Pulmonary Critical Care CRITICAL CARE CLINICIANS KNOWLEDGE OF EVIDENCE-BASED GUIDELINES FOR PREVENTING VENTILATOR-ASSOCIATED PNEUMONIA By Mohamad F. El-Khatib, MB, PhD, Salah Zeineldine, MD, Chakib Ayoub, MD, MBA, Ahmad Husari, MD, Pierre K. Bou-Khalil, MD C E 1. Hour Notice to CE enrollees: A closed-book, multiple-choice examination following this article tests your under standing of the following objectives: 1. Identify evidence-based guidelines for preventing ventilator-associated pneumonia. 2. Identify 2 knowledge deficits of participants in this research study.. Discuss the results of this research study and the implications for critical care nursing. To read this article and take the CE test online, visit www.ajcconline.org and click CE Articles in This Issue. No CE test fee for AACN members. 29 American Association of Critical-Care Nurses doi: 1.4/ajcc29 Background Ventilator-associated pneumonia is the most common hospital-acquired infection among patients receiving mechanical ventilation in an intensive care unit. Different initiatives for the prevention of ventilator-associated pneumonia have been developed and recommended. Objective To evaluate knowledge of critical care providers (physicians, nurses, and respiratory therapists in the intensive care unit) about evidence-based guidelines for preventing ventilator-associated pneumonia. Methods Ten physicians, 41 nurses, and 18 respiratory therapists working in the intensive care unit of a major tertiary care university hospital center completed an anonymous questionnaire on 9 nonpharmacological guidelines for prevention of ventilator-associated pneumonia. Results The mean (SD) total scores of physicians, nurses, and respiratory therapists were 8.2% (.4%), 8.1% (1.6%), and 8.% (6%), respectively, with no significant differences between them. Furthermore, within each category of health care professionals, the scores of professionals with less than years of intensive care experience did not differ significantly from the scores of professionals with more than years of intensive care experience. Conclusions A health care delivery model that includes physicians, nurses, and respiratory therapists in the intensive care unit can result in an adequate level of knowledge on evidence-based nonpharmacological guidelines for the prevention of ventilator-associated pneumonia. (American Journal of Critical Care. 21;19:22-2) 22 AJCC AMERICAN JOURNAL OF CRITICAL CARE, May 21, Volume 19, No. www.ajcconline.org
Ventilator-associated pneumonia (VAP) is the most common hospital-acquired infection among patients who receive mechanical ventilation in the intensive care unit (ICU). 1,2 VAP is associated with delayed extubation, prolonged stays in the ICU and hospital, increased mortality and morbidity, and increased use of health care resources.,4 As such, prevention of VAP is an essential objective of health care delivery in ICUs. Many strategies and guidelines have been developed and proposed for the prevention of VAP. - Adherence to and implementation of the adopted VAP prevention guidelines have been variable 8,9 and were affected by lack of training, lack of an adequate infection control program, and lack of knowledge among health care providers of such guidelines. 1, Although knowledge of the guidelines does not guarantee implementation and adherence, lack of knowledge may be a barrier to adherence to and implementation of VAP prevention guidelines. Many studies have focused on assessing the knowledge of ICU nurses regarding measures for the prevention of VAP. 9-1 Other ICU health care providers particularly respiratory therapists, who are involved in controlling endotracheal cuff pressure, avoiding microaspiration of subglottic secretions, and controlling contamination of mechanical ventilator equipment can have a significant effect on the prevention of VAP in patients receiving mechanical ventilation in the ICU. 14 The aim of this study was to assess the knowledge of ICU health care providers (ie, physicians, nurses, and respiratory therapists) related to evidence-based guidelines for prevention of VAP. Methods A multiple-choice questionnaire consisting of 9 items (Table 1) that had been developed, validated, and tested by Blot et al 12 and Labeau et al 1 was distributed to all physicians, nurses, and respiratory therapists working in the ICU of a 42-bed university hospital. The ICU had 2 beds with an approximate daily average of 12 patients receiving mechanical ventilation. Any staff member who was About the Authors Mohamad F. El-Khatib is a professor and Chakib Ayoub is an associate professor in the Department of Anesthesiology