A quality improvement initiative to optimize diagnostic and antimicrobial stewardship of ventilator-associated tracheitis in the pediatric intensive care unit.

OBJECTIVE

To reduce frequency of endotracheal aspirate culture (EAC) collection and decrease antibiotic days of therapy (DOT) for ventilator-associated tracheitis (VAT).

DESIGN

Quality improvement intervention.

SETTING

Tertiary-care pediatric intensive care unit (PICU).

PATIENTS: Admitted to the PICU with an endotracheal tube (ETT) or tracheostomy.

INTERVENTIONS: A clinical decision-support tool was implemented to provide clinical criteria for culture collection and microbiologic criteria for diagnosis, and to reduce treatment duration to 3 days. Key stakeholders were engaged, a nurse champion was identified, and a protocol was implemented. Culture rates (overall and serially repeated) and antibiotic DOT for VAT, each per 100 ETT/tracheostomy days, were analyzed. The proportion of VAT episodes treated for 3 days was also evaluated. Balancing measures included PICU mortality, ventilator-associated events, ventilator days, and length of stay. Statistical process control methods were used to analyze the data.

RESULTS

Across 1072 EACs sent and 213 VAT cases diagnosed, interventions led to a 23% reduction in monthly cultures (9.2 to 7.1 per 100 ETT/tracheostomy days) and a 53% reduction in serial culture use (1.5 to 0.7 per 100 ETT/tracheostomy days). There was a 53% reduction in monthly antibiotic DOT for VAT (10.8 to 5.1 per 100 ETT/tracheostomy days) and a 13-fold increase in the proportion of 3-day antibiotic prescriptions (5 to 65%). There was no increase in mortality, ventilator-associated events, ventilator days, or length of stay.

CONCLUSIONS

Standardized VAT guidelines in critically ill children can safely and effectively decrease culture and antibiotic use.