Why Do Physicians Not Follow Evidence-Based Guidelines for Preventing Ventilator-Associated Pneumonia?

Rello, Jordi; Lorente, Carmen; Bodí, M.; Dı́az, Emili; Ricart, Maite; Kollef, Marin H.

doi:10.1378/chest.122.2.656

Cited by 195 publications

(128 citation statements)

References 17 publications

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“…Nursing convenience also may preclude semirecumbency, because this position may be difficult to maintain for patients receiving multiple interventions. 36 We included "procedure underway" as a contraindication in an attempt to account for patients undergoing interventions such as chest radiography, www.ajcconline.org A AJ JC CC C AMERICAN JOURNAL OF CRITICAL CARE, Online NOW e105 Higher elevations occurred with enteral feeding and weaning status.…”

Section: Discussionmentioning

confidence: 99%

Semirecumbent Positioning in Ventilator-Dependent Patients: A Multicenter, Observational Study

Rose¹,

Baldwin²,

Crawford³

et al. 2010

American Journal of Critical Care

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Background Positioning of patients is a modifiable risk factor for ventilator-associated pneumonia. Current guidelines for prevention of ventilator-associated pneumonia recommend semirecumbency at 30º, with 45º preferable unless contraindicated. Objective To assess the use of semirecumbency for ventilator patients in Australian and New Zealand intensive care units. Methods In a multicenter, observational study, backrest elevation, mean arterial pressure, use of inotropic agents, enteral feeding, and weaning status were recorded 3 times per day by using a predetermined randomization schedule for 7 consecutive days (maximum 21 observation episodes). Severity of illness was recorded daily by using the Sepsis-Related Organ Failure Assessment (SOFA) score. Results Measurements (n = 2112) were recorded for 371 ventilator patients in 32 intensive care units. Backrest elevation at ≥45º was noted for 112 of 2112 (5.3%; 95% confidence interval [CI], 4.3-6.3) measurements; elevation ≥30º but <45º for 472 of 2112 (22.3%; 95% CI, 20.6-24.1). Contraindications to semirecumbency were noted during 447 measurements. Increased backrest elevation occurred during enteral feeding (2.2º, P < .001) and weaning (3.1º, P < .001). Decreased backrest elevation was associated with inotropic support (2.8º, P < .001), decreased mean arterial pressure (0.7º/10 mm Hg, P < .001), and organ failure (0.5º/1-point increment in SOFA max score, P < .001). For measurements recorded with no contraindication to semirecumbency, weaning status (P = .003) and SOFA max score (P = .008) remained associated with the degree of backrest elevation. Conclusions The findings of this multicenter, observational study suggest that backrest elevation was less than recommended and was influenced by clinical practices and patient condition.

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Section: Discussionmentioning

confidence: 99%

Semirecumbent Positioning in Ventilator-Dependent Patients: A Multicenter, Observational Study

Rose¹,

Baldwin²,

Crawford³

et al. 2010

American Journal of Critical Care

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“…[2][3][4]7,8 Prevention of VAP is much more costeffective than treatment, and several guidelines have recommended measures to decrease the incidence of VAP. [9][10][11][12][13][14][15] The most important measures are continuous medical education, [16][17][18] continuous suctioning of subglottic secre-tions, 19 semi-recumbent position, 11,[20][21][22][23][24][25] oral hygiene with chlorhexidine, 26 and selective digestive decontamination. 6,[27][28][29][30][31] Knowledge of guidelines for prevention of VAP among healthcare workers (HCWs) has been infrequently assessed and mainly in staff nurses only.…”

Section: Introductionmentioning

confidence: 99%

Prevention of Ventilator-Associated Pneumonia: Can Knowledge and Clinical Practice Be Simply Assessed in a Large Institution?

Pérez‐Granda

Muñóz

Heras³

et al. 2012

Respir Care

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OBJECTIVE: User-friendly scores to assess knowledge of guidelines for prevention of ventilatorassociated pneumonia (VAP) are scarce and have mainly evaluated nurses, but not students or physicians. Gaps between knowledge and actual clinical practice have not been sufficiently analyzed. We assessed knowledge of and adherence to guidelines for prevention of VAP among physicians, nurses, and students in adult ICUs. METHODS: All adult ICU healthcare workers were invited to complete a 20-point questionnaire. The first part assessed personal knowledge of international guidelines for prevention of VAP; the second part assessed daily clinical practice. Personal knowledge and daily practice were scored from 0 to 10 points. RESULTS: We invited 257 ICU healthcare workers to participate in the study, and 167 (65%) accepted (32/54 physicians, 108/176 nurses, and 27/27 students). The median (IQR) personal knowledge scores for physicians, nurses, and students were 6 (5-7), 5 (4 -6), and 5 (4 -7), respectively. The median scores for daily clinical practice for physicians and nurses were 5 (4 -6) and 4 (3-5), respectively. Healthcare workers with more than 1 year of ICU experience scored significantly better in personal knowledge than those with less experience: 6 (5-7) versus 4 (3-6), P ‫؍‬ .004. CONCLUSIONS: A simple, easy-to-complete questionnaire enabled us to rapidly evaluate personal knowledge and reported clinical practice in prevention of VAP in large teaching institutions. These scores will be used as baseline figures to assess the impact of educational and intervention campaigns.

