Ventilator-associated pneumonia (VAP) is an EVIDENCE-BASED PRACTICE: USE OF THE VENTILATOR BUNDLE TO PREVENT VENTILATOR-ASSOCIATED PNEUMONIA

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1 EVIDENCE-BASED PRACTICE: USE OF THE VENTILATOR BUNDLE TO PREVENT VENTILATOR-ASSOCIATED PNEUMONIA By Arlene F. Tolentino-DelosReyes, RN, MSN, ACNP, Susan D. Ruppert, RN, PhD, APRN, BC, NP-C, Shyang-Yun Pamela K. Shiao, RN, PhD. From the School of Nursing, The University of Texas Health Science Center at Houston, Houston, Tex (AFT-D, SDR), and School of Nursing, University of Houston Victoria and University of Houston System at Sugar Land, Sugar Land, Tex (S-YPKS). PURPOSE To examine critical care nurses knowledge about the use of the ventilator bundle to prevent ventilator-associated pneumonia. METHOD Published reports were reviewed for current evidence on the use of the ventilator bundle to prevent ventilator-associated pneumonia, and sessions were held to present the findings to 61 nurses in coronary care and surgical intensive care units. Changes in the nurses knowledge were evaluated by using a 1-item test, given both before and after the sessions. Changes in the nurses practices related to ventilator-associated pneumonia, including elevation of the head of the bed to 3º to 45º, were observed in 99 intubated patients. RESULTS After the sessions, the nurses performed better on 8 of the 1 items tested (P from.3 to ). The areas of most significant improvement were elevation of the head of the bed (P <.1), charting of the elevation of the head of the bed (P=.9), oral care (P=.9), checking of the nasogastric tube for residual volume (P=.8), washing of hands before contact with patients (P), and limiting the wearing of rings (P <.1) and nail polish (P =.4). Even after the sessions, the nurses compliance with hand-washing recommendations before contact with patients was low, though statistically some improvement was apparent. Contraindications to elevation of the head of the bed did not appear to affect the nurses practices (P=.38). CONCLUSION Education sessions designed to inform nurses about the ventilator bundle and its use to prevent ventilator-associated pneumonia have a significant effect on participants knowledge and subsequent clinical practice. (American Journal of Critical Care. 27;16:2-27) Ventilator-associated pneumonia (VAP) is an important safety issue in critically ill patients and in patients receiving mechanical ventilation. The American Association of Critical-Care Nurses (AACN) recommended steps for reducing the incidence of VAP; these steps are based on the bestpractice guidelines for patients receiving mechanical Corresponding author: Susan D. Ruppert, RN, PhD, APRN, BC, NP-C, The University of Texas Health Science Center at Houston, School of Nursing, 691 Bertner Ave, Room 694, Houston, TX 773 ( Susan.D.Ruppert@uth.tmc.edu). To purchase reprints, contact The InnoVision Group, 11 Columbia, Aliso Viejo, CA Phone, (8) or (949) (ext 532); fax, (949) ; , reprints@aacn.org. ventilation. Called the ventilator bundle, these steps incorporate the following guidelines from the Centers for Disease Control and Prevention (CDC) for preventing nosocomial pneumonia 1,2 : elevation of the head of the bed (HOB) to 3º to 45º unless medically contraindicated, continuous removal of subglottic secretions, change of ventilator circuit no more often than every 48 hours, and washing of hands before and after contact with each patient. These steps are considered feasible, safe, and cost effective for preventing VAP. 2 AMERICAN JOURNAL OF CRITICAL CARE, January 27, Volume 16, No. 1

2 The CDC has not offered any recommendations about oral care or about how often to check the residual volume in nasogastric tubes. Nor has it suggested modifications in tube feeding procedures to prevent VAP, such as suspending feedings while patients are being repositioned or turning patients supine before commencing feedings. Research is still needed to ascertain at what level gastric residual volume increases aspiration risk and at what level feedings should be withheld. More research is needed on oral care and on procedures for checking residual volume in nasogastric tubes. There are no CDC recommendations about gastric residual checking or oral care to prevent ventilator-associated pneumonia. Current best practices for patients at risk of VAP can be established by conducting systematic literature reviews on the ventilator bundle and factors related to VAP and by communicating evidence-based findings through sessions. Supported by current research and scientific evidence, this clinical project was aimed at examining critical care nurses knowledge of the ventilator bundle and its applications for preventing VAP. Current Evidence About the Ventilator Bundle and VAP Most published studies have focused on the relationship between HOB elevation and the incidence of VAP. Table 1 presents current evidence on the prevention of VAP, with respect to HOB elevation, hand washing, and oral care. A significant relationship between HOB elevation to 3º to 45º and a reduced incidence of VAP has been reported. 