and Salah Zeineldine, Ahmad Husari, and Pierre K. Bou-Khalil are assistant professors in the Department of Medicine in the School of Medicine at the American University of Beirut, Beirut, Lebanon. Corresponding author: Dr Pierre Bou-Khalil, Assistant Professor, Division of Pulmonary and Critical Care, Department of Internal Medicine, American University of Beirut, PO Box -26, Beirut, Lebanon (e-mail: pb@aub.edu.lb). aware of the previous 2 studies by Blot et al 12 and Labeau et al 1 was not allowed to participate in the study; such exclusion was intended to eliminate any potential bias in the answers of participants. Knowledge of the recently published articles was determined by a direct question to the participant. Additional demographic information obtained in the survey included the participant s professional category, sex, and years of ICU experience. Data were collected from June 1 to June 1, 28. During this period, one of the investigators (M.F.K.) distributed the questionnaire by hand to all critical care physicians, ICU nurses, and respiratory therapists. Eligible participants were given 1 minutes to complete the questionnaire, similar to previous studies. 12,1 For each item of the questionnaire, the percentage of correct answers was determined, then mean total scores were calculated. All data were compared among the categories of health care professionals. Continuous data are presented as means and standard deviations and were compared with analysis of variance and Scheffe test for post hoc analysis. The χ 2 test was used to compare percentages of correct answers. Linear regression analysis was used to assess the relationship between scores and participants demographic characteristics. SPSS for Windows 1. (SPSS, Chicago, Illinois) was used for statistical analysis. Statistical significance was set at P <.. Results All 1 critical care physicians (1%), 41 of the 4 ICU nurses (8%), and all 18 respiratory therapists (1%) who were given the questionnaire completed it (Table 2). In the physician category, % were men and % were women, and their mean ICU Knowledge of VAP guidelines was compared among nurses, physicians, and respiratory therapists. www.ajcconline.org AJCC AMERICAN JOURNAL OF CRITICAL CARE, May 21, Volume 19, No. 2
Table 1 Scores (%) by each category Physicians (n = 1) Nurses (n = 41) Scores, % Respiratory therapists (n = 18) 1. Oral vs nasal route for endotracheal intubation a. Oral intubation is recommended b. Nasal intubation is recommended c. Both routes of intubation can be recommended 2. Frequency of ventilator circuit changes a. Recommended to change circuits every 48 h (or when clinically indicated) b. Recommended to change circuits every week (or when clinically indicated) c. Recommended to change circuits for every new patient (or when clinically indicated). Type of airway humidifier a. Heated humidifiers are recommended b. Heat and moisture exchangers are recommended c. Both types of humidifiers can be recommended 4. Frequency of humidifier changes a. Recommended to change humidifiers every 48 h (or when clinically indicated) b. Recommended to change humidifiers every 2 h (or when clinically indicated) c. Recommended to change humidifiers every week (or when clinically indicated). Open vs closed suction systems a. Open suction systems are recommended b. Closed suction systems are recommended c. Both systems can be recommended 6. Frequency of change in suction systems a. Daily changes are recommended (or when clinically indicated) b. Weekly changes are recommended (or when clinically indicated) c. Recommended to change systems for every new patient (or when clinically indicated). Endotracheal tubes with extra lumen for drainage of subglottic secretions a. These endotracheal tubes reduce the risk for VAP b. These endotracheal tubes increase the risk for VAP c. These endotracheal tubes do not influence the risk for VAP 8. Kinetic vs standard beds a. Kinetic beds increase the risk for VAP b. Kinetic beds reduce the risk for VAP c. The use of kinetic beds does not influence the risk for VAP 9. Patient positioning a. Supine positioning is recommended b. Semirecumbent positioning is recommended c. The position of the patient does not influence the risk for VAP Total score, mean (SD) 9 1 6 21 89 1 1 1 2 68 2 84 8 2 84 16 88 12 4 1 41 26 22 4 12 4 9 1 92 8 88 12 1 2 1 8 1 8 1 9 9 8 2 2 92 6 84 9 1 8.2 (.4) 9 8.1 (1.6) 81 8. (6.) Abbreviation: VAP, ventilator-associated pneumonia. a The correct answers are indicated by the circled letters. experience was.8 (SD, 6.) years. The nursing category consisted of % men and 6% women with a mean ICU experience of 6.8 (SD, 1.4) years. Among the group of respiratory therapists, 9% were men and % were women, with a mean ICU experience of 8. (SD, 6.6) years. The mean years of 24 AJCC AMERICAN JOURNAL OF CRITICAL CARE, May 21, Volume 19, No. www.ajcconline.org
