Ventilator-Associated Pneumonia in the Pediatric Intensive Care Unit:

Characterizing the Problem and Implementing a Sustainable Solution

MICHAEL T. BIGHAM, MD, RICK AMATO, RT, PATTIE BONDURRANT, RN, JON FRIDRIKSSON, MD, CATHERINE D. KRAWCZESKI, MD,
JENNI RAAKE, RT, SUE RYCKMAN, RN, STEVE SCHWARTZ, MD, JULIE SHAW, RN, DAN WELLS, RT, AND RICHARD J. BRILLI, MD

Objectives To characterize ventilator-associated pneumonia (VAP) in our pediatric intensive care unit (PICU), implement
an evidence-based pediatric VAP prevention bundle, and reduce VAP rates.
Study design The setting is a 25-bed PICU in a 475-bed free-standing pediatric academic medical center. VAP was
diagnosed according to Centers for Disease Control and National Nosocomial Infections Surveillance System definitions. A
pediatric VAP prevention bundle was established and implemented. Baseline VAP rates were compared with implementation
and post-bundle-implementation periods.
Results VAP is significantly associated with increased PICU length of stay, mechanical ventilator days, and mortality rates
(length of stay VAP 19.5 ⴞ 15.0 vs non-VAP 7.5 ⴞ 9.2, P < .001; ventilator days VAP 16.3 ⴞ 14.7 vs non-VAP 5.3 ⴞ 8.4, P
< .001; mortality VAP 19.1% vs non-VAP 7.2%, P ⴝ .01). The VAP rate was reduced from 5.6 (baseline) to 0.3 infections per
1000 ventilator days after bundle implementation; P < .0001. Subglottic/tracheal stenosis, trauma, and tracheostomy are
significantly associated with VAP.
Conclusions PICU VAP is associated with increased morbidity and mortality rates. A multidisciplinary improvement team can
implement a sustainable pediatric-specific VAP prevention bundle, resulting in VAP rate reduction. (J Pediatr 2009;154:582-7)

ospital-acquired infections occur in up to 12% of pediatric intensive care unit (PICU) patients.1 Pneumonia is the

H second most common hospital-acquired infection and accounts for 22.7% of such infections in the PICU.1,2 The main
contributing factor for development of hospital-acquired pneumonia is mechanical ventilation, which increases the
infection risk 6- to 21-fold.2,3 Specific risk factors associated with pediatric ventilator-associated pneumonia (VAP) include the
presence of a genetic syndrome, tracheal reintubation, and transport out of the PICU.4 VAP occurs in about 5% of
mechanically-ventilated children, and of those children who acquire VAP, nearly 20% die.2,4 Data from National Nosocomial
Infection Surveillance hospitals indicate a pooled mean PICU VAP rate of 2.9 infections per 1000 ventilator days (0.0 [10th
percentile] to 8.1 [90th percentile]).5 PICU length of stay (LOS) is significantly increased in children with VAP compared with
those without VAP. Furthermore, some data suggest a trend toward increased mortality
rate for mechanically ventilated children with VAP compared with those without VAP,
although these mortality differences are not statistically different.1,4,6 Hospital costs are
significantly increased for pediatric patients with VAP compared with those without
VAP.7,8 As a result, payors and regulatory agencies have emphasized the importance of From the Department of Pediatrics, Divi-
sion of Critical Care Medicine and Pediatric
reducing or eliminating VAP in the ICU. Prevention of VAP has received even greater Intensive Care Unit (M.B., J.S., D.W., R.B.),
attention as pay for performance efforts have suggested that hospital acquired infections, Division of Neonatology and Neonatal In-
tensive Care Unit (R.A., P.B., J.F.), and the
such as VAP or nosocomial blood stream infections may disqualify providers from Division of Cardiology and Cardiac Inten-
receiving Medicaid or Medicare reimbursement. sive Care Unit (C.K., J.R., S.R., S.S.), Cincin-
As part of our hospital’s effort to improve patient care and prevent hospital acquired nati Children’s Hospital, Cincinnati, OH.
The authors declare no conflicts of interest.
infections, a Critical Care Unit Quality Improvement Collaborative was developed and
Submitted for publication Jun 10, 2008; last
focused on VAP prevention as its first quality improvement initiative. We hypothesized revision received Aug 14, 2008; accepted
that reliable implementation of and adherence to a pediatric specific VAP prevention care Oct 14, 2008.
bundle would decrease the VAP rate in our PICU. Reprint requests: Richard J. Brilli, MD,
FAAP, FCCM, Chief Medical Officer, Na-
tionwide Children’s Hospital, 700 Chil-
dren’s Drive, Columbus, OH 43205. E-mail:
rbrilli@nationwidechildrens.org.
0022-3476/$ - see front matter
Copyright © 2009 Mosby Inc. All rights
LOS Length of stay VAP Ventilator-associated pneumonia reserved.
PICU Pediatric intensive care unit
10.1016/j.jpeds.2008.10.019