3,5,9 Factors affecting the incidence of VAP include early, low back-rest elevation and severity of illness; backrest elevation alone has no relationship to the Clinical Pulmonary Infection Score. 6 In addition, high acuity levels with higher scores on the Acute Physiology and Chronic Health Evaluation II were directly associated with development of VAP, 3,4,6 and patients with VAP had higher mortality rates. 4 In a replication study, 8 the mean observed HOB position was 23º for intubated patients and 38º for nonintubated patients (P <.1). Kollef et al 5 reported that patients transported out of the intensive care unit (ICU) are at greater risk for development of VAP. Other researchers explored the barriers to using HOB elevation as a method of preventing VAP 14 and examined the relationship between VAP, days of mechanical ventilation, and ICU days, and thus hospital cost. 13 These researchers concluded with a recommendation that the HOB be elevated to 3º to 45º in patients receiving mechanical ventilation unless doing so is medically contraindicated. Babcock et al 1 reported a decrease in the rate of VAP after an al intervention (from 8.75 cases per 1 ventilator days before to 4.74 cases per 1 ventilator days after; P <.1). Results of other studies 11,12 confirmed that staff decreased the incidence of VAP (46% to 57.6%, P values from to.2). Studies on hand-washing practices focused on comparing bacterial counts before and after hands were washed with an alcohol-based solution and on comparing the incidence of VAP when chlorhexidine was used and when an alcohol-based solution was used. 19 In one study, 2 researchers observed a decrease in bacterial contamination after hand washing. In another study, 17 wearing at least one ring during contact with a patient was directly associated with increased frequency of hand contamination with S aureus, gram-negative bacilli, or Candida species. Thus, regular hand washing with an alcohol-based solution and limited wearing of rings are directly related to a decreased rate of VAP. Based on these results, Trick et al 17 recommended that hands be washed with an alcohol-based solution and rings be removed before contact with a patient. Wearing at least one ring during contact with patients increases hand carriage of ventilator-associated pneumonia pathogens. Although the CDC has not recommended strategies for oral care, a literature search revealed that the use of chlorhexidine oral rinse is directly associated with reduced rates of respiratory infection (3% with chlorhexidine vs 1% with placebo; P <.5). 23 Studies have addressed the use of chlorhexidine before intubation, 23 in patients scheduled for elective cardiac surgery, 23,26 and in patients with respiratory infections such as tracheobronchitis and pneumonia. 23 Two randomized controlled s 21,22 showed that tracheobronchial colonization causing VAP occurred less often in patients whose mouths had been decontaminated with topical antibiotics than in those who were given a placebo (P <.1 to.4). Topical prophylaxis using antibiotics eradicated oropharyngeal bacterial colonies on admission (75%, P <.1) and prevented bacterial AMERICAN JOURNAL OF CRITICAL CARE, January 27, Volume 16, No. 1 21

