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adherence, both HCPs and the BCW framework suggested 2 main interventions, ‘restructuring the environment’ and ‘enablement of HCP.’ VAP prevention measures were shown to be poorly executed by
other investigators: Adherence to head of bed elevation or to daily sedation interruption, for example, was reported to be 25%– 35%,36–39 and 29%–56%,40,41 respectively. In our study, we found good adherence for sedation vacation, but adherence rates may have been overly optimistic because a considerable percentage of patients were judged to have contraindications for this prevention measure and because some of these contraindications might have been relative. On the other hand, the interviews revealed that adherence to oral care with chlorhexidine was low due to poor documentation rather than missing execution. For the other 3 measured bundle elements, self-assessment of interviewees corresponded largely with the measured adherence. For another 3 of the 5 bundle elements not measured (ie, hand hygiene, NIV, and daily evaluation of stress ulcer prophylaxis), adherence was considered improvable by the interview participants (data not shown). Semi-structured interviews identified 2 main facilitators for
bundle adherence, both belonging to the BCW component ‘reflec- tivemotivation.’ First, VAP was perceived as a serious and common problem among ICU
patients.Many interviewees, especially nurses, estimated VAP incidence at 50% of ventilated patients, corre- sponding to VAP rates of around 40% of studies applying the Clinical Pulmonary Infection Score (CPIS) criteria.3,42 Second, HCPs perceived prevention measures to lower VAP rates by as much as 30%–80%, corresponding to 52% and 55% in scientific reports.23,24 These noticeably accurate estimations might represent important prerequisites for protocol adherence. Many of the barriers belonged to the BCW component ‘phy-
sical capability.’ HCPs were not satisfied with the quality of the equipment or regretted lack of specific devices (eg, tracheal tubes with a suction port) and staffing levels. From the existing litera- ture, the unavailability of resources is a well-known barrier.43,44 On the other hand, many HCPs raised concern over side effects of prevention measures (eg, head of bed elevation leading to increased need for catecholamines, belonging to component ‘physical capability’). Some HCPs were subjectively concerned about the patient’s well-being (eg, perception that head of bed elevation is uncomfortable for the patient, belonging to the component ‘automatic motivation’). These findings have not been described elsewhere in the literature. The BCW framework offers specific interventions to change
behavior by linking sources of behavior to intervention functions (Table 1).32 Notably, the proposals of interviewees matched those found in the BCW (Table 5). To approach the 2 main barrier components ‘physical opportunity’ and ‘automatic motivation,’ the BCW proposes ‘environmental restructuring’ and ‘enablement’;the latter is considered to ‘going beyond education and training and beyond environmental restructuring.’32 This is consistent with our finding that HCPs asked for better equipment, checklists, and alerts. Of special interest, both the interviewees and the BCW proposed almost exclusively technical solutions. The benefit of technical solutions is supported by Cafazzo’s ‘hierarchy of intervention effectiveness.’45 This management theory promotes system-focused or technological interventions over interventions that require con- scious effort and change of behavior because the latter are notor- iously more difficult to implement and sustain.45,46 Concretely, our study revealed that the HCPs in our ICUs need (and request) a restructured work environment that provides forcing functions and automated or computerized processes.
Aline Wolfensberger et al Our study has several limitations. While we included all partici-
pating ICUs, the individual participants were recruited from a con- venience sample of HCPs with an oversampling of nurses, and we cannot fully exclude the possibility that some opinions may have been missed. The quantitative measures were conducted in a pragmatic quality improvement context and included measurement points with small numbers of observations. Observations were not covered and adherencemight have been overestimated because individuals modify their behavior when being observed (ie, the Hawthorne effect). Because this was a single-center study, the findings might not be generalizable to other settings. However, it covered 6 self-contained ICUs of different specializations and cultures. In conclusion, adherence to 2 of 4 assessed prevention mea-
sures of our VAP bundle was assessed to be improvable, and barriers for adherence predominantly belonged to external rea- sons such as lack of adequate equipment or staffing or side effects of prevention measures. Mapping the inductively identified themes against the BCW framework pinpointed the need to ‘restructure the environment’ and to ‘enable HCPs.’ These find- ings were underpinned by the proposals of the interviewees, who also predominantly advocated for technical solutions to improve their adherence to VAP prevention measures. The BCW- informed mixed-method approach is an effective means for guiding infection prevention efforts. Further research is needed to assess the impact of these interventions on adherence rates.
Acknowledgments. We thank the HCPs of the 6 ICUs at University Hospital Zurich for their participation in the study and the University Hospital Zurich Infection Prevention and Control Team for collecting the adherence data.
Financial support. This study was partially funded by the Swiss National Science Foundation (grant no. 32003B_149474, principal investigator, Hugo Sax). A.W. is supported by the academic career program “Filling the Gap” of the Medical Faculty of the University of Zurich.
Conflicts of interest. All authors report no conflicts of interest relevant to this article.
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