582
 METHODS
Setting
Our hospital is a 475-bed academic quaternary-care
free-standing Children’s Hospital. It is the only pediatric
hospital in a large Midwest metropolitan area. In fiscal year
2006, the hospital had more than 25 000 admissions, 3067
ICU admissions, and 8125 ventilator days for all 3 intensive
care units: PICU, cardiac intensive care unit, and neonatal
intensive care unit. The PICU is a 25-bed multidisciplinary
unit providing around-the-clock physician and nursing cov-
erage for all children beyond the newborn age and in fiscal
years 2004 –2007 averaged 3690 ventilator days per year
(range 3054 to 4149 days).
Data Collection
All mechanically ventilated patients from January 2004
to December 2007 were included. Demographic information,
PICU admission Pediatric Risk of Mortality scores, PICU
and hospital LOS, duration of mechanical ventilation, and
hospital outcome (death or alive) were gathered retrospec-
tively. Bundle compliance and respiratory culture information
was gathered and recorded in real time.
Definitions
VAP was defined in accordance with criteria established
by the Centers for Disease Control and Prevention and the
National Nosocomial Infections Surveillance System.9 The
VAP definition was unchanged and interpreted by the same
group of infection control practitioners throughout the study.
The VAP diagnosis was made independently by trained in-
fection control program practitioners using chart review and
including but not limited to culture and radiologic reports.
The diagnosis was not made in consultation with the PICU
clinical service. VAP onset date was defined as the date a
culture was obtained and subsequently confirmed as positive
by the infection control staff. Respiratory cultures were ob-
tained as blind tracheal aspirates or by directed bronchoscopic
aspiration if requested by the clinical team caring for the
patient. Infection rate was defined as VAP infections per total
number of mechanically ventilated patients, expressed as a
percent. VAP rates were expressed as infections per 1000
mechanical ventilator days.
Process-Improvement Initiative
The model for improvement focusing on rapid-cycle
small tests of change formed the basis for our bundle devel-
opment and implementation strategies.10 A multidisciplinary
task force (Critical Care Unit Quality Improvement Collabo-
rative–VAP Prevention Collaborative) was established and
focused on eliminating or reducing VAP rates in all the
hospitals’ ICUs. The VAP prevention collaborative consisted
of physician, nursing, and respiratory therapy leaders from all
the ICUs, along with infection control staff, and quality
improvement consultants. The VAP Collaborative estab-
Ventilator-Associated Pneumonia in the Pediatric Intensive Care Unit: Characterizing the Problem and
Implementing a Sustainable Solution
lished the following specific aims for VAP reduction in the
pediatric intensive care unit: (1) Reduce VAP rates by 50%
during the first phase of project implementation compared to
baseline CY 2004 rates; (2) Reduce and sustain VAP rates to
National Nosocomial Infection Surveillance 50th percentile
for 6 consecutive months; and (3) Target completion date for
full and reliable implementation of VAP prevention bundle by
January 1, 2006. Using Institute for Healthcare Improvement
recommendations, targeted literature review, and intrainsti-
tutional expert clinician consensus, a pediatric-specific VAP
prevention bundle (Figure 1; available at www.jpeds.com) was
identified for implementation. The Institutional Review Bo-
ard approved this performance improvement collaborative.
Implementation Strategies
Implementation of each bundle element was led by the
PICU respiratory therapist. In contrast to a traditional “top-
down” method of new clinical practice implementation, this
collaborative was led by bedside practitioners (respiratory
therapists and nurses) who, by using rapid cycle tests of
change (Plan-Do-Study-Act), established the best methods
to achieve high reliability compliance with each bundle ele-
ment.11 The pediatric-specific VAP prevention care bundle
was codified during January and February 2005. Clinical staff
education and bundle implementation tests of change were
initiated during the remainder of the implementation period
(March–August 2005). Bedside clinician self-reporting “bun-
dle compliance checklists” were used to educate, remind, and
measure staff compliance with each bundle element (Figure 2;
available at www.jpeds.com). Compliance with each bundle
element and in aggregate was determined. New mouth care
packages were purchased and conveniently placed on the wall
in each patient’s room and served as reminders to the clinical
staff about this bundle element and as such made it easier for
staff to “do the right thing” by reducing their need to “re-
member” all the bundle elements. To engage all clinical staff
and heighten awareness about the initiative, posters were
placed around the ICU depicting VAP rates, bundle compli-
ance rates, and “days since” last VAP. New with this collab-
orative was infection control “real-time” reporting of each
VAP case. The ICU leadership received notification within 1
day of the VAP diagnosis. This timely notification facilitated
and improved the quality of real time root cause analysis of
each event. Monthly ICU leadership meetings were held to
review data and guide and facilitate the work of the front-line
leadership team.
Sustaining Strategies
Multiple actions were implemented that were intended
to sustain and maintain reduced VAP rates. These actions
included the following: (1) revising ventilator care policies to
reflect the new clinical practices; (2) adding VAP bundle
education to the orientation for float pool nursing staff; (3)
creating new ICU flow sheets with the VAP bundle as stan-
dard documentation (eliminating the VAP bundle checklist)
583
Table I. Demographics of mechanically ventilated patients by study timeframe
Jan 2005-Aug 2005 Sept 2005-Dec 2007
Jan 2004-Dec 2004 (n ⴝ 447) (n ⴝ 1782)
(n ⴝ 617) Baseline Implementation Post-Implementation P value
Age (months) 74.1 ⫾ 80.6 84.9 ⫾ 85.6 81.5 ⫾ 82.4 .07
Male sex* 414 (67.1%) 283 (63.3%) 957 (53.7%) ⬍.01*
PRISM (severity of illness) 7.20 ⫾ 8.4 7.5 ⫾ 8.7 7.2 ⫾ 8.2 .78
PICU LOS (days) 7.1 ⫾ (7.2) 7.0 ⫾ (7.0) 7.4 ⫾ (8.1) .51
Deaths 45 (7.3%) 31 (6.9%) 134 (7.5%) .91
*P ⱕ .05.

