Preventing Ventilator-Associated Tracheitis in the Pediatric Cardiac Intensive Care Unit

The Centers for Disease Control and Prevention has reported that, each day in the United States, about 1 in every 31 hospital patients develops a health care–associated infection (HAI).1 This statistic is alarming; however, because the available data are limited by the scope and accuracy of reporting, the true prevalence and impact of HAIs are likely much larger. This article describes how a group of nurses in a pediatric cardiac intensive care unit (CICU) identified an overlooked infection, ventilator-associated tracheitis (VAT), that was occurring at concerning rates in their patient population and created and implemented an evidence-based prevention bundle to reduce the incidence of infection and improve patient outcomes.Seattle Children’s Hospital is a 407-bed pediatric teaching hospital in Seattle, Washington. It is the pediatric referral center for the “WAMI” region, which includes Washington, Alaska, Montana, and Idaho. The 24-bed CICU serves patients from birth to young adulthood and is home to extracorporeal membrane oxygenation, ventricular assist device, and heart transplant programs.Ventilator-associated tracheitis and ventilator-associated pneumonia (VAP) are 2 relatively common complications of intubation. Their diagnostic criteria are almost identical, with both infections characterized by a combination of fever, increased work of breathing, and increased respiratory secretions. Unlike VAT, VAP requires evidence on chest radiograph for diagnosis.2 Consequently, many infections may fall short of meeting the diagnostic criteria for VAP and are, therefore, not reported in the HAI data that are tracked. Although VAT may seem like a lesser infection, the complications of the 2 infections are almost identical. Both VAT and VAP lead to prolonged intubation, prolonged hospital stay, increased use of antibiotics, and increased metabolic demand. Ventilator-associated tracheitis may also predispose patients to subsequent episodes of VAP.3,4From August 2020 through January 2021, the CICU at Seattle Children’s Hospital had 1 case of VAP and 27 cases of VAT. In considering the VAP rate alone, respiratory infections for intubated children in the CICU appear to be quite infrequent. However, many of the CICU patients diagnosed with VAT were symptomatic and required treatment for the infection with antibiotics. There also appeared to be a correlation with central line [catheter]–associated bloodstream infections (CLABSIs). During the 1-year period from October 2019 through September 2020, 53% of CLABSIs in the CICU occurred in patients who had previously had an episode of tracheitis involving the same organism. This finding indicates that although VAT is not a condition traditionally tracked by hospitals, it warrants more attention. A group of nurses from the CICU investigated the problem and ultimately designed a quality science project through the American Association of Critical-Care Nurses Clinical Scene Investigator Academy to address this issue on the unit.The purpose of this project was to create and implement a nurse-driven, evidence-based VAT prevention bundle. The goal of the project was to achieve compliance greater than 90% for all measured bundle elements and a subsequent 15% reduction in VAT rate by 6 months after implementation.The team of nurses conducted a literature review to better understand VAT and VAP, including their causes, complications, long-term outcomes, and prevention strategies. Because of the overwhelming similarities between the infections, data related to VAT and VAP were used in the design of the bundle elements. The mnemonic “COMBAT VAT” was chosen to summarize the bundle elements. COMBAT stands for the following: change equipment, oral care, maintain closed circuit, bed elevation, and thorough hand hygiene (see Table).Once the bundle elements were defined, audits were performed to determine a baseline understanding of current practice. A survey was sent to all staff members to assess the team’s current understanding of the issue. The survey results confirmed that most nurses did not know the difference between VAT and VAP. In comparison of survey results with audit data, it was clear that most nurses believed they were following infection prevention practices to prevent both VAT and VAP. Unit audits revealed that actual compliance with infection prevention practices was much lower than nurses’ perception of compliance with these practices.After collection of 2 months of baseline bundle element compliance data, the prevention bundle was rolled out. An education module was shared with CICU nursing, respiratory therapy, and provider teams in July 2021. Promotional materials including reference cards and mouse pads were distributed throughout the unit to serve as reminders of the new bundle elements and to encourage culture change. In August 2021, postintervention bundle element audits began. A bulletin board was created to display current bundle element compliance rates and to encourage increased awareness and culture change (Figure 1).The