform hand hygiene when

necessary. This is contradicted by a study by Kim et al. (2015) where only 31% of nurses reported

that they were willing to be reminded by parents to perform hand hygiene, and 26% of physicians

supported this view. A previous study reported that healthcare workers perceived that a reminder

from parents was less important to their hand hygiene adherence (Ciofi degli Atti et al., 2011).

Possible factors that would contribute to better perception of nurses towards reminders of hand

hygiene from parents and other PICU staff include increased concern of the unit itself regarding hand

hygiene and the willingness to increase hand hygiene compliance (Boscart et al., 2012). The Patient

Safety and Quality Unit in the study setting published a video promoting ‘Speaking up for hand

hygiene’ and added colourful visual hand hygiene reminders during our data collection period. The

video includes PICU staff holding a poster with the message, ‘It is OK to ask me to wash my hands’.

The main reason for nurses’ reluctance to remind parents to perform hand hygiene was due to the

concern about the parents’ attitudes and behaviour (such as parents being in a state of emotional

distress). It may not be appropriate to ask parents to perform hand hygiene in these circumstances.

This is because nurses are more focused on the immediate consequences of families’ safety, especially

parental emotional status, than on reminding families to perform hand hygiene (Boscart et al., 2012).

The findings of these surveys reveal that nurses were reluctant to remind other PICU staff to perform

hand hygiene if they felt that their working colleagues were unapproachable, moody, or not willing

to accept reminders. This was also related to their perception of the attitudes and behaviours of other

PICU staff (Okuyama et al., 2014). Some felt uncomfortable reminding their colleagues because of

the staff hierarchy; being a junior often prevented them from feeling comfortable advising senior

colleagues (Samuel et al., 2012). One driving factor in hand hygiene concerns maintaining staff

wellbeing — for example, if an infection risk exists (e.g. tuberculosis) (Bellissimo-Rodrigues et al.,

2014). Another factor is motivation, which includes the acuity of patient care, social influences, self-

protection, and the use of cues (Okuyama et al., 2014; Smiddy et al., 2015).

From nurses’ perspectives, suggestions to increase hand hygiene practise were related to the active

involvement of PICU and organisational efforts. These results corroborate the findings of a previous

study that utilised a novel multi-modal strategy of education, performance feedback and the use of an

easy-to-use pocket hand rub dispenser which resulted in improved compliance among nurses,

respiratory therapists and medical personnel (Koff et al., 2011). The use of a similar device attached

135

to the scrubs or gown improved hand hygiene among anaesthetists in operating theatres (Koff et al.,

2009). Efforts initiated by the unit were also found to be an innovative approach to increase adherence

to hand hygiene among healthcare workers; the introduction of badges worn by individuals which

prompted staff to wash their hands resulted in a marked increase in hand hygiene (Boscart et al., 2008;

Levchenko, Hufton, Boscart, & Fernie, 2010). Interestingly, offering rewards to those who comply

with hand hygiene has been found to work exceedingly well. Talbot et al. (2013) enacted this

approach using a financial incentive, and their assessment of healthcare workers’ hand hygiene

compliance improved to more than 95%.

Summary

This chapter has presented the results of Phase 2: VAP compliance auditing and parental and nursing

staff surveys. The findings demonstrated acceptable to high compliance with VAP preventative

strategies was being achieved through VAP education with feedback by both PICU staff and parents.

Both parents and nurses were motivated by the ‘Speaking up for hand hygiene’ initiative to improve

hand hygiene practise in the unit, but a gap persists in the willingness to remind each other to perform

hand hygiene. The findings from the parental and nurses’ surveys have challenged existing evidence,

showing parents and nurses having more positive perceptions about being reminded by each other to

perform hand hygiene than has been previously shown. However, caution should be exercised in

drawing firm conclusions based on these findings due to the small sample sizes. Associations between

these two groups were not examined. Furthermore, the perception of other PICU staff towards parents

and nurses on ‘Speaking up for hand hygiene’ was not examined and remains an area with potential

to improve the study.

Chapter 7 presents the results and discussion for Phase 3: Prospective study.

136

Results and discussion Phase 3: Prospective Study

Introduction

This chapter presents the results and discussion of the prospective study and includes a comparison

with the retrospective study results presented in Chapter 5. The aim of the six-month prospective

study (from the 12th of June until the 12th of December 2017) was to evaluate the incidence of

VAP/VAE in the PICU of Queensland Children’s Hospital (QCH) following the implementation of

the VAP education package and compliance auditing. This chapter addresses the following three

research questions:

1. What was the incidence of VAP and VAE in QCH PICU as defined by the PNU1/VAP and

the VAE surveillance tool?

2. What was the compliance of VAP preventative strategies and potential risk factors for

VAP/VAE in QCH PICU?

3. Was there any improvement in VAP/VAE incidence and VAP preventative strategies

compliance after implementation of the VAP education and compliance preventative

strategies auditing with feedbacks?

The methodology used to produce this chapter’s results is described in Chapter 4, Section 4.3.3.

Results

During the six months of data collection for this study there were 120 episodes of mechanical

ventilation meeting the inclusion criteria (see Chapter 4, Section 4.4.3.1) in 110 patients with 115

admissions. The PNU1/VAP and the VAE surveillance tools were applied to the 120 episodes of

mechanical ventilation. The total mechanical ventilator days as defined by the CDC calculation (end

of ventilation) was 922 days across the 120 episodes recorded. The total number of end points until

patients were no longer at risk of VAP/VAE was 860.96 and 838.43 ventilator days respectively.

Baseline demographic characteristics

Demographic characteristics of patient based on PICU admission

Table 7.1 outlines the demographic characteristics of 110 patients from 115 admissions. More than

60% of the patients were male and aged (<one year) with the median weight of six kilograms. The

PICU admissions in this prospective study mostly came from direct admission (44.3%). The majority

of patients (64%) admitted to PICU were categorised under medical discipline for PICU diagnosis

137

category. Twenty-one percent were associated with cardiovascular and respiratory respectively. The

median of paediatric index mortality 3 (PIMS 3) score was at 4.92. These indicate that the overall

probability of death in this cohort was 4.92%.

The demographic characteristics of prospective and retrospective studies were homogenous except

for underlying disease for PICU admission (p=0.035) and the PIMS3 score (p<0.0001). These suggest

that underlying disease responsible for PICU admission in the prospective study were different in

proportion and the prospective cohort had a higher risk of death compared to those in the retrospective

study. These two sets of data were not comparable.

Table 7.1: Demographic characteristics comparison of patients in prospective study versus

retrospective study on PICU admission (n=115; n= 253) respectively

Variables Prospective

n (%)

Retrospective

n (%)

p-value

Gender Male 71 (61.7) 145 (57.3) 0.42

Female 44 (38.3)

108 (42.7)

Age <1 year 70 (60.9) 158 (62.5) 0.44

1- 12 year 34 (29.6) 80 (31.6)

13 and above 11 (9.6) 15 (5.9)

Weight (kg, median

(IQR))

5.9 (3.5- 16.0)

5.8 (3.6- 15.0)

0.71

PICU source of

admission

0.22

OT/ Recovery 40 (34.8) 70 (27.7)

Emergency Department 9 (7.8) 37 (14.6)

Ward (other inpatient

area)

15 (13.1) 37 (14.6)

Direct admission 51 (44.3) 109 (43.1)

PICU Diagnosis

Category

0.51

Medical 71 (61.7) 163 (64.4)

Surgical 38 (33.0) 71 (28.1)

Trauma 6 (5.2) 19 (7.5)

Underlying disease

Trauma/ Injury 6 (5.2) 29 (11.5) 0.035

Cardiovascular 30 (26.1) 94 (37.2)

Neurological 14 (12.2) 21 (8.3)

Respiratory 30 (26.1) 50 (19.8)

Gastrointestinal 8 (7.0) 10 (4.0)

Miscellaneous 27 (23.5) 29 (11.5)

PIMS 3 (median, IQR) 0.0001

PIMS3 risk of death 4.92 (0.49-

3.44)

1.90 (0.70-

5.50)

OT= Operation Theatre; PIMS= Paediatric Index of Mortality Score; IQR= Interquartile range

138

Outcome variables according to mechanical ventilation episodes at prospective study

Table 7.2 shows the outcome variables according to mechanical ventilation episodes. The median

duration of mechanical ventilation was 4.9 days (IQR: 2.9 - 8.0), median length of PICU stay 7.7

days (IQR: 5.0 - 14.7), and median length of stay of hospital was 20.6 days (IQR: 10.3 - 52.4). There

were 12 patients still in PICU, and five deaths reported when data collection ended on the 12 th

December 2017. Outcome variables were homogenous between prospective and retrospective study

(p>0.05).

Table 7.2: Outcome variables according to mechanical ventilation episodes prospective versus

retrospective study (n=120; n= 262)

Variables Prospective

n (%)

Retrospective

n (%)

p-value

Duration of

mechanical

ventilation

(days, median

(IQR))

4.9 (2.9- 8.0) 4.2 (2.8- 7.5) 0.097

Length of

PICU stay

(days, median

(IQR))

7.7 (5.0- 14.7) 7.6 (4.8- 13.5) 0.32

Length of

hospital stay

(days, median

(IQR))

20.6 (10.3- 52.4) 18.9 (9.8- 34.4) 0.32

PICU

outcome

0.25

Discharge to

ward/home

99 (82.5) 227

Died 5 (4.2) 26

Transferred to

another ICU

(includes

Neonatal ICU)

4 (3.3) 9

Still in ICU 12 (10.0) -

Mortality

(*n=110; n=

234)

0.59

Yes 5 (4.6) 25

No 105 (95.4) 209

* patient level

139

Incidence of VAP and VAE at prospective study

In the prospective study, five episodes of VAP (4.2%) (five patients) and six episodes of VAE (5.0%)

(six patients) were identified in the 120 cases of mechanical ventilation studied (110 patients) using

the PNU1/VAP and the VAE surveillance tools respectively.

The incidence rates for VAP and VAE are given in Table 7.3. As can be seen, there was a reduction

of the VAP rate by 3.9 per 1000 ventilator days (end of ventilation) and 4.4 per 1000 ventilator days

(until the patients were no longer at risk). The rate of VAE dropped by 2.8 per 1000 ventilator days

(end of ventilation) and 3.2 per 1000 ventilator days (until the patients were no longer at risk)

respectively. The different VAP and VAE rates between two phases was not significant (p>0.05).

Table 7.3: Comparison of VAP and VAE incidence between retrospective and prospective studies

measured on end of ventilation and until the patient is no longer at risk

Incidence Retrospective

study

Prospective study Difference/Reduction p-value

(95% CI)

VAP

1) End of

ventilation

9.3 per 1000

ventilator days

5.4 per 1000

ventilator days

3.9 per 1000 ventilator

days

0.31 (-3.61-

11.41)

2) Until the

patient is no

longer at risk

10.2 per 1000

ventilator days

5.8 per 1000

ventilator days


days

0.27 (-3.44-

12.24)

VAE

1) End of

ventilation

9.3 per 1000

ventilator days

6.5 per 1000

ventilator days


days

0.48 (-4.99-

10.59)

2) Until the

patient is no

longer at risk

10.4 per 1000

ventilator days

7.2 per 1000

ventilator days


days

0.45 (-5.02-

11.42)

Of six VAE cases, one was categorised as IVAC, and no mechanical ventilation episode/patient met

the PVAP tier (Table 7.4). One patient met both surveillance tools (VAC as per VAE surveillance

tool and VAP as per PNU1/VAP).

Parallel to the retrospective study, one patient on the same mechanical ventilation episode was

identified as both VAP and VAE, but according to VAE surveillance tool it was further classified as

VAC instead of VAP defined by PNU1/VAP in the prospective study. One patient was further

identified as IVAC instead of VAP defined by PNU1/VAP in the retrospective study.

140

Table 7.4: VAP and VAE counts (tiers) according to mechanical ventilation episode prospective and

retrospective studies

Variable Prospective

n=120

Retrospective

n=262

VAP

Yes 5 16

VAE

VAC 6 16

IVAC 1 4

PVAP 0 3

Discussion

Discussion of demographic and outcome variables of the prospective study

It was found that male patients dominated PICU admissions in the prospective study. Patients aged

less than one year constituted more than half of PICU admissions. In most paediatric VAP research,

this distribution is similar; e.g. Gautam et al. (2012) prospective study undertaken in an Australian

PICU. The PICU and hospital length of stay were similar to those of other paediatric studies, which

report between five and ten days (Bigham et al., 2009; Elward et al., 2002; Gautam et al., 2012; Gupta

et al., 2015; Srinivasan et al., 2009).

Most patient admissions to PICU in the prospective study were by direct admission (44.3%) or via

operation theatre/recovery (34.8%), which is congruent with data from previous years (2014–2016)

reported by the Australian and New Zealand Intensive Care Society, (2017). The PIMS3 score was

4.92%, which was higher than that of the retrospective data; however, this result may not reliably

reflect the final PIMS3 score because this score is only available after patients have been

discharged/died, and some of the patients in this study were still in the PICU/hospital when data

collection ended.

Therefore, the demographic and outcome variables were homogenous between prospective and

retrospective study except for PIMS3. This suggests that the distribution of patients’ demographic

characteristics in QCH’s PICU were comparable throughout the year, allowing meaningful statistical

comparison to assess possible relationships concerning VAP/VAE development.

Discussion of incidence of VAP and VAE at prospective study

VAP rates were measured at 5.4 per 1000 ventilator days and VAE rates were 6.5 per 1000 ventilator

days during the six-month prospective study. These results appear relatively high compared to a

previous study by Narayanan et al. (2016); their six-month prospective study found rates of 2.4 (VAP)

141

and 4.2 (VAE) per 1000 ventilator days. To date, Narayanan’s study has been the only prospective

study to follow paediatric patients for a period of six months, evaluating the application of new VAE

surveillance tools and comparing them to existing PNU1/VAP surveillance tools.

The findings of the present study should be cautiously compared to Narayanan’s study as no

comparable Australian study has been undertaken. One Australian study by Gautam et al. (2012)

evaluated only VAP rates in a one-year prospective study, finding a VAP rate of 7.02 per 1000

ventilator days. The present study found lower VAP rates compared to a recent six-month prospective

study in 16 PICUs in the USA, which found 7.1 per 1000 ventilator days (Gupta et al., 2014). These

differences may be due to the demographic variations in respective PICUs, institutional preventative

strategies, and varying treatment options (Awasthi et al., 2013; Bassant Salah, Sally, & Seham Awad

El, 2017; Srinivasan et al., 2009).