Table III. VAP infections by timeframe for all mechanically ventilated patients
Jan 2005-Aug 2005 Sept 2005-Dec 2007
Jan 2004-Dec 2004 (n ⴝ 447) (n ⴝ 1782) Post-
(n ⴝ 617) Baseline Implementation implementation P value
# Infections 17 22 3 n/a
Infection Rate 2.8% 4.9% 0.2% ⬍.0001*
Ventilator Days 3054 2502 9319 n/a
Infections per 1000 MV days 5.6 8.8 0.3 ⬍.0001*
*P ⱕ .05.

and making this documentation part of routine practice; (4)
adding bundle compliance to leadership and staff evaluations;
(5) developing a trigger tool (increase in VAP rate) that
initiated analysis of bundle compliance data; and (6) periodic
random and unannounced surveys of bundle compliance. We
are still evaluating appropriate disciplinary actions for staff
who do not comply with bundle care practices.
Study Periods and Implementation Schedule
The 3-year study collaborative (January 2004 –Decem-
ber 2007) was divided into 3 time periods. The baseline
(pre-implementation) period extended from January 1, 2004,
through December 31, 2004. The implementation period
spanned from January 1, 2005, through August 31, 2005, and
was defined as that study period from bundle identification
until full implementation of all bundle elements. Full bundle
implementation was defined as greater than 90% compliance
with each bundle element and with the aggregated bundle for
one full month. The post-implementation period continues;
however, for the purposes of publication, it is defined as
September 1, 2005, through December 31, 2007.
Statistical Analysis
Data were analyzed for all mechanically ventilated pa-
tients with and without VAP from January 2004 through
December 2007. To compare categorical data between VAP
and non-VAP groups and pre-implementation and post-
implementation groups, ␹2 testing was used for large groups
and Fisher exact for small groups. One-way analysis of vari-
ance was used for comparisons between continuous variables.
Two statistical software packages were used: SigmaStat ver-
sion 3.1 (Systat Software, Inc., San Jose, California) and
SAS/STAT version 9.1.3 (SAS Analytics Inc., Cary, North
Carolina).
RESULTS
During the study collaborative, 2846 PICU patients
were mechanically ventilated. During the baseline period 617
patients received mechanical ventilation; 447 during the im-
plementation period; and 1782 during the post-implementa-
tion period. Table I outlines comparative demographic, se-
verity of illness, and mortality data for the 3 time periods.
There were no significant demographic differences between
these 3 patient groups in terms of age, severity of illness,
PICU LOS, or death, although male sex was significantly
more common in the baseline and implementation periods
compared with the post-implementation period.
Table II (available at www.jpeds.com) describes
changes in VAP bundle compliance over time. During the
early implementation period compliance with each bundle
element was 50% to 60%; however, by September 2005,
compliance with each bundle element increased to 90% or
greater and persisted, although there was a small statistically
insignificant decrease in bundle compliance by September
2007.
There were 42 episodes of VAP during the 3-year study
collaborative (Table III). During the 2 study periods before
full implementation, the infection rate was 2.8% (baseline)
and 4.9% (implementation period) compared with the post-
implementation infection rate of 0.2%. VAP rates were signifi-
cantly lower post-implementation compared with the pre-im-
plementation and implementation periods. Figure 3 depicts
VAP rates during the 3 study time periods.

584 Bigham et al The Journal of Pediatrics • April 2009

Figure 3. Pediatric intensive care unit VAP rates per 1000 ventilator days for the 3 study time periods demonstrating significant and sustained reduction
in VAP rates after implementation of the pediatric specific VAP prevention bundle (P ⬍ .0001).

Table V. Demographic and risk factor comparison for mechanically ventilated patients with and without
VAP (Jan 2004-Dec 2007)
Demographics VAP (n ⴝ 42) No VAP (n ⴝ 2804) P value
Age (months) 80.9 ⫾ 83.5 79.1 ⫾ 81.0 .85
PRISM (severity of illness) 9.1 ⫾ 10.3 7.1 ⫾ 8.5 .17
PICU LOS (days) 19.5 ⫾ 15.0 7.5 ⫾ 9.2 ⬍.001*
Number of deaths (%) 8 (19.1) 202 (7.2) .01*
Mechanical ventilator days 16.3 ⫾ 14.7 5.3 ⫾ 8.4 ⬍.001*
Diagnosis/Risk factor
Subglottic or tracheal stenosis with or without 11 (26.2%) 344 (12.3%) .02*
airway reconstructive surgery
Trauma 8 (19.1%) 222 (7.9%) .02*
Tracheostomy 9 (21.4%) 303 (10.8%) .04*
Seizure 3 (7.1%) 254 (9%) 1.0
Liver/small bowel transplant 4 (9.5%) 278 (9.9%) 1.0
Bone marrow transplant 2 (4.8%) 191 (6.8%) 1.0
*P ⱕ .05.

