Infection Control & Hospital Epidemiology
selected bundle elements and found suboptimal overall adherence rates. Therefore, the IPC team chose a mixed-methods approach to assess adherence to VAP prevention measures and identify barriers to and facilitators of protocol adherence.
Methods Setting
The study took place at the University Hospital Zurich (UHZ), Zurich, Switzerland, a 900-bed tertiary-care teaching hospital featuring all medical specialties except pediatrics and orthopedics. In total, the study included 64 beds in 6 ICUS: medical ICU, general thoracic and transplant surgery ICU, trauma ICU, burn ICU, cardiac surgery ICU, and neurosurgery ICU.
The University Hospital Zurich (UHZ) VAP bundle
The UHZ VAP bundle was created by an interprofessional group comprising IPC team members, ICU nurses and physicians, and anesthesiologists. It included 9 elements: (1) continuous application of a sedation and weaning protocols with daily sedation interrup- tions; (2) head of the bed elevation of ≥30°; (3) oral decontami- nation with chlorhexidine mouth wash twice daily; (4) the use of endotracheal tubes with continuous subglottic secretion drainage; (5) hand hygiene according to the WHO Five Moments concept31; (6) use of noninvasive ventilation (NIV) whenever feasible; (7) periodic changes of ventilator tubing and filters biweekly; (8) use of closed suction systems; and (9) daily evaluation of stress ulcer prophylaxis to limit its use. The bundle was enacted by the medical director in 2011, and the standard operating procedure (SOP) was made accessible via the hospital’s intranet. In 2013, the UHZ VAP bundle was formally implemented under the lead of ICU nurses by providing education and practical training. In June 2016, an ‘action month,’ 5 of the 9 bundle elements (ie, head of bed elevation, oral care with chlorhexidine, hand hygiene, NIV, closed suction system) were again addressed by providing education, practical training, contests, and posters and stickers as reminders. The elements were chosen by the ICUteams based on feedback adherence rates and the anticipated need for training.
Adherence measurements
Adherence to VAP prevention elements was assessed by overt, nonparticipatory observations in February 2015 (measurement 1), in August 2015 (measurement 2), in July 2016 (measurement 3) and continuously from July to September 2017 (measurement 4). Investigators visited all ICUs once or twice daily during weekdays between 8 AM and 6 PM. We evaluated 4 bundle elements whose execution relied on HCP decision making rather than on standar- dized workflows. (1) Daily sedation interruption was assessed by reviewing the handwritten tracking sheet and by oral confirmation by the responsible nurse. We excluded patients with severe hemo- dynamic shock, a subset of specified intracranial injuries or neu- rologic diseases that challenge cerebral perfusion, extracorporeal membrane oxygenation, neuromuscular blocking agents, and ther- apeutic hypothermia, as well as those in need of a kinetic bed system. (2) Head of bed elevation was measured using a Smart- phone application for angle measurement (Mammut Safety APP, version 1.0, Mammut Sports Group AG, Seon, Switzerland). We excluded patients with hemodynamic instability, instable spinal or pelvic fracture, and specific intracranial injuries or neurologic dis- eases that impair cerebral perfusion pressure. (3) Twice-daily oral
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care with chlorhexidine was assessed by review of the electronic patient record. (4) Continuous subglottic secretion drainage was assessed by direct observations. We excluded patients with endo- tracheal or tracheostomy tubes not featuring a suction port. In measurement 2, sedation interruption and subglottic drainage were not assessed. In measurement 4, subglottic drainage was not assessed. Good, intermediate, and poor adherence were defined as ≥80%, ≥50%–80%, and <50% adherence, respectively.
Theoretical framework
The behavior change wheel (BCW) is a theoretical framework that incorporates several existing behavior-change frameworks into a behavioral system (COM-B) composed of 3 ‘sources of behavior’: capability, opportunity, and motivation.32 The BCW was chosen to guide the analysis in this study because it is an overarching framework that considers the influence of context on individual behavior. A further advantage of the BCW is that it links barriers and facilitators identified within the COM-B system to proposed interventions that may be effective in addressing deficits (Table 1).
Focus group interviews—Data collection and analysis
The 6 focus group interviews, 1 per ICU, were conducted between May 4 and June 5, 2015. We used a purposeful criterion sampling approach,33 and we sought to include both nurses and physicians from each of the 6 ICUs to gather a broad range of experiences related to VAP prevention. Beyond these criteria, participants included convenience samples of ICU nurses and physicians on duty who were available when the group interview took place. They represent a subset of the observed HCP. All semi-structured interviews were conducted by the same IPC nurse (M.T.M.). The interview guide is shown in Table 2. Written informed consent was obtained from all interviewees. Interviews were held in Swiss- German, audiotaped, and transcribed verbatim. Following a grounded theory approach, initial data analysis was conducted inductively by 2 investigators (A.W. and M.T.M.) to summarize interview content and to inform the ongoing data collection.34 Following data collection, the same 2 investigators (A.W. and M.T.M.) deductively coded all identified barriers and facilitators according to the BCW behavioral system components: capability, opportunity, or motivation.32 Any discrepancies in coding were resolved by a health psychologist (L.C.). Using the same approach, participant ideas for better bundle implementation approaches were deductively coded according to the intervention functions of the BCW with its 9 components: education, persuasion, incentivization, coercion, training, restriction, environmental restructuring, model- ing, and enablement. These participant suggestions were then compared with the intervention functions proposed by the BCW for addressing identified barriers and facilitators (Table 1).
Results Adherence measurements
Data regarding adherence rates are shown in Table 3. Adherence was poor for head of bed elevation (27%; 95% confidence intervals [CI], 23%–31%) and oral care (41%; 95% CI, 36%–45%), though it was good for daily sedation interruption (81%; 95% CI, 74%– 85%) and subglottic suctioning (88%; 95% CI, 83%–92%). A considerable number of patients had a contraindication for head of bed elevation (27%; 95% CI, 23%–31%) and sedation inter- ruption (41%; 95% CI, 36%–46%). Also, 41% (95% CI, 36%–46%)
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