3 Table 1 Current evidence on the prevention of VAP Reference HOB elevation Drakulovic et al 3 Kollef 4 Kollef et al 5 Grap et al 6 Metheny et al 7 Hanneman and Gusick 8 Torres et al 9 Babcock et al 1 Salahuddin et al 11 Zack et al 12 Warren et al 13 Cook et al 14 Hand washing Girou et al 15 Lucet et al 16 Trick et al 17 Zaragosa et al 18 Trick et al 17 Doebbeling et al 19 Pittet et al 2 Oral care Bergman et al 21 Pugin et al 22 Bergman et al 21 DeRiso et al 23 Mentec et al 24 Cutler and Davis 25 Year Design Randomized controlled Inception cohort design Comparison studies, surveillance of patients, and data collection Longitudinal, descriptive design Prospective, descriptive design Cross-sectional design, observational data Comparison Before and after Association and multiple regression Semistructured interviews and focus groups Crossover Observation study Observation before and after Significant outcomes HOB elevation and VAP Mortality rate and VAP Transport of patients and VAP rate Height of back rest and VAP, comfort and skin integrity of patient HOB and outcomes; risk factors for VAP HOB and outcomes, supine and 3º, semiprone with head down 15º-2º Comparison of semirecumbent and supine positions Staff decreased VAP incidence VAP and length of stay in intensive care unit, hospital stay, mortality rate, hospital cost Barriers leading to underuse of HOB elevation Bacterial count for alcohol-based solution and hand washing Wearing rings and hand contamination Use of chlorhexidine, soap, and alcohol and VAP incidence Hand washing and bacterial count Tracheobronchial colonization and VAP incidence Antibiotics and colonization Chlorhexidine reduced respiratory infection Gastric residual volume and vomiting increased incidence of VAP Implementation of oral care protocol improved oral care Hanneman and Gusick 8 25 Cross-sectional survey Mean documented oral care Abbreviations: HOB, head of bed; VAP, ventilator-associated pneumonia. Suggested practice HOB elevation at 3º-45º HOB elevation HOB elevation >3º HOB elevation HOB elevation at least 45º prophylactic measure for gastric aspiration Staff on VAP Use of alcohol-based solution for hand washing Refraining from wearing rings during work Use of chlorhexidine, soap, and alcohol Hand washing before and after contact with patient Prophylactic antibiotics Oral care Check gastric residual volume Oral care protocol and provision of appropriate tools 22 AMERICAN JOURNAL OF CRITICAL CARE, January 27, Volume 16, No. 1

4 colonization of the trachea (52%, P =.3). 21 The documented mean frequency of oral care for nonintubated patients was 1.8 (SD 1.5) times, and nurses self-reported mean frequency was 3.3 (SD 1.8) times. The documented mean frequency for the intubated patients was 3.3 (SD 1.8) times, and nurses self-reported mean frequency was 4.2 (SD 2.1) times (P <.1). 8 Implementation of an oral care protocol and provision of appropriate oral hygiene tools increased the frequency and comprehensiveness of oral care (oral cavity assessment P=.1, all types of oral care P). 25 Oral aspiration could be a factor that contributes to VAP. Current recommendations for general practice in tube-fed patients include routine checking of gastric residual volume every 4 to 6 hours and withholding of feeding for 1 hour if gastric residual volume is more than 1 to 1.5 times the amount provided in an hour, or more than 15 ml before bolus feeding. 27 These practices, however, have not been specifically studied in relation to VAP. In one study, 24 elevated gastric residual volume and vomiting were associated with an increased incidence of VAP. In another study, 9 the supine position and the length of time the patient stayed in that position were risk factors for gastric aspiration. In a study by McClave and colleagues, 28 the occurrence of regurgitation, regardless of its frequency or whether aspiration had occurred, was not associated with a higher incidence of pneumonia. More recently, an association was found between the occurrence of aspiration and the development of pneumonia. In that study, 7 pneumonia rates increased from 24% on day 1 to 48% on day 4. On day 4, the mean percentage of pepsin-positive tracheal secretions was twice as high for patients with pneumonia as for patients without pneumonia. Methods We conducted a clinical project to assess nurses knowledge about use of the ventilator bundle to prevent VAP and the related practice patterns in a coronary care unit (CCU) and surgical ICU (SICU) at a large hospital based in a medical center in a major metropolitan city. Changes in knowledge and nursing practices related to the ventilator bundle and VAP prevention were examined before and after sessions about current evidence-based interventions. A total of 8 sessions were conducted to include most of the nurses working in the 2 units. These sessions included a 3-minute presentation, a pretest, and a posttest. An al poster containing a copy of the presentation was placed in each unit after the sessions for those nurses who were unable to