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“…2 VAP increases the duration of mechanical ventilation and hospital length of stay by a mean of 7 to 9 days, 2 costing $10 000 to $40 000 per case. [3][4][5][6] Maintaining oral hygiene is one of the key components of VAP prevention. [7][8][9][10][11] For intubated patients, endotracheal tube placement provides a direct pathway for bacteria to enter the body, reduces the cough reflex, and decreases salivary flow, which inhibits mechanical removal of plaque by saliva.…”

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confidence: 99%

Influence of Institutional Guidelines on Oral Hygiene Practices in Intensive Care Units

Kiyoshi‐Teo

Blegen

2015

American Journal of Critical Care

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Background Maintaining oral hygiene is a key component of preventing ventilator-associated pneumonia; however, practices are inconsistent. Objectives To explore how characteristics of institutional guidelines for oral hygiene influence nurses' oral hygiene practices and perceptions of that practice. Methods Oral hygiene section of a larger survey study on prevention of ventilator-associated pneumonia. Critical care nurses at 8 hospitals in Northern California that had more than 1000 ventilator days in 2009 were recruited to participate in the survey. Twenty-one questions addressed oral hygiene practices and practice perceptions. Descriptive statistics, analysis of variance, and Spearman correlations were used for analyses. Results A total of 576 critical care nurses (45% response rate) responded to the survey. Three types of institutional oral hygiene guidelines existed: nursing policy, order set, and information bulletin. Nursing policy provided the most detail about the oral hygiene care; however, adherence, awareness, and priority level were higher with order sets (P < .05). The content and method of disseminating these guidelines varied, and nursing practices were affected by these differences. Nurses assessed the oral cavity and used oral swabs more often when those practices were included in institutional guidelines. Conclusions The content and dissemination method of institutional guidelines on oral hygiene do influence the oral hygiene practices of critical care nurses. Future studies examining how institutional guidelines could best be incorporated into routine workflow are needed. (American Journal of Critical Care. 2015;24:309-317) 2 VAP increases the duration of mechanical ventilation and hospital length of stay by a mean of 7 to 9 days, 2 costing $10 000 to $40 000 per case. 3-6Maintaining oral hygiene is one of the key components of VAP prevention. [7][8][9][10][11] For intubated patients, endotracheal tube placement provides a direct pathway for bacteria to enter the body, reduces the cough reflex, and decreases salivary flow, which inhibits mechanical removal of plaque by saliva.9 Ideally, oral hygiene care of patients receiving mechanical ventilation should consist of oral cavity assessment, swabbing the oral cavity using an oral swab or "toothette," toothbrushing, suctioning, oral rinse, and providing moisture.12 Professional organizations recommend that hospitals implement comprehensive oral hygiene programs to prevent VAP. 13,14 However, professional recommendations often lack the specifics needed to be practical in bedside practice. 7,15The American Association of Critical-Care Nurses (AACN) guideline 14 presents one of the most comprehensive lists of oral hygiene recommendations. Their recommendations are as follows: (1) brush teeth, gums, and tongue at least twice a day using a soft pediatric or adult toothbrush; (2) provide oral moisture to oral mucosa and lips every 2 to 4 hours; and (3) use an oral chlorhexidine gluconate (0.12%) rinse twice a day during the perioperative period for...

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Why Do Physicians Not Follow Evidence-Based Guidelines for Preventing Ventilator-Associated Pneumonia?

Cited by 195 publications

References 17 publications

Semirecumbent Positioning in Ventilator-Dependent Patients: A Multicenter, Observational Study

Semirecumbent Positioning in Ventilator-Dependent Patients: A Multicenter, Observational Study

Prevention of Ventilator-Associated Pneumonia: Can Knowledge and Clinical Practice Be Simply Assessed in a Large Institution?

Influence of Institutional Guidelines on Oral Hygiene Practices in Intensive Care Units

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