Infection Control & Hospital Epidemiology (2018), 39, 1222–1229 doi:10.1017/ice.2018.195
Original Article
Preventing ventilator-associated pneumonia—a mixed-method study to find behavioral leverage for better protocol adherence
Aline Wolfensberger MDa, Marie-Theres Meier RNa, Lauren Clack PhD, Peter W. Schreiber MD and Hugo Sax MD Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zürich, University of Zurich, Zurich, Switzerland
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.
(Received 8 May 2018; accepted 22 July 2018; electronically published August 31, 2018)
Intensive care unit (ICU) patients are at high risk for developing healthcare-associated infections, and ventilator-associated pneu- monia (VAP) is the most common of these infections.1 VAP is defined as pneumonia occurring 48 h following endotracheal intubation with the ventilator being in place the date of event or the day before.2 The incidence of VAP was reported to be as high as 42%,3–5 but estimates vary substantially depending on different diagnostic scoring systems.3,6 Also, VAP is associated with sub- stantial morbidity, an increase in mortality, and excess costs.7,8 Multiple international guidelines regarding the prevention of
VAP are available.9–13 Most hospitals implement VAP prevention elements as part of a prevention bundle, but the components of such bundles may vary from hospital to hospital.14 Unfortunately, sufficient evidence about the efficacy of single bundle components in preventing VAP is lacking.14 Some prevention measures, such as oral care with chlorhexidine, have recently come under suspicion as being potentially harmful.15,16 Nevertheless, the
Author for correspondence: Aline Wolfensberger, MD, Division of Infectious Dis- eases and Hospital Epidemiology, University Hospital Zurich, University of Zurich,
Rämistrasse 100 CH-8091 Zurich, Switzerland. E-mail:
aline.wolfensberger@usz.ch a Authors of equal contribution.
Cite this article: Wolfensberger A, et al. (2018). Preventing ventilator-associated
pneumonia—a mixed-method study to find behavioral leverage for better protocol adherence. Infection Control & Hospital Epidemiology 2018, 39, 1222–1229. doi: 10.1017/ice.2018.195
© 2018 by The Society for Healthcare Epidemiology of America. All rights reserved.
bundle components.14 Adherencetoand knowledgeaboutVAP preventionmeasures were shown to be poor in several studies.19,25,26 Adherence can be raised through different implementation pro- grams.19,27 A systematic review identified education (eg, training sessions or development of concise summaries of the evidence) and execution strategies (eg, standardization of care processes and building redundancies into routine care) as strategies to enhance the adoption of VAP prevention measures.28 These authors also men- tioned multidisciplinary teamwork, involvement of champions, and networking among peers as engagement strategies.28 Another sys- tematic review showed that improvement in adherence to preventive measures occurred once audit and feedback of adherence rates with or without reminder systems were introduced in addition to orga- nizational change efforts and education of frontline healthcare practitioners (HCPs).29 Generally, it is well accepted that theory- based implementation strategies are more effective in achieving sustained behavior changes.30 In our hospital, a 9-element VAP bundle was designed in 2011
potential to decrease VAP rates using VAP prevention bundles has been demonstrated by many authors,17–22 and the preventable proportion of VAP was estimated to be 52%–55%.23,24 Effective implementation is as important as choosing the right
by an interprofessional working group. Implementation of the bundle began in 2013. In February 2015, the hospital infection prevention and control (IPC) team measured adherence to
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