attend. The 3-minute PowerPoint and poster presentation included materials from AACN s VAP practice alert, information from the literature obtained through Internet research, and the guidelines from the CDC. A 1-item test was constructed to examine nurses knowledge about VAP and its prevention by using interventions that are based on the ventilator bundle. The questions on the 1-item test contained information from the PowerPoint presentation. The project director conducted all the sessions in the CCU and the SICU. Additionally, the project director created the PowerPoint and poster presentations as well as the 1- item test, all of which were reviewed by 2 critical care nursing experts and educators to establish content validity. The test included 1 questions on such topics as best-practice guidelines, microorganisms that cause VAP, hand washing, supine positioning, enteral feeding, factors related to VAP, definition of VAP, and diagnosis of pneumonia. Participants included 14 night-shift nurses and 14 day-shift nurses from the SICU and 15 day-shift nurses and 18 night-shift nurses from the CCU. These participants comprised approximately 65% to 7% of all the nurses in each unit. Pretests and posttests were administered immediately before and after the in-service sessions. In addition, the practice patterns of nurses were observed during the 1 month preceding and the 1 month following the sessions. Practice patterns were assessed both before and after the sessions by observing the care rendered to 3 patients in the SICU and 69 patients in the CCU, all of whom were receiving mechanical ventilation. HOB elevation was measured by checking the beds that were equipped with angle measurement to specify the degrees of elevation. Practice was observed during shift reports at 7 AM and 7 PM. Factors assessed included whether HOB elevation was addressed during shift reports; the handwashing practices of nurses; and whether nurses had artificial nails, wore nail polish, or wore rings (with the number of rings noted) during contacts with patients. Records in the computer information system were used to audit patients charts for HOB elevation, frequency of oral care, and frequency of nasogastric tube checking in the preceding 12 hours. All data were collected and analyzed by the project director and reviewed by 2 critical care nursing experts who were project team members. Project implementation and evaluation took 6 months. Results Demographic data for the nurses showed a range of ages, al levels, years of experience in critical care, and total hospital experience (Table 2). Most nurses in the CCU (79%) and the SICU (86%) were AMERICAN JOURNAL OF CRITICAL CARE, January 27, Volume 16, No. 1 23

5 Table 2 Demographic data for nurses in the study No. (%) of nurses Parameter Sex of nurse Female Male Age, y >61 Highest al level in nursing Diploma Associate s degree Bachelor s degree Graduate degree Nursing experience, y < >5 Critical care experience, y < >5 Shift worked 7 AM 7 PM 7 PM 7 AM Coronary care unit (n = 33) Surgical intensive care unit (n = 28) Total (N = 61) 26 (79) 7 (21) 24 (86) 4 (14) 5 (82) 11 (18) 9 (27) 7 (21) 13 (39) 3 (9) 1 (3) 7 (25) 11 (39) 4 (14) 5 (18) 1 (4) 16 (26) 18 (3) 17 (28) 8 (13) 2 (3) 1 (3) 12 (36) 2 (61) 1 (4) 5 (18) 22 (79) 2 (3) 17 (28) 42 (69) 6 (18) 2 (6) 4 (12) 21 (64) 3 (11) 4 (14) 3 (11) 18 (64) 9 (15) 6 (1) 7 (11) 39 (64) 6 (18) 2 (6) 4 (12) 21 (64) 2 (7) 5 (18) 2 (7) 19 (68) 8 (13) 7 (11) 6 (1) 4 (66) 15 (45) 18 (55) 14 (5) 14 (5) 29 (48) 32 (52) female. Most (57%) were between 31 and 5 years of age; 13 CCU nurses (39%) were 41 to 5 years old, and 11 SICU nurses (39%) were 31 to 4 years old. Most nurses in both the CCU (61%) and the SICU (79%) had a bachelor of science degree in nursing. Hospital experience for most CCU (64%) and SICU (64%) nurses was 5 years or more. Similarly, most CCU (64%) and SICU (68%) nurses had 5 years or more of critical care experience. Nurses scores on the pretests and posttests are compared in Table 3. The changes in test scores indicate that the 3-minute session increased the knowledge gained by the nurses about VAP and the ventilator bundle (independent t test, P). Scores changed significantly (χ 2 tests, P<.5) from pretests to posttests for 8 of the 1 questions. The 2 questions that did not show improvements in scores were 2 true-false choice items regarding best-practice guidelines and hand washing (98%-1% correct on both the pretest and the posttest). As