The microbiology of ventilator-associated pneumonia is DISCUSSION

summarized in Table IV (available at www.jpeds.com).
Pseudomonas aeruginosa, Staphylococcus aureus, and non-typable
Haemophilus influenzae were the predominant infectious or-
ganisms identified.
The characteristics of the 3-year cohort of mechanically
ventilated patients with and without VAP are depicted in
Table V. There was no difference in age or severity of illness
between patients with and without VAP. For ventilated pa-
tients with VAP, PICU LOS, and total mechanical ventilator
days were significantly greater than for ventilated patients
without VAP. The mortality rate for patients with VAP was
significantly higher compared to patients without VAP de-
spite similar PICU admission severity of illness. Airway ste-
nosis, trauma, and tracheostomy were significantly more com-
mon in the mechanically ventilated patients with VAP
compared with those without VAP.
We demonstrate that sustained reduction in VAP rates
can occur in a PICU patient population after reliable imple-
mentation of a pediatric-specific VAP prevention bundle and
further that VAP in children is significantly associated with
increased mortality rates compared to mechanically ventilated
children without VAP.
Our data support other published reports which indi-
cate that VAP increases PICU LOS and duration of mechan-
ical ventilation.1,4,6 Reports describing outcomes in the adult
ICU population have shown that VAP is associated with
increased ventilation days, ICU and hospital LOS, and mor-
tality rates.12-14 Elward et al1,4,6 previously demonstrated
trends toward increased mortality in mechanically ventilated
children with VAP compared with those without VAP; how-
ever, the differences did not reach statistical significance. This
report is the first to show a highly significant increase in