There was a reduction of VAP and VAE in comparison to Phase 1: Retrospective study. The incidence

rate of VAP was reduced by 3.9 per 1000 ventilator days and the VAE incidence rate to 2.8 per 1000

ventilator days. These reductions are within the expected range seen in other published VAP studies

assessing the changes following implementation of VAP education, compliance auditing with

feedback, and VAP bundle implementation in PICUs (Bigham et al., 2009; Brierley et al., 2012;

Casado et al., 2011; Gupta et al., 2014; Rosenthal, Alvarez-Moreno, et al., 2012). These reductions

did not reach statistical significance; however, similar findings were reported in Gupta et al. (2014),

where the incidence of VAP was reduced by 5.6 pre to post implementation of VAP education (20.2

versus 14.6 per 1000 ventilator days respectively) with p=0.21.

Before this present study was undertaken, there had been no specific paediatric study undertaken to

prospectively evaluate VAE rates before and after education, compliance auditing and feedback. The

reduction rate of VAE found in this study was within the ranges found by Cocoros et al. (2016) in

their multi-centred paediatric retrospective study (3.3 to 4.6 per 1000 ventilator days), but they did

not assess the VAE rate after any interventions.

A possible explanation for the reduction in VAP/VAE rates is the ability for daily surveillance to

detect early changes due to nosocomial infections (Ford-Jones et al., 1989). Another possible reason

behind this reduction could be the positive improvement derived from VAP education, compliance

auditing and feedback, as well as other quality improvement activities commenced concurrently in

the study setting (see Chapter 4, Section 4.4). Despite statistical insignificance, clinically, this study

142

suggests a positive influence of VAP education and compliance auditing with feedback undertaken

in unit. The relationship between preventative strategies and the reduction of VAP rates has been

previously seen in PICUs where similar approaches have been implemented (Bigham et al., 2009;

Brierley et al., 2012; De Cristofano et al., 2016; Gupta et al., 2014; Obeid et al., 2014).

Overall, in this study the VAE rates were the same or higher than VAP rates when the two surveillance

tools were applied in both the retrospective and prospective studies. In the retrospective and

prospective studies one patient met both VAP and VAE (using both surveillance tools respectively)

but appeared different in terms of further classification based on VAE tier; IVAC and VAC versus

VAP using PNU1/VAP. This suggested that the new VAE tool described complications other than

VAP or the criteria in respective tiers (VAC, IVAC and PVAP) are strict enough to distinguish

whether or not there is VAP in mechanically ventilated children. These results further support the use

of the VAE surveillance tool in extending beyond VAP identification as seen in previous adult studies

and a few paediatric studies (Cirulis et al., 2016; Klompas, 2013b; Lutmer & Brilli, 2016; Magill et

al., 2014).

Potential risk factors according to mechanical ventilation episodes

Sixty three percent of mechanical ventilation episodes were a single episode of intubation. Some

patients in this cohort were administered paralytic agents (31.7%) and gastrointestinal (GI)

prophylaxis (61.7%). Just over half (53.8%) of the patients received mechanical ventilation via nasal

endotracheal tubes (ETT), and most (74.2%) received light sedation during mechanical ventilation.

All patients had a nasogastric tube in-situ. The majority were intubated with a cuffed ETT (96.7%).

Only 43.3% of patients in this cohort received steroids while 57.5% received blood products at some

time during mechanical ventilation.

No data were collected for ETT cuffed tube, steroid prescription or blood transfusion in the

retrospective study. A homogeneity test for applicable risk factors between the prospective and

retrospective studies revealed that these risk factors were not comparable to each other (p<0.05)

(Table 7.5).

143

Table 7.5: Potential risk factors according to mechanical ventilation episode (n= 120) in prospective

study, compared to retrospective study (n= 262)

Risk Factors Prospective

n (%)

Retrospective

n (%)

p-value

Reintubation 0.033

Yes 44 (36.7) 68 (26.0)

No 76 (63.3) 194 (74.0)

Paralytic agent 0.030

Yes 38 (31.7) 56 (21.4)

No 82 (68.3) 206 (78.6)

GI prophylaxis 0.006

Yes 74 (61.7) 122 (46.6)

No 46 (38.3) 140 (53.4)

Nasogastric presence n/a

Yes 120 (100) 259 (98.9)

No 0 (0) 3 (1.1)

Routes of intubation 0.038

Nasal 64 (53.4) 169 (64.5)

Oral 56 (46.6) 93 (35.5)

Sedation level

Deep sedation 31 (25.8) 15 (5.7) 0.0001

Light sedation 89 (74.2)

247 (94.3)

ETT types Cuffed 116 (96.7) - n/a

Un-cuffed 4 (3.3)

Steroid prescriptions Yes 52 (43.3) - n/a

No 68 (56.7)

Blood transfusion Yes 69 (57.5) - n/a

No 51 (42.5)

ETT=Endotracheal tube; n/a=not applicable

Compliance of preventative strategies of VAP in the prospective study

Table 7.6 shows the compliance rates for VAP preventative strategies implemented in the prospective

study. The overall compliance to VAP preventative strategies in this phase was 90.9%. Hand hygiene

compliance in the prospective study was sustained within the Australian Hand Hygiene Initiative

benchmark and congruent to the retrospective study. Likewise, in the retrospective study, ETT

suctioning achieved full compliance.

Oral hygiene was performed regularly, averaging five times/day; this was close to the unit’s guideline

(six times/day), achieving a compliance rate of 88.3%. In addition, the majority of PICU staff adhered

to 12-hourly oral health assessments (94.2%) and adhered to oral hygiene based on age-appropriate

factors stated in the PICU guideline (65.0%). The median frequency for ETT cuff pressure assessment

144

was 2.5 times/day which achieved the recommended compliance of twice per day. Nurses

demonstrated 90.0% adherence to 12-hourly cuff pressure checks and consistently maintained

pressure within the range limits set by the unit.

Early commencement of enteral feeding within 24 hours of PICU admission achieved full

compliance. This study revealed that 65.0% of patients with no contraindication had received enteral

feeding within 24 hours of admission, while the remaining 35.0% had reasonable clinical indications

which prevented them from receiving feeding.

Overall, the compliance rate for VAP preventative strategies in the prospective study showed an

increase of 1.9% from the retrospective study (89.0%). Hand hygiene compliance was maintained

within national benchmarks in both phases of the study. Descriptively, other individual preventative

strategies were recorded as having increases in compliance.

145

Table 7.6: Comparison of VAP compliance preventative strategy performance with PICU standard/National standard

VAP Preventative Strategies Mean (SD)

n (%) PICU/ national standard % compliance in comparison

to PICU /national standard

Hand hygiene 84.1% (3.7) > 80% ≥100

Oral hygiene 5.3 (1.1) 6 times/24 hours 88.3

Adhered to 12-hourly oral

health assessment

Yes 113 (94.2) 2 times/24 hours 94.2

No 7 (5.8)

Adhered to age-appropriate oral

hygiene guideline

Yes 78 (65.0) i) Child under 6 months old without teeth

Moistening (4 hourly or 6 times)

Pink swab with sterile water (0800 & 2000; 1200 & 2400;

0400 & 1600)

ii) Above 6 months with teeth

Tooth brush (2 times) - Toothpaste (0800 & 2000)

Mouth rinse (2 times) - Chlorhexidine (1200 & 2400)

Moistening (2 times) - Pink swab with sterile water (0400

& 1600)

65.0

No 42 (35.0)

ETT suctioning 7.0 (2.2) 4 times/ 24 hours ≥100

HOB elevation (median (IQR)) 22.8 (21.3-

23.8)

24 times/24 hours 95.0

Cuff pressure checks (median

(IQR)) (*n=114)

2.5

(2.0 -3.7)

2 times/24 hours ≥100

Adhered to 12 hourly cuff

pressure checks

Yes

102 (89.5)

89.5

No 12 (10.5)

146

Maintained cuff pressure

readings within the limit

Yes 108 (94.7) Min 10cmH2O to max 20cmH2O 94.7

No 6 (5.3)

Ventilator circuits checks 18.7 (5.3) 24 times/24 hours 77.9

Enteral feeding commencement

within 24 hours of PICU

admission

Yes 78 (65.0) Started within 24 hours of admission if not contraindicated 100

No 42 (35.0)

(contra-

indicated)

SD=Standard deviation; IQR= Interquartile range

147

Compliance of VAP preventative strategies: Retrospective versus prospective studies

The overall compliance to VAP preventative strategies in the prospective study increased from 89.0%

to 90.9%. As shown in Figure 7.1, the univariate analyses revealed the difference between

retrospective vs. prospective data in relation to the frequency of performance for oral hygiene, HOB

elevation, ETT cuff pressure checks, and ventilator circuit checks (p<0.05). Early enteral feeding is

presented in the figure but is not comparable to the retrospective study because it was not compared.

Figure 7:1: Comparison of individual VAP preventative strategy compliance — retrospective versus

prospective studies; p-values given where change is statistically significant.

Discussion of VAP preventative strategies compliance — retrospective versus

prospective studies

The increment of overall compliance for VAP preventative strategies as found in the prospective

study versus the retrospective study mimics the findings of several other VAP studies (Al-Thaqafy,

El-Saed, Arabi, & Balkhy, 2014; Babcock et al., 2004; Bigham et al., 2009; Bouadma, Mourvillier,

Deiler, Le Corre, et al., 2010; Brierley et al., 2012; Lawrence & Fulbrook, 2012). Interestingly,

differences between individual VAP preventative strategies reported in the retrospective versus the

prospective study were statistically significant (oral hygiene, HOB elevation, cuff pressure and

ventilator checks). The statistically significant compliance improvement between prospective and

retrospective study found in this study, however, may not strongly suggest improvement at practise

100

81.6

10091.6 90

70.8

100

88.3

10095

100

77.9

100

0

20

40

60

80

100

120

Hand hygiene Oral hygiene

(p= 0.009)

ETT

suctioning

HOB

elevation (p=

0.014)

Cuff pressure

checks (p=

0.001)

Ventilator

circuits

checks (p=

0.025)

Early enteral

feeding

% o

f co

mp

lian

ce


Retrospective Prospective

148

level. This may be due to challenges in sustaining compliance in behavioural change (Bigham et al.,

2009; Bouadma, Mourvillier, Deiler, Le Corre, et al., 2010). For example, a recent study by Belela-

Anacleto, Kusahara, Peterlini, and Pedreira (2019) revealed that social pressure of PICU staff

influenced the intention to perform hand hygiene. Minor improvement in hand hygiene compliance

was reported after infrastructure, educational and performance feedback interventions were

implemented.

The results of this study may be explained by several factors; updated VAP education and compliance

auditing with feedback as undertaken may have resulted in compliance improvement. Updated VAP

preventative strategies were made available in the TEACHQ platform from August 2016. During the

compliance auditing, reinforcement for PICU staff to visit the online module was emphasised and

staff were encouraged to view the displayed posters on VAP bundles. These served as a reminder to

PICU staff to practise and maintain compliance with VAP preventative strategies (Borgert et al.,

2015; Flodgren et al., 2013; Hamishehkar et al., 2014; Jansson et al., 2013). The differences may also

have been associated with active compliance auditing and feedback which were concurrently

delivered during and after compliance auditing. Many studies have shown that compliance

enforcement coupled with feedback are key strategies to minimising non-compliance with hospital

guidelines (Helder et al., 2010; Klompas, Branson, et al., 2014; Kollef, 2011; Rosenthal, Guzman,

Pezzotto, & Crnich, 2003) .

Hand hygiene and ETT suctioning remained at full compliance rates in the prospective study, likely

due to ongoing and routine hand hygiene compliance auditing by the hospital staff. This strategy may

encourage long-term compliance, as demonstrated across a number of studies (Bouadma, Mourvillier,

Deiler, Derennes, et al., 2010; Bouadma, Mourvillier, Deiler, Le Corre, et al., 2010; Rosenthal,

Guzman, & Safdar, 2005). With ETT suctioning, the rate of compliance may be due to the nature of

the procedure itself in which the nurse assesses the clinical indications prior to performing it, and this

likely serves as a reminder to perform the preventative strategy (Davies et al., 2011). Enteral feeding

commencement had 100% compliance. This result is to be expected, as in this study setting it is

assessed on admission and at regular intervals during patient rounding thereafter (Bouadma,

Mourvillier, Deiler, Le Corre, et al., 2010).

Univariate analysis

Univariate analyses were conducted to assess associations between possible explanatory variables

and the outcome of either VAP or VAE in the six-month prospective study. A p-value was significant

at ≤0.05.

149

Association of demographic characteristics with VAP and VAE in the prospective study

Univariate analyses for the demographics revealed that none were associated with the development

of VAP and VAE (p-value >0.05; Table 7.7). These findings were consistent with the dataset of the

retrospective study.

Table 7.7: Univariate analysis for association of demographic characteristics with VAP and VAE

(n=120)

Variables VAP p-

value

VAE p-

value

Yes No Yes No

Gender Male 2 (40.0%) 73

(63.5%)

0.36 4 (66.7%) 71 (62.3%) 1.00

Female 3 (60.0%) 42

(36.5%)

2 (33.3%) 43 (37.7%)

Age <1 year 2 (40.0%) 72

(62.6%)

0.28 1 (16.7%) 73 (64.0%) 0.062

1- 12 year 3 (60.0%) 32

(27.8%)

4 (66.7%) 31 (27.2%)

13 and above 0 (0.0%) 11 (9.6%)

1 (16.7%) 10 (8.8%)

Weight 15.8 (5.2 -

29.0)

5.7 (3.5-

15.0)

0.29 23.1 (7.6-

48.5)

5.5 (3.5-

15.2)

0.084

PICU

Diagnosis

Category

Medical 4 (80.0%) 69

(60.0%)

0.65 12 (75.0%) 160

(65.0%)

0.21

Surgical 1 (20.0%) 46

(40.0%)

4 (66.7%) 43 (37.7%)

PICU

source of

admission

OT/ Recovery 1 (20.0%) 42

(36.5%)

0.27 4 (66.7%) 39 (34.2%) 0.24

Emergency Department 0 (0.0%) 9 (7.8%) 1 (16.7%) 8 (7.0%)

Ward (other inpatient

area)/other

ICU/Neonatal ICU-same

hospital

2 (40.0%) 13

(11.3%)

0 (0.0%) 15(13.2%)

Direct admission 2 (40.0%) 51

(44.3%)

1 (16.7%) 52(42.6%)

Underlying

disease

Cardiovascular 0 (0.0%) 33

(28.7%)

0.36 0 (0.0%) 33(28.7%) 0.20

Respiratory 2 (40.0%) 29

(25.2%)

3 (50.0%) 28(24.6%)

Others 3 (60.0%) 53

(46.1%)

3 (50.0%) 53(46.5%)

PIMS3

score

PIMS3 risk for death 1.42(0.66-

28.14)

1.71(0.51-

3.44)

0.81 0.95(0.33-

2.58)

1.71 (0.53-

3.59)

0.25

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Association of patient outcome characteristics with VAP and VAE

Table 7.8 shows that duration of mechanical ventilation and length of PICU are associated with VAP

and VAE occurrences (p<0.05). This was also found in the retrospective study, but not for the length

of hospital stay (p>0.05).

