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Preventing ventilator-associated pneumonia—a mixed-method study to find behavioral leverage for better protocol adherence

Published online by Cambridge University Press:  31 August 2018

Aline Wolfensberger ,
Marie-Theres Meier ,
Lauren Clack ,
Peter W. Schreiber  and
Hugo Sax
Aline Wolfensberger*
Affiliation:
Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zürich, University of Zurich, Zurich, Switzerland
Marie-Theres Meier
Affiliation:
Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zürich, University of Zurich, Zurich, Switzerland
Lauren Clack
Affiliation:
Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zürich, University of Zurich, Zurich, Switzerland
Peter W. Schreiber
Affiliation:
Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zürich, University of Zurich, Zurich, Switzerland
Hugo Sax
Affiliation:
Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zürich, University of Zurich, Zurich, Switzerland
*
Author for correspondence: Aline Wolfensberger, MD, Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Rämistrasse 100 CH-8091 Zurich, Switzerland. E-mail: [email protected]
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Abstract

Objective

Preventing ventilator-associated pneumonia (VAP) is an important goal for intensive care units (ICUs). We aimed to identify the optimal behavior leverage to improve VAP prevention protocol adherence.

Design

Mixed-method study using adherence measurements to assess 4 VAP prevention measures and qualitative analysis of semi-structured focus group interviews with frontline healthcare practitioners (HCPs).

Setting

The 6 ICUs in the 900-bed University Hospital Zurich in Zurich, Switzerland.

Patients and participants

Adherence to VAP prevention measures were assessed in patients with a device for invasive ventilation (ie, endotracheal tube, tracheostomy tube). Participants in focus group interviews included a convenience samples of ICU nurses and physicians.

Results

Between February 2015 and July 2017, we measured adherence to 4 protocols: bed elevation showed adherence at 27% (95% confidence intervals [CI], 23%–31%); oral care at 41% (95% CI, 36%–45%); sedation interruption at 81% (95% CI, 74%–85%); and subglottic suctioning at 88% (95% CI, 83%–92%). Interviews were analyzed first inductively according a grounded theory approach then deductively against the behavior change wheel (BCW) framework. Main behavioral facilitators belonged to the BCW component ‘reflective motivation’ (ie, perceived seriousness of VAP and self-efficacy to prevent VAP). The main barriers belonged to ‘physical capability’ (ie, lack of equipment and staffing and side-effects of prevention measures). Furthermore, 2 primarily technical approaches (ie, ‘restructuring environment’ and ‘enabling HCP’) emerged as means to overcome these barriers.

Conclusions

Our findings suggest that technical, rather than education-based, solutions should be promoted to improve VAP prevention. This theory-informed mixed-method approach is an effective means of guiding infection prevention efforts.

Type
Original Article
Information
Infection Control & Hospital Epidemiology , Volume 39 , Issue 10 , October 2018 , pp. 1222 - 1229
Copyright
© 2018 by The Society for Healthcare Epidemiology of America. All rights reserved 