Ventilator-Associated Pneumonia in the Pediatric Intensive Care Unit: Characterizing the Problem and
Implementing a Sustainable Solution 585
mortality rates for patients with VAP compared to those
without VAP, despite similar levels of admission severity of
illness, thus highlighting the need to focus efforts on VAP
reduction in the PICU.
Using improvement science strategies described by
Langley, Nolan, and Provost, this report demonstrates that
reliable implementation of a pediatric specific VAP preven-
tion bundle can produce sustained decreases in PICU VAP
rates (Figure 3 and Table III).10,15 We believe there are
several factors that contributed to these results. First are the
specifics of the VAP prevention bundle that was imple-
mented. There are multiple publications describing decreased
VAP in the adult ICU population following implementation
of an adult specific VAP prevention bundle.16-18 Our pedi-
atric bundle included elements similar to those found in adult
VAP bundles— hand hygiene, head of bed elevation, sched-
uled mouth care, and changing ventilator circuits only when
soiled; however, other items in our bundle were dissimilar to
adult VAP bundle elements. For example, our bundle did not
include care changes related to gastrointestinal bleed preven-
tion. Additionally we implemented the use of “heated-wire
ventilator circuits,” which nearly eliminated water rainout in
the ventilator circuit, thus reducing the risk of aspiration of
circuit contents when turning or moving the patient. Consis-
tent mouth hygiene, though common in adult ICUs, was
uncommon in our PICU before bundle implementation and,
we believe, contributed significantly to reducing the risk of
aspirating contaminated oral secretions. A second factor was
the methods used to reliably implement the bundle. Small
tests of change and front-line clinician testing of bundle
elements before full-scale roll out contributed to bedside
practitioner ownership and buy-in to the project. For exam-
ple, the use of mouth care kits, checklists to ensure bundle
compliance, and heated wire circuits were tried on 1 patient
and then several patients, each time allowing for staff feed-
back about what did and did not work. Frontline leaders
developed and tested the best methods to engage and educate
PICU staff about the VAP initiative, further contributing to
bedside clinician ownership of the project. Finally, we believe
that the use of real-time data to drive change and “sustain the
gain” was another mechanism that contributed to our out-
comes. For example, because we received reports within days
of the identification of a VAP event, the quality of failure
mode analysis for each event was enhanced. VAP rate reports
were updated within days of each event and posted for all
clinical staff to review. In addition, by posting weekly bundle
compliance reports, staff could see the correlation between
increasing bundle compliance and decreasing VAP rates.
Other process factors that may have contributed to these
results include the following: (1) a multidisciplinary leader-
ship team; and (2) bundle compliance checklists, which in-
cluded an option for clinical staff to provide rapid feedback
about changes—positive or negative.
Common risks for the development of VAP and mi-
crobiologic causes of VAP are described by our work. Among
the 42 cases of VAP in this 3-year cohort, the most common
586 Bigham et al
organism identified was P. aeruginosa. This finding is similar
to that of Elward et al4 who also described Pseudomonas as the
most common offending agent in their PICU. No single
agent accounted for even 20% of the cases of VAP in our
cohort, and 13 different organisms were identified among the
42 infections. Several diagnoses were more common in our
patients with VAP compared to those without VAP. These
included patients with tracheal stenosis with or without prior
airway reconstructive surgery, trauma patients, and patients
with tracheostomies. Patients with congenital or acquired
tracheal anatomic abnormalities, many of whom receive air-
way reconstructive surgery, are common in our PICU. A high
percentage of these patients have had prior tracheostomies,
which may put them at risk for colonization with organisms
such as Pseudomonas sp. thereby increasing the risk of VAP.19