Table 7.8: Univariate analysis for association of outcome characteristics with VAP and VAE (n=120)

Variables VAP p-

value

VAE p-

value

Yes No Yes No

PICU

outcomes

Discharge

ward/home &

Trans to

another

ICU/Neonatal

ICU

4(80.0%) 96 (83.5%) 0.65 5(83.3%) 95(83.3%) 0.45

Died in ICU 0 (0.0%) 8 (7.0%) 1 (16.7%) 7 (6.1%)

Still in ICU 1 (20.0%) 11 (9.6%) 0 (0.0%) 12 (10.5%)

Mortality

Died

0 (0.0%)

8 (7.0%)

1.00

5 (83.3%)

107 (93.9%)

0.35

Not died 5 (100.0%) 107

(93.0%)

1 (16.7%) 7(6.1%)

Duration of

mechanical

ventilation

(days, median

(IQR))

10.5 (8.8-

6.4)

4.8 (2.9-

7.2)

0.001 19.8 (10.8-

29.2)

4.7 (2.9-6.9) 0.001

Length of

PICU stay

(days median

(IQR))

18.9 (12.1-

89.9)

7.6 (4.9-

13.9)

0.013 22.4 (13.5-

56.7)

7.5 (4.9-13.7) 0.004

Length of

hospital stay

(days median

(IQR))

47.1 (22.2-

70.8)

19.7 (10.2-

42.6)

0.13 52.6 (19.0-

99.5)

18.7 (10.1-

43.8)

0.082

IQR=Interquartile range

Association of possible risk factors with VAP and VAE

VAP was not found to be associated with any of the possible risk factors examined (p>0.05). The

presence of GI prophylaxis and ETT types (cuffed) were associated with the development of VAE

(p<0.05; Table 7.9) in the prospective study.

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Similarly, the presence of GI prophylaxis was associated in the development of VAE at univariate

analysis in the retrospective study. In contrast to data in the retrospective study, no significant

association was found for reintubation and development of VAE in the prospective dataset.


Variables VAP p-

value

VAE p-

value

Yes No Yes No

Reintubation Yes 4 (80.0%) 40 (34.8%) 0.060 3 (50.0%) 41 (36.0%) 0.67

No 1 (20.0%) 75 (65.2%) 3 (50.0%) 73 (64.0%)

Paralytic agent Yes 2 (40.0%) 36 (31.3%) 0.65 1 (16.7%) 37 (32.5%) 0.66

No 3 (60.0%) 79 (68.7%) 5 (83.3%) 77 (67.5%)

GI prophylaxis Yes 3 (60.0%) 43 (37.4%) 0.37 5 (83.3%) 41 (36.0%) 0.030

No 2 (40.0%) 72 (62.6%) 1 (16.7%) 73 (64.0%)

Nasogastric

presence

Yes 5 (100.0%) 115 (100.0%) - 6 (100.0%) 114 (100.0%) n/a

No 0 (0%) 0 (0%) 0 (0%) 0 (0%)

Routes of

intubation

Nasal 3 (60.0%) 61 (53.0%) 1.00 1 (16.7%) 63 (55.3%) 0.096

Oral 2 (40.0%) 54 (47.0%) 5 (83.3%) 51 (44.7%)

Sedation level Deep

sedation

1 (20.0%) 30 (26.1%) 1.00 3 (50.0%) 28 (24.6%) 0.18

Light

sedation

4 (80.0%) 85 (73.9%) 3 (50.0%) 86 (75.4%)

ETT types Cuffed 4 (80.0%) 112 (97.4%) 0.16 4 (66.7%) 112 (98.2%) 0.012

Un-

cuffed

1 (20.0%) 3 (2.6%) 2 (33.3%) 2 (1.8%)

Steroid

prescriptions

Yes 4 (80.0%) 48 (41.7%) 0.17 4 (66.7%) 48 (42.1%) 0.40

No 1(20.0%) 67(58.3%) 2(33.3%) 66(57.9%)

Blood transfusion Yes 4(80.0%) 65(56.5%) 0.39 5(83.3%) 64(56.1%) 0.24

No 1 20.0%) 50(43.5%) 1(16.7%) 50(43.9%)

Association of preventative strategies with VAP and VAE

In the prospective study, the univariate analysis revealed that only ETT suctioning was associated

with VAP (p-value <0.05; Table 7.10). No other preventative strategies were found to be associated

with VAE development. In contrast, only cuff pressure checks were associated with the VAP and

VAE in retrospective study (p ≤ 0.05).

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Table 7.10: Univariate analysis for association of VAP preventative strategies with VAP and VAE

(n=120)

Variables VAP p-

value

VAE p-

value

Yes No Yes No

Hand hygiene 84.4 (4.9) 84.1 (3.6) 0.87 85.7 (3.6) 84.1 (3.7) 0.29

Oral hygiene 5.1 (1.1) 5.3 (1.1) 0.62 5.0 (0.9) 5.3 (1.1) 0.56

a) Adhered to 12-hourly

oral health assessment

Yes 5 (100.0%) 108 (93.9%) 1.00 5 (83.3%) 108 (94.7%) 0.31

No 0 (0.0%) 7 (6.1%) 1 (16.7%) 6 (5.3%)

b) Adhered to age-

appropriate oral hygiene

guideline

Yes 1 (20.0%) 4 (80.0%) 0.050 2 (33.3%) 76 (66.7%) 0.18

No 77 (67.0%) 38 (33.0%) 4 (66.7%) 38 (33.3%)

Endotracheal

suctioning

9.9 (3.5) 6.9 (2.0) 0.002 7.5 (2.9) 6.9 (2.1) 0.59

Head of bed elevation

(median (IQR))

22.6 (22.2- 23.8) 22.8 (21.3-

23.8)

0.69 21.9 (21.0-

22.7)

22.9 (21.3-

23.8)

0.24


(median (IQR)) (*n=

115)

2.8 (2.0- 3.4) 2.5 (2.0-3.7) 0.92 2.8 (1.0-

3.6)

2.5 (2.0- 3.7) 0.59

a) Adhered to 12 hourly

cuff pressure checks

Yes 4 (100.0%) 98 (89.1%) 1.00 3 (75.0%) 99 (90.0%) 0.36

No 0 (0.0%) 12 (10.9%) 1 (25.0%) 11 (10.0%)

b) Maintained cuff

pressure readings within

the limit

Yes 4 (100.0%) 104(94.5%) 1.00 4(100.0%) 104(94.5%) 1.00

No 0 (0.0%) 6 (5.5%) 0 (0.0%) 6 (5.5%)

Ventilator circuits

checks

18.6 (5.3) 18.7 (5.5) 0.59 16.1 (1.74) 18.7 (5.6) 0.25

Enteral feeding

commencement within

24 hours of PICU

admission

Yes 1 (20.0%) 77(67.0%) 0.050 6(100.0%) 72(63.2%) 0.090

No 4 (80.0%) 38(33.0%) 0 (0.0%) 42(36.8%)

Discussion of demographic and outcome characteristics and VAP/VAE — prospective

versus retrospective studies

No significant association was found between the demographic characteristics in the development of

VAP and VAE by univariate analyses. The results for VAP found in these studies were also observed

by Gupta et al. (2015) and Gautam et al. (2012) in their prospective studies. The development of VAP

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and VAE was found to be directly associated with the duration of mechanical ventilation. Again, this

result for VAP was consistent with previous prospective studies by Gupta et al. (2015) using

univariate analysis, and the duration of mechanical ventilation was found to be an independent risk

factor by multivariate analyses by Casado et al. (2011) and Awasthi et al. (2013). These findings may

further support the idea that patients are more readily exposed to complications which may precipitate

VAP and VAE. Most importantly, VAP/VAE preventative strategies that could assist in reducing the

duration of mechanical ventilation should be prioritised to prevent and minimise chances of

infection/events (Goutier et al., 2014; Klompas, Branson, et al., 2014; Muscedere et al., 2013; Neto

et al., 2015; Sinuff et al., 2013).

Patients developing VAP/VAE in the present study were associated with a longer duration of

mechanical ventilation and PICU stay. These findings were also reported in other VAP and VAE

studies in paediatrics (Bigham et al., 2009; Cirulis et al., 2016; Cocoros et al., 2016; Gautam et al.,

2012; Gupta et al., 2015; Phongjitsiri et al., 2015; Srinivasan et al., 2009). The findings support the

association of ventilator usage and the development of VAP/VAE in PICU.

Discussion of potential risk factors and preventative strategies and VAP/VAE —

prospective versus retrospective studies

The univariate analysis in the prospective study found that patients intubated with a cuffed ETT and

patients with a GI prophylaxis prescription were associated with the development of VAE. These

results have not been found by any parallel VAE studies in children to date. The association between

cuffed ETTs and VAE development in this study could be related to ETT management, particularly

in keeping the ETT cuff adequately inflated (Gupta & Rosen, 2016; Weiss et al., 2009).

Only GI prophylaxis was found to have a significant association with the development of VAE in the

prospective and retrospective studies. This result has not previously been described in paediatric

settings (Beardsley et al., 2016; Cirulis et al., 2016; Cocoros et al., 2016; Phongjitsiri et al., 2015).

An adult study by Klompas et al. (2016) found that GI prophylaxis was associated with the

development of PVAP by using the VAE surveillance tool. Evidence about the underlying mechanism

behind this is still unclear, but this finding may suggest that the undesired effects of GI prophylaxis

may also be present in children (Albert et al., 2016).

In the prospective study, additional potential risk factors for VAP/VAE were evaluated which were

not examined during the retrospective study. These factors include steroid and blood product

administration, but these risk factors did not reveal any statistically significant results in relation to

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the development of VAP and VAE. Blood transfusions were associated with VAE development in

the bivariate analysis by Cocoros, Priebe, Gray, et al. (2017), who also found an association with

steroid administrations; however, these were not assessed in this study (Cocoros, Priebe, Gray, et al.,

2017). A possible reason why the present study failed to find an association between these factors

may be due to the small sample size and low rates of VAP/VAE found in the data.

The frequency of ETT suctioning at a minimum of four times/day was associated with the

development of VAP (p=0.002). This finding was consistent with another prospective study by

Awasthi et al. (2013); they advised close monitoring of patients for VAP if the patient required ETT

suctioning more than once in six hours. The findings of the present study suggest that, despite full

compliance with ETT suctioning (identified in this phase), gaps in compliance of other elements

related to suctioning such as adherence to aseptic non-touch techniques (ANTT) and the practise of

draining condensate of ventilator circuits were identified. It is noted that, in compliance auditing,

these two sub-elements of ETT suctioning were only at a compliance rate of 74.2% and 22.6%

respectively. These elements may predispose the patient to the development of VAP (Auxiliadora-

Martins et al., 2012; Klompas, Branson, et al., 2014; Resar et al., 2014; Tolentino-DelosReyes et al.,

2007).

Summary

The six-month prospective study revealed a reduction in VAP/VAE incidence rates in comparison to

the retrospective study, measured by the PNU1/VAP and the new VAE surveillance tools. These

results are further supported by statistically significant improvements in VAP preventative strategy

compliance, including oral hygiene, HOB elevation, ETT cuff checks, and ventilator circuit checks

as observed at this phase in comparison to the retrospective study, but cautiously inferred to clinical

practise. Univariate analysis revealed that GI prophylaxis was associated with VAE development

which was identified in both the retrospective and prospective studies, warranting further research

around this risk factor in VAE.

Chapter 8 presents a general discussion for the thesis.

155

General Discussion

Introduction

This chapter provides a summary of ventilator-associated pneumonia (VAP) and ventilator-associated

events (VAE) in children, the challenges faced in preventing these events, and knowledge gaps in the

literature. A brief outline of the methodological approaches used and the findings from the three

phases of the study will be synthesised to draw conclusions. Finally, the chapter will detail the

limitations and implications of this study as well as recommendations for future research in this field.

Summary of the thesis

Complications related to mechanical ventilation have significant impacts on the health of patients.

Invasive mechanical ventilation is delivered with the intention of maintaining gas exchange in a

patient with as few adverse effects as possible (Keszler, 2017). For decades, any complication related

to mechanical ventilation have been viewed purely through a VAP lens (Hayashi et al., 2013;

Klompas, 2012). In the last six to seven years, there has been increased interest in VAP research

amongst medical, nursing and allied health professions (Magill et al., 2013; Mietto et al., 2013). This

interest has stemmed from a paradigm shift in VAP understanding to a broader scope of

complications, such as non-infectious conditions; i.e., atelectasis and pulmonary oedema. This shift

in thinking prompted a review and update of the surveillance tool. The controversy around VAP

surveillance tools continues; however the introduction of the Centre for Disease Control and

Prevention (CDC)’s VAE surveillance tool for adults provides a new foundation for research in

ventilator-associated complications (Klompas, 2013b; Klompas et al., 2015; Stevens et al., 2014). In

paediatrics VAP presents both a clinical and surveillance challenge to overcome. There are also

persistent challenges regarding surveillance tools in adults (Venkatachalam et al., 2011; Wright &

Romano, 2006). The body of evidence informing VAP/VAE prevention strategies is growing.

Currently the epidemiological data in paediatrics is less robust than that for adults, which may restrict

prevention strategy development (Aelami et al., 2014; Srinivasan et al., 2009).

The literature presented in Chapter 2 showed the varied incidence of VAP across PICU settings,

including the dominance of modifiable risk factors over non-modifiable risk factors (Awasthi et al.,

2013; Bigham et al., 2009; Cocoros, Priebe, Gray, et al., 2017; Gautam et al., 2012; Gupta et al.,

2015; Kusahara et al., 2014; Roeleveld et al., 2011).Very few studies have been undertaken using the

VAE surveillance in children. In particular, evidence of the application of VAE surveillance tools in

the paediatric population is currently limited to the existing VAP surveillance tool and does not extend

to cover VAE (Mohd Ali, Jauncey-Cooke, & Bogossian, 2019).