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References

1. ECDC Surveillance Report. Point prevalence survey of healthcare-associated infections and antimicrobial use in European acute care hospitals, 2011–2012. European Center for Disease Prevention and Control website. https://ecdc.europa.eu/sites/portal/files/media/en/publications/Publications/healthcare-associated-infections-antimicrobial-use-PPS.pdf. Published 2012. Accessed August 27, 2017.Google Scholar
2. CDC device associated module, pneumonia (ventilator-associated [VAP] and non-ventilator-associated Pneumonia [PNEU]) event. Centers for Disease Control and Prevention website. https://www.cdc.gov/nhsn/pdfs/pscmanual/6pscvapcurrent.pdf. Updated 2018. Accessed August 6, 2018.Google Scholar
3. Ego, A, Preiser, JC, Vincent, JL. Impact of diagnostic criteria on the incidence of ventilator-associated pneumonia. Chest 2015;147:347–355.Google Scholar
4. Galal, YS, Youssef, MR, Ibrahiem, SK. Ventilator-associated pneumonia: incidence, risk factors and outcome in paediatric intensive care units at Cairo University Hospital. J Clin Diagn Res 2016;10:SC06–11.Google Scholar
5. Elliott, D, Elliott, R, Burrell, A, et al. Incidence of ventilator-associated pneumonia in Australasian intensive care units: use of a consensus-developed clinical surveillance checklist in a multisite prospective audit. BMJ Open 2015;5:e008924.Google Scholar
6. Wallace, FA, Alexander, PD, Spencer, C, Naisbitt, J, Moore, JA, McGrath, BA. A comparison of ventilator-associated pneumonia rates determined by different scoring systems in four intensive care units in the North West of England. Anaesthesia 2015;70:1274–1280.Google Scholar
7. Safdar, N, Dezfulian, C, Collard, HR, Saint, S. Clinical and economic consequences of ventilator-associated pneumonia: a systematic review. Crit Care Med 2005;33:2184–2193.Google Scholar
8. Branch-Elliman, W, Wright, SB, Howell, MD. Determining the ideal strategy for ventilator-associated pneumonia prevention. cost-benefit analysis. Am J Respir Crit Care Med 2015;192:57–63.Google Scholar
9. Prevention of nosocomial pneumonia. Robert Koch Institute website. http://edoc.rki.de/documents/rki_ab/reKNpBgNk2ng/PDF/28b1eD9HXSlU.pdf. Published 2000. Accessed August 27, 2017.Google Scholar
10. CDC guidelines for preventing health-care–associated pneumonia, 2003. Centers for Disease Control and Prevention website. https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5303a1.htm. Published 2003. Accessed August 27, 2017.Google Scholar
11. Klompas, M, Branson, R, Eichenwald, EC, et al. Strategies to prevent ventilator-associated pneumonia in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol 2014;35 Suppl 2:S133–S154.Google Scholar
12. Rotstein, C, Evans, G, Born, A, et al. Clinical practice guidelines for hospital-acquired pneumonia and ventilator-associated pneumonia in adults. Can J Infect Dis Med Microbiol 2008;19:19–53.Google Scholar
13. American Thoracic Study Group, Infectious Diseases Society of America. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med 2005;171:388–416.Google Scholar
14. Klompas, M. What is new in the prevention of nosocomial pneumonia in the ICU? Curr Opin Crit Care 2017;23:378–384.Google Scholar
15. Klompas, M, Li, L, Kleinman, K, Szumita, PM, Massaro, AF. Associations between ventilator bundle components and outcomes. JAMA Intern Med 2016;176:1277–1283.Google Scholar
16. Price, R, MacLennan, G, Glen, J, Su, DC. Selective digestive or oropharyngeal decontamination and topical oropharyngeal chlorhexidine for prevention of death in general intensive care: systematic review and network meta-analysis. BMJ 2014;348:g2197.Google Scholar
17. Okgun Alcan, A, Demir Korkmaz, F, Uyar, M. Prevention of ventilator-associated pneumonia: use of the care bundle approach. Am J Infect Control 2016;44:e173–e176.Google Scholar
18. Dosher, WB, Loomis, EC, Richardson, SL, et al. The effect of a nurse-led multidisciplinary team on ventilator-associated pneumonia rates. Crit Care Res Pract 2014. doi: 10.1155/2014/682621.Google Scholar
19. Daniel, M, Booth, M, Ellis, K, Maher, S, Longmate, A. Details behind the dots: how different intensive care units used common and contrasting methods to prevent ventilator associated pneumonia. BMJ Qual Improv Rep 2015;4.Google Scholar
20. Rawat, N, Yang, T, Ali, KJ, et al. Two-state collaborative study of a multifaceted intervention to decrease ventilator-associated events. Crit Care Med 2017;45:1208–1215.Google Scholar
21. Marini, AL, Khan, R, Mundekkadan, S. Multifaceted bundle interventions shown effective in reducing VAP rates in our multidisciplinary ICUs. BMJ Qual Improv Rep 2016;5.Google Scholar
22. Khan, R, Al-Dorzi, HM, Al-Attas, K, et al. The impact of implementing multifaceted interventions on the prevention of ventilator-associated pneumonia. Am J Infect Control 2016;44:320–326.Google Scholar