experience did not differ significantly among the categories of participants. The questionnaire and the answers of the health care professional categories are presented in Table 1. Correct answers are indicated by a circle. Mean scores for ICU physicians, nurses, and respiratory therapists were 8.2% (SD,.4%), 8.1% (SD, 1.6), and 8.% (SD, 6.%), respectively, with no significant differences among groups. The results indicate that the participants were most frequently correct about using an endotracheal tube with a larger lumen than usual for drainage of subglottic secretions (question ) and about using open versus closed suction systems (question ). Respondents had the least knowledge about the frequency of humidifier changes (question 4) and the optimal frequency of ventilator circuit changes (question 2). No significant differences were found between male and female participants. When stratified on the basis of the numbers of years of ICU experience (ie, years vs > years), the total scores did not differ significantly between health care professionals with more than years of ICU experience and professionals with years or less of ICU experience (Table ). Discussion We found no differences in the knowledge of guidelines for the prevention of VAP among the physicians, nurses, and respiratory therapists working in the ICU. Knowledge of established measures for the prevention of VAP among nurses has been reported. -1 However, previous studies were focused exclusively on critical care nurses, whereas we compared the knowledge of other health care professionals (physicians and respiratory therapists) as well as nurses, because all of them are involved in providing direct care for patients receiving mechanical ventilation in the ICU. The nurses in our study outperformed nurses from other studies with regard to their knowledge of evidence-based guidelines for preventing VAP. In our study, the nurses mean total score of correct answers to the VAP questionnaire was 8.1%, whereas Blot et al 12 reported a mean score of 41.2% when they surveyed 68 intensive care nurses during the annual congress of the Flemish Society of Critical Care Nurses in 2. One possible explanation of this difference is the fact that the model of health care delivery in ICUs in Lebanon includes respiratory therapists, a category of health care professional not used in the European countries where knowledge of VAP prevention practices has been studied before. Respiratory therapists play an integral role in the management of patients receiving Table 2 Participants demographics Characteristic Sex Male Female Years of experience in intensive care unit <1 1-6-1 >1 Mean (SD) Physicians (n = 1) mechanical ventilation in the ICU and provide respiratory care services (eg, oral intubation, use of endotracheal tubes with subglottic suctioning to avoid microaspiration, control of endotracheal tube cuff pressure, change of ventilator circuits) that may result in lower rates of VAP. Perhaps the respiratory therapists, ICU nurses, and physicians discussed the evidence-based guidelines for prevention of VAP during daily medical rounds, performance improvement meetings, and educational activities (eg, VAP day). Previously, Labeau and colleagues 1 reported lower scores for ICU nurses on knowledge of VAP prevention guidelines than the scores reported here. They acknowledged that ICU nurses in Belgium and elsewhere in Europe manage many strategies related to the prevention of VAP, such as ventilator circuit and humidifier changes, on top of their regular nursing duties. Blot et al 12 previously reported that more experienced nurses have a higher knowledge level than do nurses with less than 1 year of experience. Our study shows that adequate knowledge of the nonpharmacological guidelines for the prevention of VAP can be gained within the first years of ICU experience. Although we originally planned to use a lower cutoff for the number of years of ICU 1 4.8 (6.) Table Scores according to participants years of experience in intensive care Years of experience > Physicians 8.2 (12.8) 8.2 (8.2) No. of participants Nurses (n = 41) 1 26 4 2 4.8 (1.4) Score, mean (SD) Nurses 6.2 (9.) 81.9 (6.9) Respiratory therapists (n = 18) 1 1 1 14 9. (6.6) Respiratory therapists 81. (6.) 8.2 (6.2) Knowledge did not differ among groups or differ depending on ICU experience. www.ajcconline.org AJCC AMERICAN JOURNAL OF CRITICAL CARE, May 21, Volume 19, No. 2