for changes in practice patterns, nurses elevated the HOB to 3º or higher for 74% of the patients after the sessions as compared with only 44% before the sessions (P <.1, Table 4). After the sessions, significantly more nurses washed their hands before contact with a patient and significantly fewer nurses wore nail polish and rings (P <.5). However, even before the sessions, most nurses washed their hands after contact with a patient (96%) and very few nurses wore artificial nails (1%). Additionally, although compliance with hand washing before contact with a patient increased significantly after the sessions, compliance was still low (11% before vs 45% after ). Possible contraindications to HOB elevation at 3º to 45º included decubitus ulcers, hemodialysis, continuous renal replacement therapy, intra-aortic balloon pump, emergency invasive procedures, hypotensive episodes, hemodynamic monitoring, and postoperative procedure(s) that may require the patient to be positioned supine or the HOB to be set at a lower elevation. Presence of possible contraindications to HOB elevation did not change from before to after the sessions (P>.5). Examination of patients charts for practices related to the ventilator bundle showed significant 24 AMERICAN JOURNAL OF CRITICAL CARE, January 27, Volume 16, No. 1

6 Table 3 Comparison of results from pretest and posttest (N = 61) No. (%) correct Subject of question 1. Ventilator bundle best-practice guidelines* 2. Microorganisms causing VAP 3. Poor hand washing and VAP* 4. Supine positioning and lung capacity 5. Enteral feeding and VAP 6. Risk factors for VAP 7. Treatment-related risk factor for VAP 8. Host-related risk factors for VAP 9. Pneumonia diagnoses* 1. Definition of VAP Total score, mean, SD (range) Pretest 61 (1) 17 (28) 6 (98) 46 (75) 32 (52) 44 (72) 12 (2) 17 (28) 54 (89) 53 (87) 6.31, 1.35 (2-1) Posttest 61 (1) 53 (87) 6 (98) 57 (93) 54 (89) 57 (93) 46 (75) 48 (79) 6 (98) 61 (1) 9.11, 1.36 (5-1) *True/false items. Abbreviation: VAP, ventilator-associated pneumonia. improvement in HOB elevation, from 51% before the sessions to 69% after the sessions (P=.9, Table 5). The frequency of oral care increased significantly (P =.9). After the sessions, 35% of the audited records showed documented oral care 3 times per shift, whereas only 16% showed the same frequency of care before the sessions. Residual volume in the nasogastric tube was also checked more frequently after the sessions; 18% of patients were checked 3 times per shift, whereas only 3% of patients were checked that often before the sessions. A 3-minute session improves knowledge and use of ventilator-associated pneumonia prevention strategies. Discussion Education sessions were presented to most nurses in the CCU and SICU. After the nurses completed the sessions, their knowledge increased and their use of evidence-based practice improved. Thus the goals of the project were successfully met, as shown by the P >.99 > Table 4 Observations of practices (N = 99) Practice Hands washed (before contact) Hands washed (after contact) Nail polish Artificial nails Rings worn Actual head-of-bed elevation <3º 3º Contraindications No. (%) of nurses performing practice Before 11 (11) 95 (96) 4 (4) 1 (1) 39 (39) 44 (44) 14 (14) 2 (2) 55 (56) 44 (44) 41 (41) After 45 (45) 99 (1) () () 65 (66) 27 (27) 4 (4) 3 (3) 26 (26) 73 (74) 35 (35) significant improvement in the nurses test scores and in the number of patients who received the level of care recommended in the ventilator bundle. These results show that targeted intervention with a 3- minute session can influence nurses knowledge and clinical practice. Significant changes were noted in the nurses hand-washing practices before contact with a patient and in their use of nail polish and wearing of rings. The actual HOB elevation used, notation of HOB elevation in patients charts, oral care, and checking of residual volume in the nasogastric tube also improved significantly. The observed practices also indicated some level of professionalism and awareness among the nurses regarding proper hand washing after contact with patients as well as the problems associated with wearing artificial nails. Such practices should be positively reinforced. Findings of this project further support results of earlier studies about educating hospital staff about VAP and the ventilator bundle. 9,11,12 Evidence-based practices, including those addressed in the ventilator bundle, should be a driving force in shaping nursing practice. The ultimate goal of evidence-based practice is high-quality healthcare with beneficial outcomes. Reinforcement of can help ensure that the improves nursing practices in a sustained manner. Consistent and accurate documentation of HOB elevation at 3º or higher, oral care, and checking of residual volume in the nasogastric tube, along with P AMERICAN JOURNAL OF CRITICAL CARE, January 27, Volume 16, No. 1 25