156

The literature appraised in Chapter 3 reported on individual VAP preventative strategies as currently

applied to children. Evidence exploring the individual preventative strategies in the bundle was

appraised. Individual preventative strategy compliance measurements were found to be unclear and

varied throughout the reviewed studies, and some did not report the compliance benchmarks to which

they were adhering (Tobias et al., 2012). The overall compliance benchmark for VAP preventative

strategies for adults is capped at >95% by the Institute for Healthcare Improvement (IHI) (Resar et

al., 2014), but some individual preventative strategies are not specified. Furthermore, some of these

preventative strategies used in the adult bundle were not applicable, or the effects were unclear in

children. Thus, translation of adult preventative strategies evidence (such as that concerning GI

prophylaxis and sedation interruption) to paediatrics poses uncertainty as to whether these would

assist VAP prevention in children (Klompas, Branson, et al., 2014; Lopriore et al., 2002; Vet et al.,

2016; Yildizdas et al., 2002). Minimal data on VAE preventative strategies is currently available

(Cocoros et al., 2016; Cocoros, Priebe, Gray, et al., 2017; Phongjitsiri et al., 2015) as a result of lack

of study in paediatric population.

Evidence continues to support ongoing challenges in VAP preventative strategy implementation in

the clinical setting, with issues such as a lack of compliance among healthcare workers (Bigham et

al., 2009; Brierley et al., 2012; Nair & Niederman, 2015; Rello et al., 2013; Smiddy et al., 2015). An

education program has been found to be beneficial to patient safety by maximising adherence to the

latest evidence-based practise recommendations (Flodgren et al., 2013; Jansson et al., 2013; Siegel et

al., 2007). However, a review of the literature identified that VAP education in PICUs is under

researched, and the possible benefits of parental involvement in VAP strategies is an opportune area

which has not been explored (Bellissimo-Rodrigues et al., 2016; Ciofi degli Atti et al., 2011). The

initiative ‘Speaking up for hand hygiene’ revealed a promising partnership between parents and PICU

staff, although the literature revealed mixed perceptions from those involved (Bsharat & Drach-

Zahavy, 2017; Pan et al., 2013; Wu et al., 2013). Methods to maximise this partnership require further

investigation. These identified gaps in knowledge informed the three phases of study design detailed

in Chapter 4; Phase 1: Retrospective study; Phase 2: VAP education, VAP preventative strategies

compliance auditing and surveys; and Phase 3: Prospective study.

Phase 1: The retrospective study provided the latest VAP/VAE epidemiological data reported from

one of the largest paediatric hospitals in Australia (Queensland Children’s Hospital (QCH)) in the

calendar year 2015. The incidence of VAP found in this study was higher compared to recent

prospective studies conducted in single PICUs in Sydney by Gautam et al. (2012) and was the first

study specifically focussed on surveillance for VAE incidence rates in an Australian paediatric ICU.

157

In the present study, the VAE incidence rate was lower than those of two paediatric studies which

adapted the VAE surveillance method for adults to children (Iosifidis et al., 2016; Phongjitsiri et al.,

2015). The rates were higher than those studies which applied some modification to adult VAE

surveillance tools — using mean arterial pressure (MAP) instead of positive end expiratory pressure

(PEEP) and applied PEEP of 2cmH2O instead of 3cmH2O (Beardsley et al., 2016; Cocoros et al.,

2016). The VAE surveillance tool appears to be stricter, helping isolate complications related to

mechanical ventilation. Three mechanical ventilation episodes met the PVAP versus 16 mechanical

ventilation episodes which met the PNU1/VAP tool. In this case VAE surveillance tool in paediatric

had classified 13 mechanical ventilator episodes as other possible ventilator-associated

complications.

The overall compliance of VAP preventative strategies was 89.2% in the retrospective study.

Multivariate analysis findings suggest that increased frequency of oral hygiene performance and GI

prophylaxis prescriptions may cause more harm to paediatric patients, which was congruent with an

adult study by Klompas et al. (2016). Thus, higher levels of evidence from randomised controlled

trials are required for future research to confirm these findings.

Given the ongoing challenges with VAP preventative strategy implementation in PICUs, VAP

education and compliance auditing with feedback were carried out in Phase 2. These approaches are

consistent with the most frequently used implementation of care bundles in ICUs (Borgert et al.,

2015). In this study, the involvement of parents and staff was increased including assessing their

perceptions in the ‘Speaking up for hand hygiene’ initiative. The overall compliance rate for VAP

prevention strategies in this phase was within an acceptable range (Tabaeian et al., 2017). While hand

hygiene compliance among PICU staff was in the range of the Australian national benchmark (>80%),

parents’ hand hygiene compliance was reported at 64.7%. This finding provides insight into the

importance of hand hygiene education and compliance monitoring among parents. Similarly, some

individual VAP preventative strategies/sub-elements such as oral hygiene performance, 12-hourly

cuff pressure checks, and adherence to aseptic non-touch techniques during ETT suctioning were

reported at compliance within a relatively acceptable range (50–75%) (Tabaeian et al., 2017). These

findings suggest that there may be some potential for further improvement, and therefore consistent

compliance auditing may help to close this gap. The findings from the parent and nurse surveys

supported the benefits derived from ‘Speaking up for hand hygiene’ in PICUs. Overall, there was a

positive perception of the willingness to remind each other to perform hand hygiene. These findings

suggest a future study with a larger sample size of parents and nurses would be required to reach a

158

firm conclusion. The reasons reported by parents and nurses that make them reluctant to remind each

other to perform hand hygiene warrant further exploration.

To evaluate the changes made in the PICU after delivering updated VAP education, and compliance

auditing with feedback and surveys (see Chapter 4, Section 4.4.3), a six-month prospective study was

conducted where the incidence rates of VAP/VAE were enumerated. The results showed that the rates

were reduced and there was an increase in overall compliance with preventative strategies. This

improvement of overall compliance was supported by the statistically significant difference reported

for individual VAP preventative strategies for oral hygiene, HOB elevation, ETT cuff pressure

checks, and ventilator circuit checks. Clinically, the improvement of compliance is often associated

with improved incidence rates of VAP. These results supported the idea that updated VAP education

for nurses and parents, and compliance auditing with feedback were able to significantly increase

compliance rates, and this was associated with a reduction in VAP/VAE incidence in the PICU. Due

to low event rates in this study, the analysis of possible risk factors and VAP preventative strategies

were limited to univariate analysis only.

New VAE surveillance tool for global surveillance

VAP surveillance activities are crucial for internal quality assessment and external benchmarking in

intensive care settings (Klompas, Branson, et al., 2014; Klompas, Kleinman, et al., 2012; Rosenthal,

Alvarez-Moreno, et al., 2012). The impact of VAP relates not only to morbidity, but also to increases

in healthcare expenditure (Muscedere, Day, & Heyland, 2010). Despite the limitations of current

VAP surveillance tools, surveillance is vital to assess VAP incidence rates, the development of

preventative strategies and strategic planning (Hebert et al., 2017; VICNISS Healthcare Associated

Infection Surveillance, 2015). Furthermore, surveillance enables evaluation of improvements in VAP

preventative measures undertaken in the unit (Wong, Mathieu, & Williams, 2012).

Lapses in surveillance can have a major impact. Benet, Allaouchiche, Argaud, and Vanhems (2012)

evaluated the impact of a lapse of one year in VAP surveillance that resulted in an increased VAP

rate from 13.4 to 22.9 per 1000 ventilator days and increased the duration of mechanical ventilation

from 7.7 to 11.3 days (p= 0.007). In the USA, surveillance data reporting to the National Healthcare

Safety Network (NHSN) is mandatory for healthcare facilities as an inpatient quality indicator and

for hospital reimbursement purposes (Magill et al., 2013; Stoeppel et al., 2014). However, in Australia

and New Zealand VAP surveillance is an optional module at a national level (VICNISS Healthcare

Associated Infection Surveillance, 2015). The barriers to mandatory VAP surveillance include the

159

substantial time required, difficulties in applying the surveillance criteria, and often a lack of

confidence at an institutional level regarding what to do with the data obtained from surveillance

(Friedman et al., 2005).

At present globally, PNU/VAP surveillance is considered adequate to monitor VAP in children

(Lutmer & Brilli, 2016), but this surveillance proves challenging for hospitals to maintain due to the

subjectivity of its criteria and difficulty in implementation (Hayashi et al., 2013; Klompas, 2010,

2012; Magill et al., 2013; Magill et al., 2014). This study has offered the groundwork to support the

validation of the VAE surveillance tools in paediatrics. This VAE tool is believed to overcome the

limitations of the present PNU/VAP surveillance through its potential to increase validity and

reliability (Boyer et al., 2015; Klompas, 2013a; Phongjitsiri et al., 2015). Initial efforts to test the

feasibility of VAE surveillance in children started in 2012 when the CDC Paediatric and Neonatal

Ventilator-Associated Event Working Group was formed. Subsequent discussion has concluded that

additional data is required before this will be mandated in mechanically ventilated paediatric patients

(Cocoros et al., 2016). VAE surveillance has only recently been tailored for use with children,

although the surveillance tool has been used in adult ICUs (Cocoros et al., 2016; Cocoros, Priebe,

Logan, et al., 2017; Klompas, 2012, 2013a, 2013b). More studies are required to further refine the

current tool so that it is appropriate for PICU use.

The available studies in children to date have involved the evaluation of the current PNU/VAP

surveillance tool and the new VAE surveillance tool (Iosifidis et al., 2016; Narayanan et al., 2016;

Phongjitsiri et al., 2015). However, given the variability and difference between adults and children,

a group of researchers have started testing different VAC criteria in children, including altering FiO2

thresholds and replacing PEEP with MAP, modifying PEEP levels, altering the tool of period of

stability, and reducing abnormal temperature and WBC count (for IVAC) in the VAE surveillance

tool (Beardsley et al., 2016; Cirulis et al., 2016; Cocoros et al., 2016; Cocoros, Priebe, Logan, et al.,

2017).

Furthermore, the variability of ventilator management in paediatrics, such as in the case of acute

respiratory distress syndrome (ARDS), may also contribute to the significant difference in defining

VAC in children (Khemani, Markovitz, & Curley, 2009; Mhanna, 2016). Further research is needed

to refine the VAE surveillance tool for children in PICUs.

The new VAE surveillance tool has the potential for international comparison for collaborative

surveillance on ventilator-associated complications in children (Cocoros et al., 2016; Cocoros, Priebe,

Logan, et al., 2017; Taylor et al., 2014). However, this is only possible once VAE data becomes

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readily available globally and consistency in reporting is achieved. A literature review by Mohd Ali

et al. (2019) found that current published VAE data for children is limited to a few countries, with

data only available from five studies in the USA, one study in Greece and one study in the United

Kingdom (Iosifidis et al., 2016; Narayanan et al., 2016).

Lessons learnt from paediatric VAP surveillance include that the incidence rates varied partly due to

the subjectivity of the PNU/VAP surveillance tool and the diversity of demographic characteristics

of the included paediatric patients (Awasthi et al., 2013; Nair & Niederman, 2015; Srinivasan et al.,

2009). Meaningful comparison for planning strategic preventative strategies would benefit from the

use of objective criteria in the VAE surveillance tool and an automatic data extraction device, such

as a VAE dashboard. This may overcome the subjectivity and labour requirements currently

hampering VAP surveillance activities (Hebert et al., 2017).

The role of VAP education, compliance auditing with feedback, and parents’ involvement

in VAP/VAE prevention

This study emphasised the role of VAP education, compliance auditing with feedback, and parental

involvement in the improvement of compliance and the reduction of VAP/VAE rates in a PICU.

Implementation of VAP preventative strategies that addressed staff education and compliance

monitoring with feedback have previously resulted in the reduction of VAP rates significantly, from

52% to 6% in a pre- and post-intervention study (Obeid et al., 2014). Kunzmann, Dimitriades,

Morrow, and Argent (2016) also achieved a VAP reduction, from 55 per 1000 to 19.1 per 1000

ventilator days over the first five months of their study, with greater reductions achieved down to 4

per 1000 ventilator days with an improvement of VAP preventative strategies compliance from 57%

to 83%.

Some researchers have argued that it is unlikely that universally accepted paediatric VAP preventative

measures will be achieved. This is due to the diversity of underlying diseases, pathogenesis of patient

conditions, treatments, and different training and qualifications of PICU staff (Morrow, Argent,

Jeena, & Green, 2009). The VAP education for PICU staff in this study drew on the latest evidence

on individual preventative strategies that best suit paediatric patients. Education on healthcare-

associated infections requires frequent updating to ensure it is in line with epidemiological changes

and advancement in the latest medical technologies (Hellyer et al., 2016; Nair & Niederman, 2015;

Pittet, 2010). These findings are congruent with the findings of a systematic review, which stated that

education strategies through staff education, auditing and feedback, reminders, and VAP surveillance

161

may be associated with an increase in healthcare workers’ knowledge and compliance (Jansson et al.,

2013).

The findings of VAP preventative strategies compliance auditing at Phase 2 showed acceptable

compliance, but some sub-elements of individual preventative strategies were below the acceptable

range. This suggests that these elements should not be ignored and need to be examined thoroughly.

The compliance rates of preventative strategies and the subsequent reduction of VAP/VAE require

sustainable measures in clinical practise as part of a quality improvement framework to address the

complexity of VAP and VAE (Jansson et al., 2013). It is recommended that providing feedback to

healthcare workers on hand hygiene performance, as well as education, will help motivate and

optimise compliance (Yokoe et al., 2014).

This study extends VAP education to parents, encouraging them to contribute to VAP minimisation

in PICU. Parents play an important role in patient care, and this role should therefore be looked at

from a broader perspective. Their voices when speaking up for hand hygiene are one of many ways

to integrate parents’ participation in VAP/VAE prevention in PICUs (Bellissimo-Rodrigues et al.,

2016).

Education should be openly delivered in a simple, informative, and easily understood way, tailored

to the target group to ensure maximum engagement and retention of the lessons within. In this study,

in the QCH PICU environment, pamphlets on hand hygiene promotion and VAP prevention were

given to parents. These pamphlets were intended as a way to maximise parental engagement with

hand hygiene during the time of their child’s PICU admission.

Overall, the present study provides some insight into the need for consistency when updating

educational information on VAP in PICU and involving staff and parents to overcome challenges in

compliance with VAP preventative strategies.

Limitations and strengths

The primary limitation of this study is that it involved a single setting, limiting the scope of advanced

statistical modelling, as the VAP/VAE rates were very low. This ultimately restricted the

generalisability of the data gathered (Al-Thaqafy et al., 2014; Cirulis et al., 2016; Gautam et al.,

2012). The VAP/VAE surveillance tools were applied on the same data, which may potentially have

included inaccurate clinical data. Data collected retrospectively may have been subject to investigator

bias, thus the associations could not be assumed as causal (Hatachi et al., 2015; Phongjitsiri et al.,

162

2015). However, these biases would be equally applicable to both tools. The data from the electronic

records were in the form of real-time data which reduced the possibility of transcription errors, which

may have been encountered if paper-based chart reviews were used instead for data collection (Stein

et al., 2014).