23. Umscheid, CA, Mitchell, MD, Doshi, JA, Agarwal, R, Williams, K, Brennan, PJ. Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs. Infect Control Hosp Epidemiol 2011;32:101–114.Google Scholar
24. Lambert, ML, Silversmit, G, Savey, A, et al. Preventable proportion of severe infections acquired in intensive care units: case-mix adjusted estimations from patient-based surveillance data. Infect Control Hosp Epidemiol 2014;35:494–501.Google Scholar
25. Aloush, SM. Nursing students' knowledge about ventilator-associated pneumonia prevention guidelines: effectiveness of a teaching program. Am J Infect Control 2017;45:544–546.Google Scholar
26. Yeganeh, M, Yekta, H, Farmanbar, R, Khalili, M, Atrkar Roushan, Z. Knowledge of evidence-based guidelines in ventilator-associated pneumonia prevention. J Evid Based Med 2016. doi: 10.1111/jebm.12188.Google Scholar
27. McLean, SE, Jensen, LA, Schroeder, DG, Gibney, NR, Skjodt, NM. Improving adherence to a mechanical ventilation weaning protocol for critically ill adults: outcomes after an implementation program. Am J Crit Care 2006;15:299–309.Google Scholar
28. Goutier, JM, Holzmueller, CG, Edwards, KC, Klompas, M, Speck, K, Berenholtz, SM. Strategies to enhance adoption of ventilator-associated pneumonia prevention interventions: a systematic literature review. Infect Control Hosp Epidemiol 2014;35:998–1005.Google Scholar
29. Mauger, B, Marbella, A, Pines, E, Chopra, R, Black, ER, Aronson, N. Implementing quality improvement strategies to reduce healthcare-associated infections: a systematic review. Am J Infect Control 2014; 42:S274–S283.Google Scholar
30. Michie, S, Johnston, M, Francis, J, Hardeman, W, Eccles, M. From theory to intervention: mapping theoretically derived behavioural determinants to behaviour change techniques. Applied Psychology 2008;57:660–680.Google Scholar
31. Sax, H, Allegranzi, B, Uckay, I, Larson, E, Boyce, J, Pittet, D. ‘My five moments for hand hygiene’: a user-centred design approach to understand, train, monitor and report hand hygiene. J Hosp Infect 2007;67:9–21.Google Scholar
32. Michie, S, van Stralen, MM, West, R. The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implement Sci 2011;6:42.Google Scholar
33. Palinkas, LA, Horwitz, SM, Green, CA, Wisdom, JP, Duan, N, Hoagwood, K. Purposeful sampling for qualitative data collection and analysis in mixed method implementation research. Admin Policy Mental Health Mental Health Serv Res 2015;42:533–544.Google Scholar
34. Strauss, AL, Corbin, JM. Grounded Theory in Practice. Thousand Oaks, CA: Sage; 1997.Google Scholar
35. Saunders, B, Sim, J, Kingstone, T, et al. Saturation in qualitative research: exploring its conceptualization and operationalization. Quality Quantity 2018;52:1893–1907.Google Scholar
36. Llaurado-Serra, M, Ulldemolins, M, Guell-Baro, R, et al. Evaluation of head-of-bed elevation compliance in critically ill patients under mechanical ventilation in a polyvalent intensive care unit. Med Intensiva 2015;39:329–336.Google Scholar
37. Rose, L, Baldwin, I, Crawford, T, Parke, R. Semirecumbent positioning in ventilator-dependent patients: a multicenter, observational study. Am J Crit Care 2010;19:E100–E108.Google Scholar
38. Bloos, F, Muller, S, Harz, A, et al. Effects of staff training on the care of mechanically ventilated patients: a prospective cohort study. Br J Anaesth 2009;103:232–237.Google Scholar
39. DuBose, JJ, Inaba, K, Shiflett, A, et al. Measurable outcomes of quality improvement in the trauma intensive care unit: the impact of a daily quality rounding checklist. J Trauma 2008;64:22–27, discussion 27–29.Google Scholar
40. Crunden, E, Boyce, C, Woodman, H, Bray, B. An evaluation of the impact of the ventilator care bundle. Nurs Crit Care 2005;10:242–246.Google Scholar
41. Mendez, MP, Lazar, MH, Digiovine, B, et al. Dedicated multidisciplinary ventilator bundle team and compliance with sedation vacation. Am J Crit Care 2013;22:54–60.Google Scholar
42. Pugin, J. Clinical signs and scores for the diagnosis of ventilator-associated pneumonia. Minerva Anestesiol 2002;68:261–265.Google Scholar
43. Ricart, M, Lorente, C, Diaz, E, Kollef, MH, Rello, J. Nursing adherence with evidence-based guidelines for preventing ventilator-associated pneumonia. Crit Care Med 2003;31:2693–2696.Google Scholar
44. Rello, J, Lorente, C, Bodi, M, Diaz, E, Ricart, M, Kollef, MH. Why do physicians not follow evidence-based guidelines for preventing ventilator-associated pneumonia? A survey based on the opinions of an international panel of intensivists. Chest 2002;122:656–661.Google Scholar
45. Cafazzo, JA, St-Cyr, O. From discovery to design: the evolution of human factors in healthcare. Healthc Q 2012;15 Spec No:24–29.Google Scholar
46. McHugh, ML. Interrater reliability: the kappa statistic. Biochem Med (Zagreb) 2012;22:276–282.Google Scholar