7 Table 5 Chart audit (N = 99) Practice Head-of bed elevation Not recorded on chart <3º 3º Frequency of oral care in 12-hour shift Frequency of checking residual volume in nasogastric tube during a 12-hour shift Not applicable No. (%) of charts with practice noted Before 33 (33) 16 (16) 5 (51) 45 (45) 25 (25) 13 (13) 16 (16) 13 (13) 12 (12) 12 (12) 3 ( 3) 59 (6) After 26 (26) 5 ( 5) 68 (69) 27 (27) 25 (25) 12 (12) 35 (35) 11 (11) 6 ( 6) 8 ( 8) 18 (18) 56 (57) P surveillance of proper hand-washing practice among nurses, should be recommended. Use of the ventilator bundle includes elevating the HOB to 3º to 45º to prevent VAP among ICU patients who are receiving mechanical ventilation. Patients in the ICU, who are frequently positioned supine because of the presence of decubitus ulcers, for hemodynamic monitoring, or for particular bedside procedures, should be consistently returned to a semirecumbent position. If HOB elevation at 3º to 45º is a factor in the formation of decubitus ulcers, then the patient could still be placed in the semi-fowler s position but turned from side to side at least every 2 hours. The limitations of this project included the fact that not all the nurses in the CCU and SICU were able to participate in the live sessions; for those who could not attend, the information was provided through an al poster that was posted in the unit. In some cases, nurses who attended the sessions shared the information with those who did not attend. Because of the nature of the project and the scheduling of staff, no comparisons were made between nurses who attended the sessions and those who did not. One factor that may have affected the results was the nurses awareness of being observed before and after the sessions, which may have led to more conscientious practice. Moreover, few patients received feedings via a nasogastric tube. Most patients receiving mechanical ventilation were receiving total parenteral nutrition, which meant that the number of patients with nasogastric tubes to be checked was limited. As with all chart audits, data are limited to the entries that were made; practices may have occurred without being documented. Finally, other limitations of the clinical project included absence of a control group against which to compare findings, the unknown reliability of the test questions, and the use of documentation as a proxy for actual practice. Future studies should focus on high-risk and higher acuity patients and those patients receiving mechanical ventilation who are admitted to chronic care facilities, which would involve a longer period of observation. Future studies are needed to examine nursing practices, including oral care and nasogastric tube feedings, as related to prevention of VAP. Studies that would establish a direct relationship between oral care, checking of residual volume in the nasogastric tube, and the development of VAP are essential to formulating evidence-based protocols for these practices. Scientific inquiries are needed to determine whether continuous pump or drip feedings via a nasogastric tube should be turned off while patients are being repositioned or placed supine for procedures. The ventilator bundle should be used to implement practice changes for patients, with specification of a safe gastric residual volume and recommendation of a frequency for checking residual volume in the nasogastric tube to prevent pulmonary aspiration. ACKNOWLEDGMENTS The authors thank Patricia S. Lewis, RN, MS, CNAA, associate chief of nursing, and Lisa Hanna, RN, BSN, director of nursing at The Methodist Hospital, Houston, Tex, for their contributions to the implementation of this study. The authors also thank the nurses in the coronary care unit and the surgical intensive care unit at The Methodist Hospital for their participation in the project. FINANCIAL DISCLOSURES None reported. REFERENCES 1. American Association of Critical-Care Nurses. American Association of Critical Nurses practice alert: ventilator-associated pneumonia. Available at: /VentilatorAssociatedPneumonia.pdf. Accessed October 11, Tablan O, Anderson L, Besser R, Bridges C, Hajjeh R. Guidelines for preventing health care-associated pneumonia, 23: recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee. MMWR Recomm Rep. March 26, 24;53(RRO3): Drakulovic MB, Torres A, Bauer TT, Nicolas JM, Nogue S, Ferrer M. Supine body position as a risk factor for nosocomial pneumonia in mechanically ventilated patients: a randomized. Lancet. 