Another restriction of the study lay in the lack of data on the possible risk factors of VAE in children.

When the data collection sheet for the retrospective study was being designed, limited information

on risk factors for VAE in paediatrics had been established (in part due to the lack of information

available in related literature); thus the study aimed to assess the most reported VAP risk factors and

VAP preventative strategies. However, in the prospective study, data on these additional risk factors

and preventative strategies was collected. These additional risk factors add new information to the

literature. Multivariate analysis could not be completed due to the low event rates encountered over

the six-month prospective study (Cocoros et al., 2016). In addition to this, discussion on the

application of the new VAE surveillance tools was limited to a very few paediatric studies, which

only provide scarce evidence to support the possible explanation of what this study has found

(Cocoros et al., 2016; Cocoros, Priebe, Logan, et al., 2017; Phongjitsiri et al., 2015). Thus, the study

should be duplicated in a selection of other PICUs and involve more patients to increase external

validity and the availability of data for analysis and generalisation (Cocoros et al., 2016; Phongjitsiri

et al., 2015).

The survey was undertaken in single study site with a small sample size and low response rates.

Although the parents received the education and pamphlet, in some circumstances they declined to

participate in the survey, contributing to the low response rate. In the nurses’ survey, although the

survey was available online or in a hard copy the response rate remained very low. Several reminders

had no impact on the response rate. This may be due to various reasons such as unit activity or patient

acuity. Response bias is also a study limitation. Parents and nurses may provide the answers to the

surveys that were influenced by the ongoing hand hygiene campaign in the PICU or other source of

information regarding hand hygiene. Thus, caution should be exercised in drawing firm conclusions

based on these findings. Furthermore, the perception of other PICU staff towards parents and nurses

on ‘Speaking up for hand hygiene’ was not examined and remains an area of potential improvement.

Despite the limitations discussed above, this study presents several strengths. The retrospective study

provides robust data on recent VAP epidemiology in an Australian context; surveillance for

VAP/VAE is an optional module with only five adult hospitals in Australia reporting VAE, and no

PICUs or Neonatal ICUs participating in VAP/VAE surveillance (VICNISS Healthcare Associated

163

Infection Surveillance, 2015). Although limited to a single setting and retrospective in nature, this

study is one of the first studies to test the CDC’s VAE surveillance tool in paediatric patients, and

among the first to examine present VAP/VAE preventative strategies in children. Although

insufficient VAP/VAE events were found in this study, two VAP preventative strategies (oral hygiene

and GI prophylaxis associated with VAE) were identified, which may provide a starting point for

further research.

The incidence rate calculation in this study extends the calculation used by the CDC (total number of

days/patients on ventilator) (Centers for Disease Control and Prevention (CDC) & National

Healthcare Safety Network (NHSN), 2015a), to the total time (hours) until the VAP/VAE is

diagnosed, ventilator is ceased in the absence of development of VAP/VAE, or death. In doing so,

the study was able to predict the development of VAP/VAE per hour of ventilation. This is crucial to

be able to revise nursing care or VAP/VAE preventative strategies, especially in terms of frequency

and timing of performance. For instance, the frequency of individual VAP preventative strategies

often described as ‘routine’ failed to distinguish the optimum frequency which would best suit

paediatric patients: the frequency of oral hygiene, endotracheal tube (ETT) cuff pressure checks, ETT

suctioning, and the level of HOB elevation in the practise examples are unclear (Brierley et al., 2012;

Jácomo et al., 2011; Kusahara et al., 2012; Memela & Gopalan, 2014; Morrow & Argent, 2008;

Munro & Ruggiero, 2014; Wip & Napolitano, 2009). Future research should assess in detail the

frequency and timing of VAP preventative strategies.

The multivariable models used in this study are an exercise in decision making, and appropriate

interpretation of the results is required because the events rate was very low. The inclusion of the

modelling work within the thesis, however, is beneficial for future research.

Another strength of this study is that parents were included in VAP education. In doing so, this study

involved parents in one of the key VAP preventative strategies: hand hygiene. The decision to involve

parents in this strategy arose from discussions with respective clinicians, educators and researchers.

This particular partnership between nurses and parents is also recommended by the World Health

Organisation (World Health Organization (WHO), 2009b). No survey or hand hygiene auditing

among parents in PICU had been undertaken before this study. More studies are needed to set the

hand hygiene benchmark for parents and visitors in PICUs.

This study successfully used appropriate methodologies to comprehensively examine VAP/VAE in

PICUs and define measures to overcome the existing challenges in preventing VAP/VAE in children.

164

The retrospective study enabled evaluation of the magnitude of VAP in a PICU, and at the same time

tested the applicability of the new VAE surveillance tool. Although the retrospective study in Phase

1 did not directly inform Phase 2; VAP education, compliance auditing with feedback and surveys,

the relevancy of VAP education involving PICU staff and parents, compliance, and feedback were

found to be crucial elements in minimising the impact of VAP in PICUs. The study concluded by

evaluating possible improvements for implementation after reinforcement of VAP education, and

compliance auditing with feedback in a six-month prospective study where patients were followed to

observe their progress.

General implications and future directions

The present study contributes to VAP epidemiological data in children and also adds to the growing

body of clinical knowledge on VAE surveillance in critically ill children receiving mechanical

ventilation in PICUs. In the Australian context, this is the first time that the CDC’s VAE surveillance

tool for adults has been applied to paediatric patients. This study has been cautious in applying VAE

tools to historical data, as the data gathered may not be wholly accurate due to the method in which

it was collected (via retrospective studies) (Phongjitsiri et al., 2015; Stein et al., 2014).

Retrieving data from medical records can be challenging, especially when data is not electronically

recorded, and automatic data retrieval is not available (Cocoros, Priebe, Logan, et al., 2017). It is

expected that the application of VAE surveillance tools will be mandated in children, although the

present evidence on paediatric versions of VAE surveillance version is still insufficient (Mohd Ali et

al., 2019). The ready availability of the clinical data in the electronic medical records made

surveillance of VAE in children possible and may have been able to minimise inter-observer bias as

well as increase the accuracy of data collected (as compared to what might be gathered via the manual

method) (Hebert et al., 2017; Stevens et al., 2014). The electronic medical record Metavision

(iMDsoft®), used in this study is not able to perform an automatic retrieval of the clinical data for

VAE surveillance purposes, but this presents an opportunity for future collaboration between

information technology personnel and clinicians in designing automatic data retrieval, which could

reduce the amount of time required to collate data (Hebert et al., 2017; Stevens et al., 2014). Since

the VAE surveillance criteria consists of objective data which is readily available within electronic

medical records, the reliability of the data obtained has increased (Klompas, 2013a; Klompas et al.,

2011; Magill et al., 2013; Stevens et al., 2014). Further studies may find it useful to develop an

algorithm to capture elements of VAE tiers in children.

165

The tools of VAP prevention strategies compliance (VAP bundle) and individual VAP prevention

strategies need to be clearly defined to enable inter-institutional comparison and benchmarking.

Similarly, the benchmark for parents’ and visitors’ hand hygiene compliance needs to be clearly

defined. This classification of compliance is vital, yet noticeably missing in current literature. This

study proposes the need for hand hygiene compliance monitoring among them as similarly

highlighted in a recent study by Giannini et al. (2016). Thus, future research may focus on this area.

VAP education in this study was delivered through online learning (TEACHQ platform), an internal

learning platform available within the hospital. The study used this approach to maximise the

engagement of PICU staff with VAP education materials (Blot, Koulenti, & Labeau, 2017; Cirulis et

al., 2016; Labeau et al., 2016), but assessing the effectiveness of this method was not a focus of this

study, so it is recommended that future research may assess the usefulness of this method.

Conclusion

The findings of this study demonstrated a reduction of VAP/VAE in a six-month prospective study

defined by two surveillance tools. Although generalisation is limited, this study demonstrated that a

decrease of VAP/VAE incidence rates can occur in a PICU after updated VAP education is

undertaken through educating PICU staff and parents, coupled with compliance auditing and

feedback in the PICU. This study demonstrated that these changes in the process of care for the

patients in PICU improved patient outcomes in terms of reduced rates of VAP and VAE, although

this reduction may also be influenced by the case-mix. This study contributes to and extends the work

of previous literature, especially the understanding of VAP preventative strategies tailored to

paediatrics. The new VAE surveillance tools applied to 2015 patient cohorts revealed a similar

incidence rate, although very small differences were reported when the incidence calculation was

based on the patients no longer at risk. Although poor agreement between PNU/VAP and the new

VAE surveillance tool and low sensitivity were found, the high specificity suggests the merit of the

new VAE tools to identify complications other than VAP.

While a multivariate analysis in this study found no significant association between the tested

potential risk factors and VAP preventative strategies in VAP models, the VAE model results showed

that frequent oral hygiene performance and the presence of GI prophylaxis was associated with VAE

development. This offers insight into current practises in PICUs, and these need further investigation.

The significant associations at univariate analyses and/or insignificant results for VAP show that VAP

is a serious complication in PICUs and requires re-evaluation in terms of individual VAP preventative

strategies. The present study utilised updated VAP education and compliance auditing with feedback

166

involving both PICU staff and parents. The surveys on ‘Speaking up for hand hygiene’ among parents

and nurses suggested that agreement on this initiative would increase good hand hygiene practise.

This study also highlighted perceptions of staff and parents about reminding each other to perform

hand hygiene. Further research exploring this relationship could also promote partnerships to ensure

optimal hand hygiene practise and prevent infection in PICUs. Significant compliance improvement

for VAP preventative strategies was achieved between retrospective and prospective studies, and this

suggests the usefulness of updated education and compliance auditing with feedback, as these were

found to directly aid the reduction of VAP/VAE incidences in PICU.

167

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188

Appendices

Appendix A Data collection sheet (Retrospective study)

No Variable Label Definition Coding in SPSS Remarks 1. Patient no Pt no Patient no labelled after met the

inclusion & exclusion criteria [Cohort

2015]

Patient 1 to 234

1

2

3 and until 234

Corresponding to the

number of patients in the

study

2. Episodes of

mechanical

ventilation

EpisodesofMV_exp

erimental_unit

The number is corresponding to the

number of mechanical episodes of

each patient

1- 262 The experimental unit

3. Admission Admission Number of PICU admission of each

patient

1 for 1st admission

2 for 2nd admission

3 for 3rd admission

Demographic

characteristics

4. Mechanical

ventilation

number

MVnumber Mechanical ventilation number

during admission for each patient

1 for MV number 1 (single)

2 for MV number 2

3 for MV number 3

4 for MV number 4

5. Age Age_in months Age of the patients - in months True age (in 2 decimal points) –

in months

Demographic

characteristics & /risk

factor 6. Gender Gender The sex of patients – male and female 1. Male

2. Female

Demographic


factor 7. Weight Wt Weight of patients- in Kg True weight in Kg Demographic


factor 8. PICU admission

source

IADM_SC_PICU The classification is based on

ANZPIC registry data collection

form- 2016

1. OT/recovery,

2. Emerg Dept

3. Ward (any other inpatient area)

4. Other ICU/NICU-same

hospital

5. Direct ICU Adm’n

Demographic


factor

189

9. Underlying

disease for

PICU admission

UDX The codes are according to ANZPIC

Diagnostic Codes Table- 2015

1. Injury/trauma (100-

2. Cardiovascular (200-

3. Neurological (300-

4. Respiratory (400-

5. Renal (500-

6. Gastrointestinal (600-

7. Infection (700-

8. Miscellaneous (800-

9. Post- procedural (1100-

Demographic

characteristics/ risk

factor

*Requirement for CDC

PNEU/VAP surveillance

tool

10. PICU_diagnosis

_cat

PICU_diagnosis_ca

tegory

The codes are according to ANZPIC


1. Medical

2. Surgical

3. Trauma

Demographic

characteristics/ risk

factor

11. PIMS 2 score PIMS2_DEATH Paediatric index of mortality score True score Demographic


factor 12. Paediatric index

of mortality 2

PIMS2_Anz11_DE

ATH

Calibrated Paediatric index of

mortality score_anz2011

True score Demographic


factor 13. PIMS 3 score PIMS3_DEATH Paediatric index of mortality score True score Demographic


factor 14. Paediatric

index_anz2013

of mortality 3

PIMS3_anz13_DE

ATH

Calibrated Paediatric index_anz2013

of mortality score

True score Demographic


factor 15. Commencement

of mechanical

ventilation

Commenceof MV Date and time commencement of

mechanical ventilation retrieved from

ANZPIC via Metavision

Date and time in the format of

dd/mm/2017 hh:mm (24hrs

system)

Commencement of


16. Cease of

mechanical

ventilation

CeaseofMV Date and time cease of mechanical

ventilation retrieved from ANZPIC

via Metavision



system)

Cease of mechanical

ventilation

17. Column ceased

commenced 1st

Columnceasedcom

menced1stidentifed

xray

Date and time of 1st identified as

ceased of mechanical ventilation for

those case that did not identified as



system)

Column ceased

commenced 1st identified

X-Ray_VAP

190

identified X-

Ray_VAP

VAP (same as date and time of ceased

of mechanical ventilation) 18. Time at risk of

VAP

TimeatriskofVAP Total of hours

Columnceasedcommenced1stidentife

dxray minus Commenceof MV

In total of hours (hh: mm: ss) Time at risk of VAP

19. Column ceased

commenced 1st

identified VAC

Columnceasedcom

menced1stidentifea

s VAC

Date and time of 1st identified as ceased of

mechanical ventilation for those case that did

not identified as VAC (same as date and time

of ceased of mechanical ventilation)



system)

Column ceased

commenced 1st identified

VAC

20. Time at risk of

VAE

TimeatriskofVAE Total of hours

Columnceasedcommenced1stidentife

dVAC minus Commenceof MV

In total of hours (hh: mm: ss) Time at risk of VAE

21. Duration of MV Duration_MV Recorded in days (commence date &

time minus cease date & time of

intubation

True numbers of days Outcomes

22. Duration of

PICU stay

(days)

Length_of_PICU_s

tay

Recorded in days (PICU admission

date & time minus PICU discharge

date & time)


23. Duration of

hospital stay

(days)

Length_of_hospital

_stay

Recorded in days (Hospital admission

date & time minus hospital discharge

date& time)


24. PICU outcomes PICU_OUTCOME The classification are based on

ANZPIC registry data collection

form- 2016:

1- Discharge to ward/home;

2- Died in ICU;

3- Transferred to another ICU

(includes NICU),

4- Still in ICU,

5- Died within 24 hours after

being discharged from ICU to

receive palliative care

Outcomes

25. Mortality Mortality Died or not died 0- Not died

1- Died

26. Ventilator-

associated

VAP yes or no Number of identified as VAP case-

meeting the CDC tool from each

0- No

1- Yes

Manually determined

based on CDC

191

pneumonia

(VAP)

experimental unit (from 261 episodes

of MV)


tool 27. Ventilator-

associated event

(VAE)

VAE classifications Number of identified as VAE (VAC,

IVAC, PoVAP - meeting the VAE

algorithm

0=No

1. VAC

2. IVAC

3. PoVAP

Manually calculated/

determined using new

CDC VAE surveillance

tool

CDC VAE calculator

version 4.0 then used to

confirmation. 28. Mechanical

ventilation days

MV_day MV days that each patient was on

ETT tube. Each patient may have

varied number of MV days

Data from Day 1…max day 49

(in this cohort) documented)

29. Reintubation

episodes

Reintubationepisod

es

The presence of any reintubation was

taken place or not.