project was well received, but lasting change takes time. In November 2021, the team introduced a peer recognition program called “VAT Heroes” to celebrate the work of team members on the unit to prevent tracheitis. Nomination cards were placed around the unit, and team members were encouraged to fill them out at any time to recognize their peers when they were following the bundle elements and modeling VAT prevention. Each week, 1 nominee was randomly selected to win a coffee gift card. The winner was announced and recognized in the weekly unit bulletin email. All the nominations were hung on a whiteboard near the staff break room, and this recognition wall grew throughout the project.Bundle element compliance (change equipment, oral care, bed elevation, and hand hygiene) was tracked for 6 months after implementation and compared with the data from the 2 months before implementation. It was difficult to measure the bundle element “maintain closed circuit” because auditors were not always present to see when the ventilator circuit was opened. Consequently, these data were not included. Hand hygiene audit data were not available for January 2022 because of a brief hospital-wide pause in that auditing program. Audits revealed a steady increase in bundle element compliance (Figure 2). In December 2021, there was a notable decline in suction equipment changes. This change was likely due to the critical supply shortages of suction buckets and tubing that the hospital experienced during this period, preventing the nurses from changing the equipment on time. When supply levels returned to normal in January 2022, compliance increased dramatically. Although the initial goal of maintaining greater than 90% compliance in all measured bundle elements was not met by 6 months after implementation, the unit demonstrated a steady increase in compliance with the bundle elements over time. With more time for this practice change to solidify on the unit, compliance is expected to continue to increase.To measure the effect of the prevention bundle on the VAT rate, VAT data were tracked before and after implementation. The VAT rate had never been measured before at this institution, so it was challenging to develop a system to accurately track the rate of infection. Cases of VAT are diagnosed with a tracheal aspirate culture. However, there is no standard for how often tracheal aspirates are collected for symptomatic patients in the CICU. Some patients had tracheal aspirates sent for culture multiple times within a week, and it was clear that positive results in these cases did not represent multiple new infections. Furthermore, once a patient had a positive tracheal aspirate culture, their future tracheal aspirate cultures would continue to be positive for the duration of their intubation because of the colonization of their airway. Given these factors, simply tracking positive tracheal aspirate culture results was not an accurate way to measure VAT rate. To track CICU VAT rate, the first positive tracheal aspirate culture per patient was counted as a case of VAT. Future positive tracheal aspirate cultures were excluded from the data because they likely either represented the same infection or reflected colonization of the patient’s airway. Although this counting method may under-represent the total number of VAT cases, any changes in the VAT rate calculated by this method should accurately reflect the overall rise or decline in the unit’s VAT rate.The 6-month VAT rate after implementation (August 2021 through January 2022) was compared with the VAT rate for the same 6 months of the previous year (August 2020 through January 2021). Between these 2 periods, the 6-month VAT rate decreased by 34%. In addition, during the postimplementation period the unit saw 2 months with zero VAT cases (Figure 3). Because of the noted correlation between CLABSI and VAT in the CICU, the CLABSI rate was also tracked as part of this project. During the same period, the CLABSI rate decreased by 14%.To achieve positive outcomes for patients and their families, harm must be prevented. Although many HAIs are monitored closely by hospitals and governing bodies, other infections garner less attention but may be equally or more prevalent in specific populations. As demonstrated by the correlation and subsequent decrease in CLABSI rate during this project, these lesser-known infections may also be a hidden factor contributing to some of the commonly measured HAIs.The correlation between VAT and CLABSI should be investigated further, along with other less commonly recognized HAIs. Nurses are in a unique position to identify and design interventions to prevent these lesser-known types of harm from occurring to patients while achieving measurable improvements in patient outcomes.The authors thank the Seattle Children’s cardiac intensive care unit team for their dedication to this project’s success. They also thank the American Association of Critical-Care Nurses Clinical Scene Investigator Academy, specifically Marian Altman, PhD, RN, CNS-BC, CCRN-K, and Debbie Brinker, MSN, RN, CNS, for their expertise and guidance.