Quality Improvement Initiative to Reduce Pediatric Intensive Care Unit Noise Pollution With the Use of a Pediatric Delirium Bundle.

OBJECTIVES:: Noise pollution in pediatric intensive care units (PICU) contributes to poor sleep and may increase risk of developing delirium. The Environmental Protection Agency (EPA) recommends <45 decibels (dB) in hospital environments. The objectives are to assess the degree of PICU noise pollution, to develop a delirium bundle targeted at reducing noise, and to assess the effect of the bundle on nocturnal noise pollution. METHODS:: This is a QI initiative at an academic PICU. Thirty-five sound sensors were installed in patient bed spaces, hallways, and common areas. The pediatric delirium bundle was implemented in 8 pilot patients (40 patient ICU days) while 108 non-pilot patients received usual care over a 28-day period. RESULTS:: A total of 20,609 hourly dB readings were collected. Hourly minimum, average, and maximum dB of all occupied bed spaces demonstrated medians [interquartile range] of 48.0 [39.0-53.0], 52.8 [48.1-56.2] and 67.0 [63.5-70.5] dB, respectively. Bed spaces were louder during the day (10AM to 4PM) than at night (11PM to 5AM) (53.5 [49.0-56.8] vs. 51.3 [46.0-55.3] dB, P < 0.01). Pilot patient rooms were significantly quieter than non-pilot patient rooms at night (n=210, 45.3 [39.7-55.9]) vs. n=1841, 51.2 [46.9-54.8] dB, P < 0.01). The pilot rooms compliant with the bundle had the lowest hourly nighttime average dB (44.1 [38.5-55.5]). CONCLUSIONS:: Substantial noise pollution exists in our PICU, and utilizing the pediatric delirium bundle led to a significant noise reduction that can be perceived as half the loudness with hourly nighttime average dB meeting the EPA standards when compliant with the bundle.

Rebound in ventilator-associated pneumonia rates during a prevention checklist washout period.

OBJECTIVE To describe the washout effect after stopping a prevention checklist for ventilator-associated pneumonia (VAP). METHODS VAP rates were prospectively monitored for special cause variation over 42 months in a paediatric intensive care unit. A VAP prevention bundle was implemented, consisting of head of bed elevation, oral care, suctioning device management, ventilator tubing care, and standard infection control precautions. Key practices of the bundle were implemented with a checklist and subsequently incorporated into the nursing and respiratory care bedside flow sheets to achieve long-term sustainability. Compliance with the VAP bundle was monitored throughout. The timeline for the project was retrospectively categorised into the benchmark phase, the checklist phase (implementation), the checklist washout phase, and the flowsheet phase (cues in the flowsheet). RESULTS During the checklist phase (12 months), VAP bundle compliance rose from <50% to >75% and the VAP rate fell from 4.2 to 0.7 infections per 1000 ventilator days (p<0.059). Unsolicited qualitative feedback from frontline staff described overburdensome documentation requirements, form fatigue, and checklist burnout. During the checklist washout phase (4 months), VAP rates rose to 4.8 infections per 1000 ventilator days (p<0.042). In the flowsheet phase, the VAP rate dropped to 0.8 infections per 1000 ventilator days (p<0.047). CONCLUSIONS Salient cues to drive provider behaviour towards best practice are helpful to sustain process improvement, and cessation of such cues should be approached warily. Initial education, year-long habit formation, and effective early implementation demonstrated no appreciable effect on the VAP rate during the checklist washout period.

Protecting fragile skin: nursing interventions to decrease development of pressure ulcers in pediatric intensive care.

BACKGROUND: The reported incidence of pressure ulcers in critically ill infants and children is 18% to 27%. Patients at risk for pressure ulcers and nursing interventions to prevent the development of the ulcers have not been established. OBJECTIVES: To determine the incidence of pressure ulcers in critically ill children, to compare the characteristics of patients in whom pressure ulcers do and do not develop, and to identify prevention strategies associated with less frequent development of pressure ulcers. METHODS: Characteristics of 5346 patients in pediatric intensive care units in whom pressure ulcers did and did not develop were compared. Multiple logistic regression was used to determine which prevention strategies were associated with less frequent development of pressure ulcers. RESULTS: The overall incidence of pressure ulcers was 10.2%. Patients at greatest risk were those who were more than 2 years old; who were in the intensive care unit 4 days or longer; or who required mechanical ventilation, noninvasive ventilation, or extracorporeal membrane oxygenation. Strategies associated with less frequent development of pressure ulcers included use of specialty beds, egg crates, foam overlays, gel pads, dry-weave diapers, urinary catheters, disposable under-pads, body lotion, nutrition consultations, change in body position every 2 to 4 hours, blanket rolls, foam wedges, pillows, and draw sheets. CONCLUSIONS: The overall incidence of pressure ulcers among critically ill infants and children is greater than 10%. Nursing interventions play an important role in the prevention of pressure ulcers.