0- No

1- Yes

Risk factor_ raw data

30. Overall

Reintubation

episodes_for

risk factor

analysis

Overall_Reintubati

onepisodes

If any event of reintubation took place

in each days of every episodes (1)

consider as yes and (0) is no.

0- No

1- Yes

Risk factor – will use to

further analysis

31. Routes of

intubation

Routes_Intubation Routes of endotracheal intubation

whether nasal or oral

1- Nasal

2- Oral


32. Overall routes

of intubation

Overall_Routes_Int

ubation

Determined as with Nasal tube if the

patient has the longest (MV days) on

nasal tube.=coded as 1

Determined as with Oral tube if


Oral tube=coded as 2

If the same total numbers of MV days

– consider the last changed/ the

newest type of tube to be overall

1- Nasal

2- Oral


further analysis

33. Highest sedation

scores

Highestsedationsco

re

-3 – unresponsive/paralysed

-2 – response to noxious stimuli

-1 – response to gentle touch/voice

0 – awake & able to calm

-3

-2

-1

0


192

+1 – restless & difficult to calm

+2- agitated

+1

+2 34. Overall Highest

sedation score

OverallHighestseda

tionscore

The score is counted as overall if the

score had the majority numbers of

MV days in episode/s of MV. If the

score found in equal number of MV

days; the score on the last day will be

taken as overall

Recoded into 3 categories

1- Deep Sedation

(Score of -2 to -3)

2 – Light Sedation

(Score of -1 to +1)

3- Agitated

(Score of +2)


further analysis

35. Paralytic agent paralyticagent The administered of any paralytic

drugs for each MV days

yes - if the infusions were given> 4

hours of infusion or > 4 times bolus

dose

no – other than the criteria above

0- No

1- Yes


36. Overall

Paralytic agent

Overall_Paralyticag

ent

Overall Yes (1) is determined if the

“yes” found in the majority of MV

days of every episodes of MV or if the

“yes” are equal with “no” in MV days

– counted as Yes (1)

0- No

1- Yes


further analysis

37. Gastrointestinal

prophylaxis

GIprophylaxis The administered of any GI

prophylaxis drugs for each MV days

0- No

1- Yes


38. Overall GI

prophylaxis

OverallGiprophylax

is






0- No

1- Yes


further analysis

39. Antibiotic What_antibiotic Name of antibiotics, which the

patients were administered for each

MV days

The antibiotics are based on list stated

in VAE surveillance tool (67

antibiotics) refer to antibiotic list at

the end of sheet).

Recorded as name of respective

antibiotic/s

NA – if the patients were on

antibiotics that not in the list

No_Ab- if the patients were not

on any antibiotic/s.

Requirement for VAE;

IVAC (2nd Tier) [new


tool]

193

40. Number of

antibiotics

Number_of_antibio

tic

Number of antibiotics corresponding

to list of antibiotics stated in VAE

surveillance tool

1- one antibiotic

2 – 2 antibiotics

3- 3 antibiotics

4- 4 antibiotics

5- 5 antibiotics

6- NA

7- No antibiotic

41. Nasogastric

(NG)tube

presence

Nasogastrictubepre

sence

The presence of NG tube for each MV

days

0- No

1- Yes


42. Overall

Nasogastric tube

presence

OverallNasogastrict

ubepresence






0- No

1- Yes


further analysis

43. X-Rays with

disease

X-Ray with disease Yes - if radiological report (in each

MV days) distinguished the findings

as: 2 or more serial X-Rays with 1 of

the following ✓ new or progressive and

persistent infiltrate

✓ consolidation

✓ cavitation

✓ pneumatoceles, in < 1 y.o

No – if none of radiological report (in

each MV days) found as the list of X-

Rays findings and no X-Ray done on

the particular days

NA- if patient without disease

0- No

1- Yes

3- NA

Requirement for CDC


tool

44. X-Rays without

disease

X-Ray without

disease

Yes - if radiological report (in each

MV days) distinguished the findings

as: 1 or more serial X-Rays with 1 of

the following

0- No

1- Yes

3- NA

Requirement for CDC


tool

194

✓ new or progressive and

persistent infiltrate

✓ consolidation

✓ cavitation

✓ pneumatoceles, in < 1 y.o



Rays findings and no X-Ray done on

the particular days

NA- if patient with disease 45. Worsening gas

exchange

[(Increased

oxygen

requirement, or

increased

ventilation

demand)]

(i)FiO2 (ii)

PEEP or iii)

Spo2 <94%

Min_FiO2 True value of minimum FiO2 at least

sustained for 1 hour in a day -for

every MV days

True value of minimum FiO2 Requirement for VAC

(VAE) -1st Tier [new


tool]

Additional parameter to

assess Worsening gas

exchange [(Increased

oxygen requirement, or

increased ventilation

demand in CDC


tool 46. Worsening gas

exchange

[(Increased

oxygen

requirement, or

increased

ventilation

demand)]

(i)FiO2 (ii)

PEEP or iii)

Spo2 <94%

Min PEEP True value of minimum PEEP at least

sustained for 1 hour in a day -for

every MV days

True value of minimum PEEP,

9999 as missing value if no PEEP

value documented.

Requirement for VAC

(VAE)- 1st Tier [new


tool]






demand in CDC


tool

195

47. Worsening gas

exchange

[(Increased

oxygen

requirement, or

increased

ventilation

demand)]

(i)FiO2 (ii)

PEEP or iii)

Spo2 <94%

SpO2 < 94% Yes- if any of SpO2 readings <94% in

a day- for every MV days

No

0- No

1- Yes

2- No value

Requirement for CDC


tool especially for infant

<1y.o apart from

worsening oxygenation

SpO2 <94%

Also, for children >1y.o

48. Temperature

instability

Temp<36oC_or>38oC

Yes- if any of temperatures was

36oC_or>38oC in a day – for every

MV days.

No

0- No

1- Yes

2- No value

Requirement for both

CDC PNEU/VAP

surveillance tool and

VAE (IVAC- 2nd tier)

[new CDC VAE

surveillance tool] 49. Tachypnea

RR_aged_based Defined as [(> 75 breath/min –

premature infants born at <37 wks &

until 40th wks; >60bpm=<2 months

old; >50bpm= 2-12 months old;

>30bpm=children >1 yr. old)].

Yes – if any of the respiration rates in

a day of each MV days met the tool

based on age classifications as above.

No

0- No

1- Yes

2- No value

Requirement for CDC


tool

50. Bradycardia or

tachycardia

HR<100or>170_inf

ant<1yr

Defined as HR <100 or

>170beats/min

Yes- if any of HR reading was <100

or >170beats/min in a day – for every

MV days.

No

NA (for infant >1.yr.o)

0- No

1- Yes

2- No value

3- NA for patients >1 yr.o.

Requirement for CDC


tool

Applicable for infant

<1y.o only

196

51. Changes in

character of the

sputum

changesputumchara

c

Defined as change in sputum

character [(i) colour; (ii) consistency;

(iii) quantity

Yes

No

Considering this character first:

Sputum colour: yellow, creamy,

green, brown

Sputum consistency: thick

Sputum quantity: large, copious,

moderate

0- No

1- Yes

Requirement for CDC


tool

52. Leukopenia or

Leukocytosis

WBCC (≤4K or

≥15K)

Yes- if any of WBCC results was ≤4K

or ≥15K in a day – for every MV days.

No

0- No

1- Yes

2- No value/no sample sent


CDC PNEU/VAP

surveillance tool and

VAE (IVAC- 2nd-Tier)

[new CDC VAE

surveillance tool]

After gathered all data &

the VAC confirmed;

second screening done

for IVAC determination

as ≥12K is required 53. Microbiological

consideration of

respiratory

secretions

Gram_staning Recorded for 1. ETA

2. BAL

3. Pleural fluid

4. Lung tissue biopsy

Gram+ve, Gram-ve, no growth, no

sample sent :(cocci, bacilli or other)

(washing BAL or BAL) (Pleural fluid

RT/LT) (Lung tissue biopsy)

Recorded as in the microbiology

findings (same as in tool column)


CDC PNEU/VAP

surveillance tool

and VAE (possible VAP

(Tier 3) [new CDC VAE

surveillance tool]

54. Corresponding

values to

quantitative

Colony_forming_u

nit

Documented as

Epi – scant, 1+ -4+

Leu- scant, 1+ - 4+




CDC PNEU/VAP

surveillance tool

197

threshold values

for cultured

specimens used

in diagnosis of

pneumonia

Sq. epi

Erythrocyte

WBC’s ___x10^6/L;

RBC’s___x10^6/L;

Polymorphs___%

Contains clots, blood stained



surveillance tool]

55. Name of the

organism with

quantitative

threshold values

for cultured

specimens used

in diagnosis of

pneumonia

Organisms isolated No organism seen, normal respiratory

flora, organism name (scant, 1+ -4+),

no fungi isolate, coagulase neg.

staphylococcus

Isolate_____CFU/ML




CDC PNEU/VAP

surveillance tool



surveillance tool]

56. HH_compliance Hand hygiene

compliance

Hand hygiene compliance in % for

each month in 2015 obtained from

Hand Hygiene Australia –

True % of hand hygiene, the

value with the respective months

that the patients were on


Missing value 9999

Requirement for VAP

preventative strategies

57. Oral hygiene

practises

MouthCare_perfor

mance

Mouth care is referred to whether it

was performed or not during MV days

Yes- if documented any of oral

hygiene was performed at daily basis

regardless of mouth care plans.

No – is not done

0- No

1- Yes

Requirement for

preventive strategies

performed by nurses

58. Overall Mount

Care

Performance

Overall_MC_perfor

mance

Counted as the majority of Yes/ No in

each MV days. If equal number of

Yes and No found in one episode of

MV – considered as Yes

0- No

1- Yes

Represent whether the


were performed or not

during each episode of

MV 59. Frequency of

oral hygiene

practises

MouthCareF Is referred to the frequency of mouth

care was performed for every MV

days

Frequency of MC performance

(count)

Raw data

198

60. Overall MC

Frequency

OverallMCFrequen

cy

Average of the frequency to MV days

of every episodes of MV

1 average value recorded

represent each episodesof MV

Further analysis required

to determine the

compliance rate based

PICU Oral Hygiene

protocol (<6 months

without teeth and > 6

months with teeth) 61. Endotracheal

(ET) suctioning

Suctioning_perform

ance

Suctioning via ET is referred to

whether it was performed or not

during MV days

0- No

1- Yes

Requirement for


performed by nurses 62. Overall

Suctioning

performance

OverallSuctioning_

performance





0- No

1- Yes





MV 63. Frequency of

ET suctioning

practises

SuctioningF Is referred to the frequency of ET

suction was performed for every MV

days

Frequency of ET performance

(count)

Raw data

64. Overall

suctioning

frequency

Overall_suctioning

_frequency




represent each episode of MV


to determine the

compliance rate based on

PICU minimum standard

of suctioning frequency

(4 times/ 24 hours) 65. Cuff pressure

checking (ETT

with cuff &

uncuffed)

Cuffpressurechecks

_performance

Cuff pressure check is referred to


during MV days including patients on

uncuffed ET

0- No

1- Yes

3 – NA (no cuff or ordered as

deflated)

Requirement for


performed by nurses

66. Overall Cuff

Pressure check

performance

OverallCuffPressur

echeck_performanc

e

Counted as the majority of Yes/ No/

NA in each MV days. If equal number

of Yes/ No /NA found in one episode

of MV – considered as Yes

0- No

1- Yes


deflated)



were performed or not or

NA for patients who were

on uncuff ETT/ ordered

199

as deflated during each

episode of MV 67. Frequency of

cuff pressure

checks practises

Cuffpressurechecks

F

Is referred to the frequency of cuff

pressure check was performed for

every MV days

Frequency of Cuff Pressure

performance (count)

Raw data

68. Overall cuff

pressure

frequency

Overallcuffpressure

_frequency






to determine the


PICU standard (at least

12 hourly or twice daily) 69. Head of bed

elevation

performance

Headofbedelevation

_performance

Head of bed elevation is referred to


during MV days including 0 degree

0- No

1- Yes

Requirement for


performed by nurses

70. Overall HOB

performance

OverallHOB_perfor

mance





0- No

1- Yes





MV 71. Frequency of

head of bed

elevation

practises

HeadofelevationF Is referred to the frequency of head of

bed elevation care was performed in a

day for every MV days

Frequency of HOB performance

(count)

Raw data

72. Overall HOB

frequency

Overall_HOB_freq

uency






to determine the


PICU standard

200

Appendix B HREC approval

203

Appendix C Governance approval

204

Appendix D PHA approval

205

Appendix E University of Queensland Ethical approval

206

Appendix F Updated VAP education package (PICU staff)

1) Ventilator-associated pneumonia: Nursing interventions with VAP preventative strategies

2) VAP preventative Strategies (‘bundle’) poster

207

Appendix G Education for parents: Pamphlet

VAP: How I Can Help My Child in PICU?

What is VAP?

Although healthcare providers try to give the best possible care to reduce the risk of

infection, sometimes patients can develop an infection while in the hospital.

Any child who is on a ventilator (breathing machine) is at risk of developing pneumonia

(lung infection), sometimes called Ventilator-associated Pneumonia (VAP).

How does VAP happen?

When your child is on a ventilator, she/he may not be able to cough and remove their

saliva easily. Their immune system is not as strong when on a ventilator.

What can I do as a parent?

The two ways to help stop VAP are:

1. Hand Hygiene

2. Mouth Care

Hand Hygiene:

The best way to prevent infections is to clean your hands. It is as simple as:

✓ Rubbing your hands with hand gel found throughout the PICU. Rub for 20-30

seconds, if hands are not visibly soiled, and making sure you get in between fingers

and under jewellery

OR

✓ Washing your hands with soap and water for 40-60 seconds when hands are

visibly dirty or after using the toilet.