Like others, we did not find that immunocompromised me-
chanically ventilated patients were more likely to develop
VAP.4,20,21 This is in contrast to Fayon et al,22 who found
that immunodeficiency and immunosuppression were inde-
pendent risk factors for pediatric VAP. Other risk factors for
VAP in the PICU include tracheostomy, witnessed aspira-
tion, prior bronchoscopy, tracheal reintubation, transport out
of the PICU, red blood cell transfusions, use of total paren-
teral nutrition, and the use of multiple central venous cathe-
ters.4,20,21 As with adult VAP patients and unlike other
pediatric reports, we found that multiple trauma (excluding
burns) was associated with VAP.23-28 The previously men-
tioned associations and risks for VAP in children have some
overlap with the adult ICU population wherein primary risks
include admitting diagnosis of trauma, sepsis or ARDS, pre-
existing pulmonary disease, tracheostomy, status epilepticus,
and tracheal reintubation.23-26,28
There are several limitations to our report. First, we
recognize the ambiguities associated with the diagnosis of
VAP in the PICU population. Multiple reports have at-
tempted to codify the best test to precisely diagnose VAP.29
Our infection control group has been using the Centers for
Disease Control and Prevention definition of VAP since its
inception and the same practitioners have been making the
diagnosis of VAP in our unit for more than a decade. In
addition, the diagnosis is made independently by these trained
practitioners and as such is less subject to bias than might
occur with PICU attending staff. As a result, although the
definition of the Centers for Disease Control and Prevention
may be more sensitive and less specific than other definitions,
we believe there is internal diagnostic consistency within our
hospital that allows comparison of our VAP rates over time
and before and after interventions. This work has been com-
pleted in 1 hospital and therefore may not be fully transferable
to other hospitals, although we believe the interventions de-
scribed and methods used to implement them are straight-
forward and inexpensive and therefore can be easily repro-
duced.
In summary, this report demonstrates that reliable im-
plementation of a pediatric-specific VAP prevention bundle
can produce sustained reductions in VAP rates. Furthermore,
The Journal of Pediatrics • April 2009
VAP in children has significant morbidity and mortality,
including increased PICU LOS and ventilator days and most
importantly increased mortality rates. Given the mortality
risk, we believe vigorous efforts should be undertaken in all
PICUs to implement strategies to reduce or eliminate VAP.
We thank Nancy Hutchinson, RN, John Butcher, RN, MaryJo
Giaccone, RN, Debbie Hershberger, and Sarah Myers for their
tireless dedication to this project.
REFERENCES
1. Grohskopf LA, Sinkowitz-Cochran RL, Garrett DO, Sohn AH, Levine GL,
Siegel JD, et al. A national point-prevalence survey of pediatric intensive care unit-
acquired infections in the United States. J Pediatr 2002;140:432-8.
2. Tablan OC, Anderson LJ, Besser R, Bridges C, Hajjeh R. Guidelines for pre-
venting health-care–associated pneumonia, 2003: recommendations of CDC and the
Healthcare Infection Control Practices Advisory Committee. MMWR Recomm Rep
2004;53(RR-3):1-36.
3. Jarvis WR, Edwards JR, Culver DH, Hughes JM, Horan T, Emori TG, et al.
Nosocomial infection rates in adult and pediatric intensive care units in the United
States. National Nosocomial Infections Surveillance System. Am J Med 1991;91:
185S-91S.
4. Elward AM, Warren DK, Fraser VJ. Ventilator-associated pneumonia in pediatric
intensive care unit patients: risk factors and outcomes. Pediatrics 2002;109:758-64.
5. National Nosocomial Infections Surveillance (NNIS) System Report, data sum-
mary from January 1992 through June 2004, issued October 2004. Am J Infect Control
2004;32:470-85.
6. Richards MJ, Edwards JR, Culver DH, Gaynes RP. Nosocomial infections in
pediatric intensive care units in the United States. National Nosocomial Infections
Surveillance System. Pediatrics 1999;103:e39.
7. Foglia E, Meier MD, Elward A. Ventilator-associated pneumonia in neonatal and
pediatric intensive care unit patients. Clin Microbiol Rev 2007;20:409-25.