These nurses outperformed nurses from other studies in knowledge of VAP guidelines. Knowledge of recommended guidelines does not necessarily reflect appropriate practice. experience, unfortunately we did not have enough participants with less than 1 year of ICU experience to be able to perform that analysis. In the current study, the lowest score achieved by all participants categories was on the question of frequency of airway humidifier changes. Only 26% of the nurses, % of the physicians, and 4% of the respiratory therapists were aware of the recommendation to change airway humidification systems weekly or when clinically indicated. This low score might be influenced by the clinical practice of the respiratory therapists who are in charge of managing these systems and who may be influenced by manufacturers recommendations to change heat and moisture exchange filters every 48 hours. Although our study has the advantage of including all health care professionals in the ICU, it has several limitations. The number of participants in this survey is smaller than in previous, similar studies. The use of a single tertiary care university hospital limits the generalizability of our findings. Also, although we excluded potential participants who might have read one or more of the previously published studies involving the survey used here, participants may still have had previous, knowledge of the survey. Also, by excluding them, we may have inadvertently excluded those professionals with more knowledge about VAP guidelines, so the actual knowledge level of the staff might be higher than what is reflected in these findings. Conclusion Knowledge of recommended guidelines does not necessarily reflect appropriate practice, but knowledge remains the first step toward the implementation of evidence-based guidelines for the prevention of VAP. Our study was intended to assess ICU health care providers (physicians, nurses, and respiratory therapists) knowledge of evidence-based guidelines for preventing VAP and not to evaluate the application and practice of evidence-based guidelines for preventing VAP. Such an evaluation is the next logical step for future study. Based on our analysis of these survey results, we conclude that an ICU health care delivery model that includes ICU physicians, nurses, and respiratory therapists can result in an adequate level of knowledge of the evidence-based nonpharmacological guidelines for the prevention of VAP. ACKNOWLEDGMENTS We thank all who participated in this study. FINANCIAL DISCLOSURES None reported. eletters Now that you ve read the article, create or contribute to an online discussion on this topic. Visit www.ajcconline.org and click Respond to This Article in either the full-text or PDF view of the article. References 1. Chaster J, Fagon J. Ventilator-associated pneumonia. Am J Respir Crit Care Med. 22;6:86-9. 2. Depuydt P, Myny D, Blot S. Nosocomial pneumonia: aetiology, diagnosis and treatment. Curr Opin Pulm Med. 26; 12:192-19.. Rello J, Ollendorf D, Oster G, et al. Epidemiology and outcomes of ventilator associated pneumonia in a large US database. Chest. 22;122:2-2121. 4. Safdar N, Dezfulian C, Collard H, Saint S. Clinical and economic consequences of ventilator-associated pneumonia: a systemic review. Crit Care Med. 2;:2184-219.. Tolentino-DelosReyes A, Ruppert S, Shiao S. Evidence-based practice: use of the ventilator bundle to prevent ventilatorassociated pneumonia. Am J Crit Care. 2;16(1):2-2. 6. Muscedere J, Dodek P, Keenan S, Fowler R, Cook D, Heyland D. Comprehensive evidence-based clinical practice guidelines for ventilator-associated pneumonia: prevention. J Crit Care. 28;2:126-1.. Sinuff T, Muscedere J, Cook D, Dodek P, Heyland D. Ventilator-associated pneumonia: improving outcomes through guidelines implementation. J Crit Care. 28;2:8-12. 8. Heyland D, Cook D, Dodek P. Prevention of ventilator-associated pneumonia: current practice in Canadian critical care units. J Crit Care. 22;1:161-16. 9. Ricat M, Lorente C, Diaz E, Kollef, Rello J. Nursing adherence with evidence-based guidelines for preventing ventilator-associated pneumonia. Crit Care Med. 2;1: 269-2696. 1. Sierra R, Benitez E, Leon C, Rello J. Prevention and diagnosis of ventilator-associated pneumonia: a survey on current practices in Southern Spanish CCUs. Chest. 2; 128:166-16.. Biancofiore G, Barsotti E, Catalane V, et al. Nurses knowledge and application of evidenced-based guidelines for preventing ventilator-associated pneumonia. Minerva Anesthesiol. 2;:129-14. 