When do I clean my hands?

1. Before entering your child’s room.

2. Before touching your child.

3. After touching your child.

4. Before leaving your child’s room.

5. If you cough/ sneeze or touch your face.

Your contribution to care is valued

208

LCCH PICU encourages you to check if I washed my hands

and check if healthcare providers or visitors have washed their

hands when caring for your child.

Mouth Care

✓ You may be able to help to perform mouth care for your child while he/she is on

the ventilator.

✓ Please let your nurse know if you would like to be involved.

✓ Your child’s nurse will teach you how to do this safely.

✓ The breathing tube must be safely secured at all times.

✓ STOP and check with your nurse before cleaning the mouth.

✓ Make sure you perform Hand Hygiene before and after performing Mouth Cares.

How can I find out more about VAP?

Please speak to the nurses or doctors caring for your child in PICU.

209

Appendix H Survey Questionnaire (Parents)

We would like you to complete this survey. We hope to learn what you understand about chest

infections that can occur when your child is on a ventilator. We would also like to learn your opinion

about ‘speaking up’ for hand hygiene.

It should take you about 10 minutes to complete this questionnaire. Please read the questions carefully

and then respond spontaneously.

✓ There is no right or wrong on your answers.

✓ Your answers are anonymous and will be kept confidential.

✓ This questionnaire has three sections.

Section A: Demographic information

Please tick (√) on designated box.

1. What is your age?

Less than 30 years old

31- 40 year old

41- 50 years old

More than 51 year old

2. What is your sex?

Male

Female

3. What is your highest completed education?

Postgraduate Degree

Bachelor Degree

Certificate (I & II and III & IV)

High School

Didn’t complete High School

*Hand hygiene is the process of cleaning your hands. There are two methods of hand

hygiene: washing with soap and water or the use of hand gel/alcohol-based rub/sanitizer.

** Other healthcare workers in this study is refer to other than nurses; example is doctor,

physiotherapist, dietitian, occupational therapist and etc.

210

4. Are you employed/ working in the healthcare field?

Yes

No

5. Has your child been admitted in Paediatric Intensive Care (PICU) before this admission?

Yes

No

Unsure

6. Has your child had previous experience receiving breathing support using a ventilator in PICU

before this admission?

7.

Yes

No

Unsure

Section B: A pamphlet of Ventilator- Associated Pneumonia (VAP): How I Can Help My Child

in PICU?

This section relates to the information provided in the pamphlet and your perception on the

importance of hand hygiene.

[Pamphlet-hard copy given]

Please tick (√) on designated box.

8. Have you ever heard about ventilator- associated pneumonia (VAP) or chest infection related to

breathing support before?

Yes

No

Unsure

9. What method do you routinely use for your hand hygiene in PICU?

Hand gel

Hand wash

Combination

211

10. Please answer the following questions or statements by ticking (√) on the most appropriate

response.

Questions Strongly

Disagree

Disagree Neither

Agree

nor

Disagree

Agree Strongly

Agree

Do you feel the pamphlet was easy to

understand? O O O O O

Did the information in the pamphlet

make you concerned? O O O O O

Did you find that the information

encourages you to participate in your

child’s care?

O O O O O

Do you think that parents’ hand

hygiene is important in the prevention

of infection in hospital including

ventilator- associated pneumonia

(VAP) in PICU?

O O O O O

Do you feel that nurses’ hand hygiene

is important? O O O O O

Do you feel that other healthcare

workers’ hand hygiene is important? O O O O O

Do you feel that nurses in PICU wash

their hands enough? O O O O O

Do you feel that other healthcare

workers’ in PICU wash their hands

enough?

O O O O O

Section C: ‘Speaking up’ for hand hygiene

This section is related to your opinion regarding ‘Speaking up’ for hand hygiene

11. Please read the following statements and tick (√) to the most appropriate response.

Statements

Strongly

Disagree Disagree

Neither

Agree nor

Disagree Agree

Strongly

Agree

I would remind nurses to perform hand

hygiene if necessary. O O O O O

I would remind other healthcare

workers to perform hand hygiene if

they did not.

O O O O O

I am willing to be reminded by nurses

to perform hand hygiene if I did not. O O O O O

I am willing to be reminded by other

healthcare workers to perform hand

hygiene if I did not.

O O O O O

212

I think by speaking up for hand

hygiene, it would increase hand

hygiene practise among nurses.

O O O O O

I think by speaking up for hand

hygiene, it would increase hand

hygiene practise among other

healthcare workers.

O O O O O

12. What would stop you from reminding nurses to perform hand hygiene if you see they are not?

You may tick (√) more than one from the responses provided and/or type your response in a

space provided.

I would be too embarrassed.

I wouldn’t want it to affect the care of my child.

I wouldn’t want to interrupt them.

I don’t feel it is my place to question nurses.

Or other reasons; please state:

………………………………………………………………………………………………………

13. What would stop you from reminding other healthcare workers to perform hand hygiene if you

see they are not?


space provided.


I wouldn’t want it to affect the care of my child.


I don’t feel it is my place to question other healthcare workers.


………………………………………………………………………………………………………

13. Your suggestions or comments to improve hand hygiene pratice in the unit?

…………………………………………………………………………………………………………

…………………………………………………………………………………………………………

---------------------------------------------------End of the questions--------------------------------------------

--

Thank you for completing this survey.

213

Appendix I Survey participant information sheets (Parents and Nurses)

217

Appendix J Survey Questionnaire (Nurses)

We would like you to complete this survey. We hope to learn what you understand about ventilator-

associated pneumonia (VAP) while taking care of your patients. We also hope to learn your opinion

about ‘speaking up’ for hand hygiene.

It should take you less than 5 minutes to complete this questionnaire. Please read the

questions carefully and then respond spontaneously.

✓ There is no right or wrong on your answers

✓ Your answers are anonymous and will be kept confidential

✓ This questionnaire has two sections

Section A: Demographic information

Please tick (√) on designated box and/ or write your response in a space provided.

1. What is your sex?

2. How long have you been working in PICU? (in months/years)

___________________________

3. What method do you routinely use for your hand hygiene in PICU?

Male

Female

Hand gel

Hand wash

Combination

*Hand hygiene is the process of cleaning your hands. There are two methods of hand

hygiene: washing with soap and water or the use of hand gel/alcohol-based rub/sanitizer.

** Other healthcare workers in this study is refer to other than nurses; example is doctor,

physiotherapist, dietitian, occupational therapist and etc.

218

Section B: ‘Speaking up’ for hand hygiene

This section is related to your opinion regarding 'Speaking up' for hand hygiene.

4. Please read the following statements and tick (√) to the most appropriate response.

Statements

Strongl

y

Disagre

e

Disagre

e

Neither

Agree nor

Disagree

Agre

e

Strongly

Agree

I would remind parents to perform hand

hygiene if necessary. O O O O O

I am willing to be reminded by parents to

perform hand hygiene if I did not. O O O O O

I am willing to be reminded by other

healthcare workers to perform hand

hygiene if I did not.

O O O O O

I think by speaking up for hand hygiene,

it would increase hand hygiene practise

among parents.

O O O O O

I think by speaking up for hand hygiene,

it would increase hand hygiene practise

among other healthcare workers.

O O O O O

5. What would stop you from reminding parents to perform hand hygiene if you see they are not?


space provided.



I don’t feel it is my place to question parents.


_________________________________________________________________________

6. What would stop you from reminding other healthcare workers to perform hand hygiene if you

see they are not?


space provided.



I don’t feel it is my place to question them.


_________________________________________________________________________

7. Your suggestions or comments to improve hand hygiene pratice in the unit.

________________________________________________________________________

________________________________________________________________________

Thank you for completing this survey.

219

Appendix K Data collection sheet (Prospective study)

No Variable Label Tool Coding in SPSS Remarks

1. Patient no Pt no Patient no labelled after met the inclusion

& exclusion criteria [Cohort 2017- six

months 12_6_17 till 12_12_17)]

Patient 1 to ….110

1

2

3 and until ….110

Corresponding to the

number of patients in the

study

2. Episodes of

mechanical

ventilation

EpisodesofMV_experi

mental_unit

The number is corresponding to the

number of mechanical episodes of each

patient

1- …120 The experimental unit

_episodes of MV evaluated

for VAP and VAE

3. Admission PICU_Admission Number of PICU admission of each

patient

1 for 1st admission

2 for 2nd admission

3 for 3rd admission

Demographic

characteristics

4. Mechanical

ventilation number

MVnumber Mechanical ventilation number during

admission for each patient

1 for MV number 1 (single)

2 for MV number 2

3 for MV number 3

5. Patient’s admission MV_Pt_admission

Number of MV in each admission

1 for MV no 1 in admission no 1

2 for MV no 2 in admission no 1

….

6. Age Age_in months Age of the patients - in months True age (in 1 decimal point) –

in months

Demographic


factor

7. Gender Gender The sex of patients – male and female Male

Female

Demographic


factor

220

8. Weight Wt Weight of patients- in Kg True weight in Kg (1 decimal

point)

Demographic


factor

9. PICU admission

source

IADM_SC_PICU The classification is based on ANZPIC

registry data collection form- 2016

1. OT/recovery,

2. Emerg Dept

3. Ward (any other inpatient

area)

4. Other ICU/NICU-same

hospital


Demographic


factor

10. IADM_SC_PICU_r

ecats_to4

Recats to 4 categories Re-categorised PICU to 4 categories only 1. OT/recovery,

2. Emerg Dept

3. Ward (any other inpatient

area); Other ICU/NICU-same

hospital


11. Principal ICU

diagnosis

PDX Code the diagnosis most directly

responsible for the ICU admission





5. Renal (500-


7. Infection (700-



12. Underlying disease

for PICU admission

UDX The codes are according to ANZPIC






5. Renal (500-


7. Infection (700-


Demographic

characteristics/ risk factor

*Requirement for CDC


tool

221


13. UDX_recat_3cats Recategories UDX to 3

main cats

The codes are according to ANZPIC


1. cardiovascular

2. respiratory

3. others

14. PIMS 3 Paediatric Index of

Mortality

True calibrated PIMS 3 score True scores – 999- missing

value

15. Immunosuppressive

patient?

Immunosuppressive

pt?

Whether the patient is immunosuppressive

or not; eg: cancer patients, transplant

patients

Yes- 1

No- 0

Demographic

characteristics

16.

PICU Diagnosis

category

PICU

Diagnosis_category

Medical, surgical and Trauma 1- Medical

2 - Surgical

3- Trauma

Demographic characteristic

&/ risk factor

17. Diagnosis written Dignosis_written Diagnosis written in the daily report

available at CHQ server

Diagnosis written in the

Metavision or in daily PICU

census

Demographic characteristic

18. PICU date and time

of admission

PICU_admission PICU date and time of admission

retrieved from ANZPIC via Metavision



system)

19. PICU date and time

discharged

PICU_Discharged PICU date and time of discharged




system)

20. Commencement of

mechanical

ventilation

Commenceof MV Date and time commencement of

mechanical ventilation retrieved from

ANZPIC via Metavision



system)

21. Cease of

mechanical

ventilation

CeaseofMV Date and time cease of mechanical

ventilation retrieved from ANZPIC via

Metavision



system)

22. Column ceased

commenced 1st

identified X-

Ray_VAP

Columnceasedcommen

ced1stidentifedxray


mechanical ventilation for those case that

did not identified as VAP (same as date

and time of ceased of mechanical

ventilation)



system)

222

23. Column ceased

commenced 1st

identified VAC

Columnceasedcommen

ced1stidentifeas VAC


mechanical ventilation for those case that

did not identified as VAC (same as date

and time of ceased of mechanical

ventilation)



system)

24. Duration of MV Duration_MV Recorded in days (MV cease date & time

minus MV commence date & time)


25. Duration of PICU

stay (days)

Length_of_PICU_stay Recorded in days (PICU discharge date &

time minus PICU admission date minus &

time)


26. Admission in

hospital

Admission_Hosp Date and time admission to hospital




system)

27. Discharged from

hospital

Discharged_Hosp Date and time discharged from hospital




system)

28. Duration of hospital

stay (days)

Length_of_hospital_sta

y

Recorded in days (Hospital discharge date

& time minus hospital admission date &

time)


29. PICU outcomes PICU_OUTCOME The classification is based on ANZPIC

registry data collection form- 2016:

1- Discharge to ward/home;

2- Died in PICU;

3- Transferred to another ICU

(includes NICU), or other

hospital

4- Still in PICU,

5- Died within 24 hours after

being discharged from ICU to

receive palliative care

Outcomes

30. Mortality Mortality_died and not

died

Categorised whether pt died or not 0- not died

1-died

31. PICU_outcome_rec

at_3cats

Recategorised to 3

categories

Recategorised to Discharge to ward/home;

Transferred to another ICU (includes

NICU), or other hospital, died in PICU

and died

1. Discharge to ward/home;

Transferred to another ICU

(includes NICU), or other

hospital; Died within 24 hours

223

after being discharged from ICU

to receive palliative care

2. Died in ICU

3. Still in PICU

32. Mechanical

ventilation days

MV_day MV days that each patient was on ETT

tube. Each patient may have varied

number of MV days

Data from Day 1…max day 61

(in this cohort) documented

33. Date of intubation Date Day 1 of patient on ETT Recorded as date eg: 12/06/2017 Important for VAE (VAC,

IVAC, PVAP is

determined)

34. Worsening gas

exchange

[(Increased oxygen

requirement, or

increased

ventilation

demand)] (i)FiO2

(ii) PEEP or iii)

Spo2 <94%

FiO2 _min True value of minimum FiO2 at least

sustained for 1 hour in a day -for every

MV days

True value of minimum FiO2,

999 as missing value if no FiO2

documented.

Requirement for VAC

(VAE) -1st Tier [new CDC

VAE surveillance tool]






demand in CDC


tool

35. Worsening gas

exchange

[(Increased oxygen

requirement, or

increased

ventilation

demand)] (i)FiO2

(ii) PEEP or iii)

Spo2 <94%

Min PEEP True value of minimum PEEP at least

sustained for 1 hour in a day -for every

MV days

True value of minimum PEEP,

999 as missing value if no PEEP

value documented.

Requirement for VAC

(VAE)- 1st Tier [new CDC







demand in CDC


tool

224

36. Minimum

temperature

Temp_min True value of min temperature of the day True value of minimum temp,

999 as missing value if no mi

temp value documented.

IVAC and VAP

determination

37. Maximum

temperature

Temp_max True value of max temperature of the day True value of maximum PEEP,

999 as missing value if no max

temp value documented.

