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Simple, Low-Cost Measures at the National Institute of Child Health’s Pediatric Intensive Care Unit in Lima, Peru, Decrease Health Care-Associated Infections

Improvement Report
Roberto Shimabuku, Graciela Nakachi, Margarita Alvarado, Danitza Fernandez.

Topics: Infection control and prevention, Patient Safety

Region and Country: South America, Peru

Organization: National Institute of Child Health of Peru
The Report

Pediatric sepsis is one of the leading causes of death worldwide. In the developing world, where hospitalized children have become more dependent on invasive technologies associated with increased risk of infection, sepsis-associated mortality remains unacceptably high, Health care-associated infections (HAIs) often lead to sepsis, resulting in death. Worldwide, the main sources of HAIs are surgical site infections, central line-associated bloodstream infections (CLABSI), catheter-associated urinary tract infections, and ventilator-associated pneumonia. A growing body of evidence has shown that the use of “bundles” can decrease HAIs, particularly among critically ill patients. Efforts to prevent sepsis and reduce infant mortality must systematically apply these practices. The National Institute of Child Health (INSN) is a government health facility in Lima, Peru, that serves as a referral center for critically ill children from all regions of the country. It has 21 intensive care beds serving 480 hospital beds, including critical areas for cardiology, heart surgery, burn unit, and neurosurgical and neonatal wards. By 2007, INSN was treating growing numbers of children with increasingly complex conditions. Critically ill patients with sepsis have often benefited from the use of invasive devices and technology, but these technologies have increased their risk of infection and sepsis-associated mortality. A study in five hospitals in Lima demonstrated that HAIs were the most important adverse events in the intensive care units. The rate of CLABSI at INSN’s Pediatric Intensive Care Unit (PICU) was high (rate = more than 10 x 1000), significantly increasing the morbidity, mortality, length of stay, and hospital costs. 


 In 2007, INSN and the Ministry of Health began to implement a series of health care quality improvement initiatives to prevent and decrease CLABSI, catheter-associated urinary tract infections, and ventilator-associated pneumonia. INSN received technical assistance from the USAID/Peru Quality Healthcare project and the Johns Hopkins University Armstrong Institute for Patient Safety and Quality (formerly Quality and Safety Research Group). The PICU team advocated ensuring decision-making and funding from the leadership of INSN to improve infrastructure, the provision of equipment and materials, and human resources to meet international standards. Two complementary but equally important strategies were implemented: (1) systematic application of evidence-based, simple, low-cost procedures to manipulate invasive devices, including hand washing, disinfection with chlorhexidine, the use of maximal protective barriers, and retiring devices when not needed; and (2) teamwork improvement and communication and learning from mistakes. Additional measures included the standardization of targeted procedures through evidence based guidelines, centralization of all the material needed in special carts, monitoring adherence standardized procedures with check lists, and reinforcing verbal and written communication among teams through the use of daily work plans and daily goals during clinical rounds. Supported and encouraged by the INSN leadership, the PICU team shared its experiences and tools with the personnel of other critical areas


 PICA saw a progressive decrease in the rate of HAIs. The rate of CLABSI dropped from 10.01 percent in 2007 to 1.66 percent in 2011 among 1,314 patients who received central line therapy. The risk of getting a blood stream infection with CVC decreased from 4.5 percent in 2010 to 1.5 percent in 2011.  


Systematic application of evidence-based practices to reduce HAIs is a necessary part of any effort to prevent sepsis and reduce infant mortality. INSN’s experience confirms that the use of simple, low-cost “bundles” can lower the rate of HAIs among hospitalized children, especially critically ill patients. This initiative has helped INSN to identify equally serious problems, such as blood stream infections associated to mechanical ventilation, the insertion of urinary catheters, and other invasive procedures.