8. Brilli RJ, Sparling KW, Lake MR, Butcher J, Myers SS, Clark MD, et al. The
business case for preventing ventilator-associated pneumonia in pediatric intensive care
unit patients. Jt Comm J Qual Patient Saf 2008;34:629-38.
9. Mayhall CG. Hospital epidemiology and infection control. 3rd ed. Philadelphia:
Lippincott Williams & Wilkins; 2004.
10. Langley GJ. The improvement guide: a practical approach to enhancing organi-
zational performance. 1st ed. San Francisco: Jossey-Bass Publishers; 1996.
11. Deming WE. The new economics: for industry, government, education. 2nd ed.
Cambridge, Mass.: MIT Press; 2000.
12. Kollef MH. Prevention of hospital-associated pneumonia and ventilator-associ-
ated pneumonia. Crit Care Med 2004;32:1396-405.
Ventilator-Associated Pneumonia in the Pediatric Intensive Care Unit: Characterizing the Problem and
Implementing a Sustainable Solution
13. Kollef MH, Shorr A, Tabak YP, Gupta V, Liu LZ, Johannes RS. Epidemiology
and outcomes of health-care-associated pneumonia: results from a large US database of
culture-positive pneumonia. Chest 2005;128:3854-62.
14. Rello J, Ollendorf DA, Oster G, Vera-Llonch M, Bellm L, Redman R, et al.
Epidemiology and outcomes of ventilator-associated pneumonia in a large US database.
Chest 2002;122:2115-21.
15. Moen RD, Nolan TW, Provost LP. Improving quality through planned experi-
mentation. New York: McGraw-Hill; 1991.
16. Berriel-Cass D, Adkins FW, Jones P, Fakih MG. Eliminating nosocomial infec-
tions at Ascension Health. Jt Comm J Qual Patient Saf 2006;32:612-20.
17. Cocanour CS, Peninger M, Domonoske BD, Li T, Wright B, Valdivia A, et al.
Decreasing ventilator-associated pneumonia in a trauma ICU. J Trauma 2006;61:122-9;
discussion 9-30.
18. Resar R, Pronovost P, Haraden C, Simmonds T, Rainey T, Nolan T. Using a
bundle approach to improve ventilator care processes and reduce ventilator-associated
pneumonia. Jt Comm J Qual Patient Saf 2005;31:243-8.
19. Rutter MJ, Cotton RT. The use of posterior cricoid grafting in managing isolated
posterior glottic stenosis in children. Arch Otolaryngol Head Neck Surg 2004;130:
737-9.
20. Almuneef M, Memish ZA, Balkhy HH, Alalem H, Abutaleb A. Ventilator-
associated pneumonia in a pediatric intensive care unit in Saudi Arabia: a 30-month
prospective surveillance. Infect Control Hosp Epidemiol 2004;25:753-8.
21. Gastmeier P, Weigt O, Sohr D, Ruden H. Comparison of hospital-acquired
infection rates in paediatric burn patients. J Hosp Infect 2002;52:161-5.
22. Fayon MJ, Tucci M, Lacroix J, Farrell CA, Gauthier M, Lafleur L, et al.
Nosocomial pneumonia and tracheitis in a pediatric intensive care unit: a prospective
study. Am J Respir Crit Care Med 1997;155:162-9.
23. Ala-Kokko TI, Saynajakangas P, Laurila P, Ohtonen P, Laurila JJ, Syrjala H.
Incidence of infections in patients with status epilepticus requiring intensive care and
effect on resource utilization. Anaesth Intensive Care 2006;34:639-44.
24. Hyllienmark P, Gardlund B, Persson JO, Ekdahl K. Nosocomial pneumonia in
the ICU: a prospective cohort study. Scand J Infect Dis 2007;39:676-82.
25. Jaimes F, De La Rosa G, Gomez E, Munera P, Ramirez J, Castrillon S. Incidence
and risk factors for ventilator-associated pneumonia in a developing country: where is
the difference? Respir Med 2007;101:762-7.
26. Noor A, Hussain SF. Risk factors associated with development of ventilator
associated pneumonia. J Coll Physicians Surg Pak 2005;15:92-5.
27. Patel JC, Mollitt DL, Pieper P, Tepas JJ, 3rd. Nosocomial pneumonia in the
pediatric trauma patient: a single center’s experience. Crit Care Med 2000;28:3530-3.
28. Tejerina E, Frutos-Vivar F, Restrepo MI, Anzueto A, Abroug F, Palizas F, et al.
Incidence, risk factors, and outcome of ventilator-associated pneumonia. J Crit Care
2006;21:56-65.
29. Gauvin F, Dassa C, Chaibou M, Proulx F, Farrell CA, Lacroix J. Ventilator-
associated pneumonia in intubated children: comparison of different diagnostic meth-
ods. Pediatr Crit Care Med 2003;4:437-43.
587
Figure 1. Key elements of the pediatric specific ventilator associated
pneumonia (VAP) prevention bundle. Prevention elements are divided
into those designed to reduce bacterial colonization and those designed
to reduce aspiration of contaminated secretions.