IVAC and VAP

determination

38. Minimum WBC WBC_min True value of min WBC of the day True value of minimum WBC,

999 as missing value if no min

WBC value documented.

IVAC and VAP

determination

39. Maximum WBC WBC_min True value of max WBC of the day True value of maximum WBC,

999 as missing value if no max

WBC value documented.

IVAC and VAP

determination

40. Antibiotic What_antibiotic Name of antibiotics, which the patients

were administered for each MV days

The antibiotics are based on list stated in

VAE surveillance tool (67 antibiotics) -refer to antibiotic list at the end of sheet)

Recorded as name of respective

antibiotic/s

NA – if the patients were on antibiotics

that not in the list

No_Ab- if the patients were not on any

antibiotic/s.

Requirement for VAE;

IVAC (2nd Tier) [new CDC


41. Respiratory

specimens

Specimen Document the respiratory secretions sent

ETA

BAL

Pleural fluid

Lung tissue biopsy

Same as in the tool column PVAP determination and

supporting for VAP

(microbiological findings)

42. Polys/epis polys/Epis Documented the gram stain

Gram+ve, Gram-ve, no growth, no sample

sent: (cocci, bacilli or other) (washing

BAL or BAL) (Pleural fluid RT/LT)

(Lung tissue biopsy)

Documented as


Leu- scant, 1+ - 4+

Same as in the tool column PVAP determination and

supporting for VAP

(microbiological findings)

225

Sq. epi

Erythrocyte

WBC’s ___x10^6/L; RBC’s___x10^6/L;

Polymorphs___%


No organism seen, normal respiratory

flora, organism name (scant, 1+ -4+), no

fungi isolate, coagulase neg.

staphylococcus Isolate_CFU/ML

43. Number of

antibiotics

Numb_of_AB Number of antibiotics corresponding to

the listed antibiotic in VAE surveillance

protocol

0 – no antibiotic

1- one antibiotic

2 – 2 antibiotics

3- 3 antibiotics

4- 4 antibiotics

5- 5 antibiotics

6- 6 antibiotics

Manually determine for

VAE (IVAC)

44. Ventilator-

associated event

(VAE)

VAE Number of episodes identified as VAE

and not

0- No

1- Yes

45. Ventilator-

associated event

(VAE)

VAE_categories Number of identified as VAE (VAC,

IVAC, PoVAP - meeting the VAE

algorithm

0=No

1. VAC

2. IVAC

3. PoVAP

Manually calculated/

determined using new


tool CDC VAE calculator

version 4.0 then used to

confirmation.

46. ETT type Cuffed or uncuffed Whether the ETT is cuffed or not 0- No

1- Yes

47. Overall ETT cuffed

or not

Overall_ETTcuffed_or

_not

Overall Yes (1) is determined if the “yes”

found in the majority of MV days of every

episodes of MV or if the “yes” are equal

with “no” in MV days – counted as Yes

(1)

0- No

1- Yes

48. Reintubation

episodes

Reintubationepisodes The presence of any reintubation was

taken place or not.

0- No

1- Yes


226

49. Overall

Reintubation

episodes_for risk

factor analysis

Overall_Reintubatione

pisodes

If any event of reintubation took place in

each days of every episodes (1) consider

as yes and (0) is no/nil.

0- No

1- Yes


further analysis

50. Routes of intubation Routes_Intubation Routes of endotracheal intubation whether

nasal or oral or tracheosotomy

1- Nasal

2- Oral

3- Tracheostomy


51. Overall routes of

intubation

Overall_Routes_Intuba

tion

Determined as with Nasal tube if the


nasal tube=coded as 1

Determined as with Oral tube if patient

has the longest (MV days) on Oral

tube=coded as 2

Determined as with tracheostomy tube if

the patient has the longest (MV days) on

tracheostomy tube after being intubated

with nasal or oral tube =coded as 3

If the same total numbers of MV days –

consider the last changed/ the newest type

of tube to be overall

1- Nasal

2- Oral

3- Tracheostomy


further analysis

52. Highest sedation

scores

Highestsedationscore -3 – unresponsive/paralysed

-2 – response to noxious stimuli

-1 – response to gentle touch/voice

0 – awake & able to calm

+1 – restless & difficult to calm

+2- agitated

-3

-2

-1

0

+1

+2


53. Overall Highest

sedation score

OverallHighestsedation

score

The score is counted as overall if the score

had the majority numbers of MV days in

episode/s of MV. If the score found in

equal number of MV days; the score on

the last day will be taken as overall

Scores Risk factor – will use to

further analysis

54. Sedation category Sedation categories Score above were recode into nominal (3

categories)

Recoded into 3 categories

1- Deep Sedation

(Score of -2 to -3)

227

2 – Light Sedation

(Score of -1 to +1)

3- Agitated

(Score of +2)

55. Paralytic agent Paralyticagent The administered of any paralytic drugs

for each MV days

yes - if the infusions were given> 4 hours

of infusion or > 4 times bolus dose

no – other than the criteria above

0- No

1- Yes


56. Overall Paralytic

agent

Overall_Paralyticagent Overall Yes (1) is determined if the “yes”




(1)

0- No

1- Yes


further analysis

57. Gastrointestinal

prophylaxis

GIprophylaxis The administered of any GI prophylaxis

drugs for each MV days

0- No

1- Yes


58. Overall GI

prophylaxis

OverallGiprophylaxis Overall Yes (1) is determined if the “yes”




(1)

0- No

1- Yes


further analysis

59. Steroid presence Steroid The presence of steroid for each MV days 0- No

1- Yes


60. Overall steroid

presence

Overall_steriod The presence of any steroid even if only

one day of MV- yes

0- No

1- Yes

61. Blood transfusion Blood transfusion The presence of blood transfusion for

each MV days

0- No

1- Yes

62. Overall blood

transfusion

Overall_BT The presence of any steroid even if only

one day of MV- yes

0- No

1- Yes

63. Nasogastric

(NG)tube presence

Nasogastrictubepresen

ce

The presence of NG tube for each MV

days

0- No

1- Yes


64. Overall Nasogastric

tube presence

OverallNasogastrictube

presence

Overall Yes (1) is determined if the “yes”


0- No

1- Yes


further analysis

228



(1)

65. X-Rays with disease X-Ray with disease Yes - if radiological report (in each MV

days) distinguished the findings as: 2 or

more serial X-Rays with 1 of the

following:

new or progressive and persistent

infiltrate

consolidation

cavitation

pneumatoceles, in < 1 y.o



Rays findings and no X-Ray done on the

particular days

NA- if patient without disease

0- No

1- Yes

3- NA

Requirement for CDC


tool

66. X-Rays without

disease

X-Ray without disease Yes - if radiological report (in each MV

days) distinguished the findings as: 1 or

more serial X-Rays with 1 of the

following

new or progressive and persistent

infiltrate

consolidation

cavitation

pneumatoceles, in < 1 y.o



Rays findings and no X-Ray done on the

particular days

NA- if patient with disease

0- No

1- Yes

3- NA

Requirement for CDC


tool

67. Worsening gas

exchange

[(Increased oxygen

SpO2 < 94% Yes- if any of SpO2 readings <94% in a

day- for every MV days

No

0- No

1- Yes

2- No value

Requirement for CDC


tool especially for infant

229

requirement, or

increased

ventilation

demand)] (i)FiO2

(ii) PEEP or iii)

Spo2 <94%

<1y.o apart from

worsening oxygenation

SpO2 <94%

Also, for children >1y.o

68. Temperature

instability

Temp<36oC_or>38oC Yes- if any of temperatures was 36oC_ or

>38oC in a day – for every MV days.

No

0- No

1- Yes

2- No value

Requirement for both CDC


tool and

VAE (IVAC- 2nd tier) [new


tool]

69. Tachypnea

RR_aged_based Defined as [(> 75 breath/min –premature

infants born at <37 wks & until 40th wks;

>60bpm=<2 months old; >50bpm= 2-12

months old; >30bpm=children >1 yr.

old)].

Yes – if any of the respiration rates in a

day of each MV days met the tool based

on age classifications as above.

No

0- No

1- Yes

2- No value

Requirement for CDC


tool

70. Bradycardia or

tachycardia

HR<100or>170_infant

<1yr

Defined as HR <100 or >170 beats /min

Yes- if any of HR reading was <100 or

>170 beats/min in a day – for every MV

days.

No

NA (for infant >1yr. old)

0- No

1- Yes

2- No value

3- NA for patients >1 y.o.

Requirement for CDC


tool

Applicable for infant <1y.o

only

71. Changes in

character of the

sputum

changesputumcharac Defined as change in sputum character [(i)

colour; (ii) consistency; (iii) quantity

Yes

No

Considering this character first:

Sputum colour: yellow, creamy, green,

brown

Sputum consistency: thick

0- No

1- Yes

Requirement for CDC


tool

230

Sputum quantity: large, copious, moderate

72. Leukopenia or

Leukocytosis

WBCC (≤4K or ≥15K) Yes- if any of WBCC results was ≤4K or

≥15K in a day – for every MV days.

No

0- No

1- Yes

2- No value/missing/no sample

sent



tool and

VAE (IVAC- 2nd-Tier)

[new CDC VAE

surveillance tool]

After gathered all data &

the VAC confirmed;

second screening done for

IVAC determination as

≥12K is required

73. Microbiological

consideration of

respiratory

secretions

Gram_staning Recorded for

ETA

BAL

Pleural fluid

Lung tissue biopsy

Gram+ve, Gram-ve, no growth, no sample

sent :(cocci, bacilli or other) (washing

BAL or BAL) (Pleural fluid RT/LT)

(Lung tissue biopsy)



tool



surveillance tool]

74. Corresponding

values to

quantitative

threshold values for

cultured specimens

used in diagnosis of

pneumonia

Colony_forming_unit Documented as


Leu- scant, 1+ - 4+

Sq. epi

Erythrocyte

WBC’s ___x10^6/L; RBC’s___x10^6/L;

Polymorphs___%




tool



surveillance tool]

75. Name of the

organism with

quantitative

threshold values for

cultured specimens

Organisms isolated No organism seen, normal respiratory

flora, organism name (scant, 1+ -4+), no

fungi isolate, coagulase neg.

staphylococcus Isolate_____CFU/ML



tool



surveillance tool]

231

used in diagnosis of

pneumonia

76. Ventilator-

associated

pneumonia (VAP)

VAP Number of identified as VAP case-

meeting the CDC tool from each

experimental unit (from 120 episodes of

MV)

0- No

1- Yes

Manually determined

based on CDC PNEU/VAP

surveillance tool

77. Hand hygiene

practise

HH % of compliance by month (June – Dec

2017)

%

78. Frequency of oral

hygiene practises

MouthCareF Is referred to the frequency of mouth care

was performed for every MV days

Frequency of MC performance

(count)

Raw data

79. Overall OH

Frequency

OverallOHFrequency Average of the frequency to MV days of

every episodes of MV



Further analysis required to

determine the compliance

rate based PICU Oral

Hygiene protocol (<6

months without teeth and >

6 months with teeth)

80. Adhered to 12 -

hourly OH

assessment

Adhered to 12- hourly

OH assessment

Adhered to 12 -hourly oh assessment in

every MV days

0- No

1- Yes

81. Overall adhered to

12- hourly OH

assessment

Overall_adhered to 12-

hourly OH assessment

Counted as the majority of yes/no in MV

days – If equal number of Yes/ No found

in one episode of MV – considered as Yes

0- No

1- Yes

82. Adhered to

appropriate OH

Age appropriate OH Adhered to age appropriate OH material <

than six months and > than 6 months as

per PICU oral hygiene protocol for every

MV days

0- No

1- Yes


appropriate OH

Overall adhered to

appropriate OH




0- No

1- Yes

84. Frequency of ET

suctioning practises

SuctioningF Is referred to the frequency of ET suction

was performed for every MV days

Frequency of ET performance

(count)

Raw data

85. Overall suctioning

frequency

Overall_suctioning_fre

quency

Average of the frequency to MV days of






rate based on PICU

232

minimum standard of

suctioning frequency (4

times/ 24 hours)

86. Frequency of cuff

pressure checks

practises

CuffpressurechecksF Is referred to the frequency of cuff

pressure check was performed for every

MV days

Frequency of Cuff Pressure

performance (count)

0 is recorded as uncuffed or

ordered as deflated

Raw data

87. Overall cuff

pressure frequency

Overallcuffpressure_fr

equency







rate based on PICU

standard (at least 12 hourly

or twice daily)

88. Adhered to 12

hourly cuff pressure

checks

Adhered to 12 hourly

cuff pressure checks

Adhered to 12 hourly cuff pressure checks

in every MV days

0- No

1- Yes


deflated)


12 hourly cuff

pressure checks

Overall_adhered to 12

hourly cuff pressure

checks




0- No

1- Yes


deflated)

90. Maintain to cuff

pressure limits

Maintain to cuff

pressure limits

Cuff pressure is maintained min 10 -

15/20cm H20 max

0- No

1- Yes

3- NA (uncuffed/ deflated)

91. Overall Maintain

cuff pressure limits

Overall_Maintain cuff

pressure limits


days – If equal number of Yes/ No /NA

found in one episode of MV – considered

as Yes

0- No

1- Yes


deflated)

92. Frequency of head

of bed elevation

practises

HeadofelevationF Is referred to the frequency of head of bed

elevation care was performed in a day for

every MV days

Frequency of HOB performance

(count)

Raw data

93. Overall HOB

frequency

Overall_HOB_frequen

cy







rate based on PICU

standard

233

94. Adhered to HOB

degree

Adhered to HOB

degree

Is keeping HOB 15-30 degree every MV

days

0- No

1- Yes

Raw data and later will

compared with unit

standard (24 times/ 24

hours)


HOB degree

Overall_Adhered to

HOB degree



in one episode of MV – considered as

Yes. (Is keep HOB 15-30 degree)

0- No

1- Yes

96. Frequency of

ventilator circuits

practises

VentilatorcircuitsF Is referred to the frequency of ventilator

circuits was performed for every MV days

(Unit standard: 24 times/ 24 hours)

Frequency of Ventilator Circuit

performance (count)

Raw data

97. Overall Vent circuit

check_ frequency

Overall_Vent_cir_chec

k_frequency




represent each episode= of MV



rate based PICU standard

98. Enteral feeding

started within 24

hours of admission

Enteral feeding started

within 24 hours of

admission

The enteral feeding is started within 24

hours of admission

0- No

1- Yes

Descriptive analysis

234

Appendix L Parents information sheet and consent form for prospective study

237

Appendix M Approval of waiver of consent for prospective study

an epidemiological study of ventilator-associated

Documents