12. Blot S, Labeau S, Vandijck D, Van Aken P, Claes B. Evidencebased guidelines for the prevention of ventilator-associated pneumonia: results of a knowledge test among intensive care nurses. Intensive Care Med. 2;:146-146. 1. Labeau S, Vandijck D, Claes B, Van Aken P, Blot S. Critical care nurses knowledge of evidence-based guidelines for preventing ventilator-associated pneumonia: development and validation of an evaluation questionnaire. Am J Crit Care. 2;16:1-. 14. Kaynar A, Mathew J, Hudlin M, et al. Attitudes of respiratory therapists and nurses about measures to prevent ventilator-asociated pneumonia: a multicenter, cross-sectional survey study. Respir Care. 2;2:168-1694. To purchase electronic or print reprints, contact The InnoVision Group, Columbia, Aliso Viejo, CA 9266. Phone, (8) 899-2 or (949) 62-2 (ext 2); fax, (949) 62-249; e-mail, reprints@aacn.org. 26 AJCC AMERICAN JOURNAL OF CRITICAL CARE, May 21, Volume 19, No. www.ajcconline.org
CE Test Test ID A9: Critical Care Clinicians Knowledge of Evidence-Based Guidelines for Preventing Ventilator-Associated Pneumonia. Learning objectives: 1. Identify evidence-based guidelines for preventing ventilator-associated pneumonia. 2. Identify 2 knowledge deficits of participants in this research study.. Discuss the results of this research study and the implications for critical care nursing. 1. Which the following numbers of evidence-based guidelines for preventing ventilator - associated pneumonia (VAP) was included in the knowledge assessment? a. c. 9 b. d. 2. Which of the following methods was used for data collection in this study? a. Questionnaire c. Medical record b. Observation d. Interview. Statistical signif icance in this study was set at which of the following levels? a. P <.1 c. P <.1 b. P <. d. P <. 4. Which of the following numbers of clinicians participated in this study? a. 41 c. 69 b. 4 d.. Evidence-based guidelines for preventing VAP recommend changing ventilator circuits how frequently? a. Every 48 hours c. Every week b. Every 2 hours d. Every new patient 6. Evidence-based guidelines for preventing VAP recommend the use of which of the following airway humidif iers? a. Heated humidifiers b. Cooled humidifiers c. Heat and moisture exchangers d. Cold and moisture exchangers. Which of the following percentages of nurses was aware of the recommendation to change airway humidif iers every week or when clinically indicated? a. 26% c. % b. 4% d. 69% 8. Which of the following percentages of nurses was aware that endotracheal tubes for drainage of subglottic secretions reduced the risk for VAP? a. 41% c. 8% b. 6% d. 9% 9. Which of the following was the mean total test score for nurses? a..% c. 8.2% b. 8.1% d. 8.% 1. Study participants had the most knowledge about which of the following evidence-based guidelines for preventing VAP? a. Endotracheal tubes for drainage of subglottic secretions b. Frequency of airway humidifier changes c. Route for endotracheal intubation d. Frequency of ventilator circuit changes. Study participants had the least knowledge about which of the following evidence-based guidelines for preventing VAP? a. Type of airway humidifier b. Frequency of ventilator circuit changes c. Route for endotracheal intubation d. Frequency of change in suction systems Test ID: A9 Contact hours: 1. Form expires: May 1, 212. Test Answers: Mark only one box for your answer to each question. You may photocopy this form. 1. a 2. a. a 4. a. a 6. a Fee: AACN members, $; nonmembers, $1 Passing score: 8 Correct (%) Synergy CERP: Category A Test writer: John P. Harper, MSN, RN-BC Program evaluation Name Member # Yes No Objective 1 was met Address Objective 2 was met Objective was met City State ZIP Content was relevant to my Country Phone E-mail address For faster processing, take nursing practice this CE test online at My expectations were met RN License #1 State www.ajcconline.org ( CE This method of CE is effective RN License #2 State Articles in This Issue ) or for this content mail this entire page to: The level of difficulty of this test was: Payment by: Visa M/C AMEX Check easy medium difficult AACN, Columbia, To complete this program, Card # Expiration Date Aliso Viejo, CA 9266. it took me hours/minutes. Signature The American Association of Critical-Care Nurses is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center s Commission on Accreditation. AACN has been approved as a provider of continuing education in nursing by the State Boards of Nursing of Alabama (#ABNP62), California (#16), and Louisiana (#ABN12). AACN programming meets the standards for most other states requiring mandatory continuing education credit for relicensure.. a 8. a 9. a 1. a. a