Figure 2. Ventilatory care checklist used at the bedside as a reminder to

“do the right thing.”

587.e1 Bigham et al The Journal of Pediatrics • April 2009

Table II. Compliance with VAP bundle individual components by time period
July 2005 Sep 2005 Nov 2005 Sep 2007
Implementation Post-Implementation
Hands washed before and after contact with ventilator circuit 60% 90% 100% Not observed
Head of bed at 30°-45°, unless contraindicated 57% 95% 100% 85%
Mouth care every 2-4 hours 60% 90% 100% 85%
Oral suction device stored in unsealed plastic bag 60% 95% 100% 78%
In-line suction catheter changed when soiled 60% 94% 100% 100%
Condensate drained every 2 to 4 hours and when turning 60% 95% 100% 90%
Ventilator circuit inspected and changed only when soiled 60% 95% 100% 85%

Table IV. Identified organisms associated with VAP

(total no. infections ⴝ 42)
Organism No. (%)
Pseudomonas aeruginosa 8 (19.0%)
Staphylococcus aureus 6 (14.3%)
Haemophilus influenzae 4 (9.5%)
Staphylococcus aureus, oxacillin-resistant 4 (9.5%)
Serratia marcescens 4 (9.5%)
Enterobacter species 3 (7.1%)
Moraxella catarrhalis 3 (7.1%)
No organism identified 3 (7.1%)
Streptococcus pneumoniae 2 (4.8%)
Candida albicans 1 (2.4%)
Citrobacter koseri 1 (2.4%)
Corynebacterium species 1 (2.4%)
Proteus mirabilis 1 (2.4%)
Stenotrophomonas maltophilia 1 (2.4%)

Ventilator-Associated Pneumonia in the Pediatric Intensive Care Unit: Characterizing the Problem and
Implementing a Sustainable Solution 587.e2