1999;354: Kollef MH. Ventilator-associated pneumonia: a multivariate analysis. JAMA. 1993;27: Kollef MH, Von Harz B, Prentice D, et al. 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8 risk factors. Crit Care Med. 26;34: Hanneman SK, Gusick G. Frequency of oral care and positioning of patients in critical care: a replication study. Am J Crit Care. 25;14: Torres A, Serra-Batiles J, Ros E, et al. Pulmonary aspiration of gastric contents in patients receiving mechanical ventilation: the effect of body position. Ann Intern Med. 1992;116: Babcock HM, Zack JE, Garrison T, et al. An al intervention to reduce ventilator-associated pneumonia in an integrated health system: a comparison of effects. Chest. 24;125: Salahuddin N, Zafar A, Sukhyani L, et al. Reducing ventilator-associated pneumonia rates through a staff programme. J Hosp Infect. 24;57: Zack J, Garrison T, Trovillion E, et al. Effect of an program aimed at reducing the occurrence of ventilator-associated pneumonia. Crit Care Med. 22;3: Warren DK, Shukla SJ, Olsen MA, et al. Outcome and attributable cost of ventilator-associated pneumonia among intensive care unit patients in a suburban medical center. Crit Care Med. 23;31: Cook DJ, Meade MO, Hand L, McMullin JP. Toward understanding evidence uptake: semi-recumbency for pneumonia prevention. Crit Care Med. 22;3: Girou E, Loyeau S, Legrand P, Oppein F, Brun-Buisson C. Efficacy of hand rubbing with alcohol based solution versus standard handwashing with antiseptic soap: randomized clinical. Br Med J. 22;325: Lucet JC, Rigaud MP, Menter F, et al. Hand contamination before and after different hygiene techniques: a randomized. J Hosp Infect. 22; 5: Trick W, Vernon M, Hayes R, et al. Impact of ring wearing on hand contamination and comparison of hand hygiene agents in a hospital. Clin Infect Dis. 23;36: Zaragosa M, Salles M, Gomez J, Bayas JM, Trilla A. Handwashing with soap or alcoholic solution? a randomized clinical of its effectiveness. Am J Infect Control. 1999;17: Doebbeling BN, Stanley GL, Sheetz CT, et al. Comparative efficacy of alternative hand-washing agents in reducing nosocomial infections in intensive care units. N Engl J Med. 1992;327: Pittet D, Dharan S, Touveneau S, Sauvan V, Perneger TV. Bacteria contamination of the hands of hospital staff during routine patient care. Arch Intern Med. 1999;159: Bergman D, Bonten M, Gaillard C, et al. Prevention of ventilator-associated pneumonia by oral decontamination. Am J Respir Crit Care Med. 21;164: Pugin J, Auckenthaler R, Lew DP, Suter PM. Oropharyngeal decontamination decreases incidence of ventilator-associated pneumonia: a randomized, placebo-controlled, double-blinded clinical. JAMA. 1991;265: DeRiso AJ 2nd, Ladowski JS, Dillon TA, Justice JW, Peterson AC. Chlorhexidine gluconate.12% oral rinse reduces the risk of total nosocomial respiratory infection and nonprophylactic systemic antibiotic use in patients undergoing heart surgery. Chest. 1996;19: Mentec H, Dupont H, Boccheti M, Cani P, Ponche F, Bleicher G. Upper digestive intolerance during enteral nutrition in critically ill patients: frequency, risk factors, and complications. Crit Care Med. 21;29: Cutler C, Davis N. Improving oral care in patients receiving mechanical ventilation. Am J Crit Care. 25;14: Houston S, Hougland P, Anderson JJ, LaRocco M, Kennedy V, Gentry LO. Effectiveness of.12% chlorhexidine gluconate oral rinse in reducing prevalence of nosocomial pneumonia in patients undergoing heart surgery. Am J Crit Care. 22;11: Bussell S, Donnelly K, Helton S, et al. Clinical Nutrition: A Resource Book for Delivering Enteral and Parenteral Nutrition for Adults. University of Washington Medical Center and Clinical Nutrition Committee, Harborview Medical Center Available at: Accessed October 13, McClave SA, Lukan JK, Stefater JA, et al. Poor validity of residual volumes as a marker of aspiration in critically ill patients. Crit Care Med. 25; 33: AMERICAN JOURNAL OF CRITICAL CARE, January 27, Volume 16, No. 1 27