- Email: [email protected]
Does educating nurses with ventilator-associated pneumonia prevention guidelines improve their compliance?
ARTICLE IN PRESS AJIC: American Journal of Infection Controlw ■■ (2017) ■■-■■
Contents lists available at ScienceDirect
AJIC: American Journal of Infection Controlw
American Journal of Infection Control
j o u r n a l h o m e p a g e : w w w. a j i c j o u r n a l . o r g
Major Article
Does educating nurses with ventilator-associated pneumonia prevention guidelines improve their compliance? Sami M. Aloush * Adult Health Nursing Department, Faculty of Nursing, Al albayt University, Mafraq, Jordan
Key Words: Nosocomial infection Mechanical ventilator Evidence based guidelines
Background: This study aimed to compare the compliance with ventilator-associated pneumonia (VAP)prevention guidelines between nurses who underwent an intensive educational program and those who did not, and to investigate other factors that influence nurses’ compliance. Method: A 2-group posttest design was used to examine the effect of the VAP-prevention guidelines education on nurses’ compliance. Participants were randomly assigned to experimental and control groups. Results: The overall nurses’ compliance scores were moderate. There was no statistically significant difference in compliance between the nurses who received VAP education and those who did not (t[100] = –1.43; P = .15). The number of beds in the unit and the nurse–patient ratio were found to influence nurses’ compliance. Conclusion: Education in VAP-prevention guidelines will not improve nurses’ compliance unless other confounding factors, such as their workload, are controlled. It is imperative to reduce nurses’ workload to improve their compliance and enhance the effectiveness of education. © 2017 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
Mechanical ventilators are widely used as a respiratory assistance device. Although a significant proportion of critically ill patients need mechanical ventilators as a life-saving measure, their use is associated with a variety of complications. These include increased cost of care, 1 increased consumption of resources, comorbidity,2 and nosocomial infection.3 Ventilator-associated pneumonia (VAP) is considered among the most common nosocomial infections. It is an infection of the lung that occurs 48 hours after insertion of an endotracheal tube,4 and studies have reported that 27% of intubated patients develop VAP during hospitalization.5 VAP results in a significant increase in the cost of care,6 prolonged hospitalization,5 an extended number of days in need of the mechanical ventilator,7 and a significant increase in the rate of mortality.8 The prevalence of VAP varies across the world. In the United States, the incidence is as low as 3-5 cases per 1,000 ventilator-days,5 but this increases to 41 cases per 1,000 ventilator-days in Tunisia.9 The cost of care for each episode of VAP is $40,000.7 In the Middle
* Address correspondence to Sami Aloush, PhD, MSN, RN, Adult Health Nursing Department, Faculty of Nursing, Al albayt University, PO Box 130040, Mafraq 25113, Jordan. E-mail address: [email protected]. Conflicts of interest: None to report.
East, mechanically ventilated patients have twice the risk of developing VAP as in the Western world,10 and overall VAP results in significantly higher mortality in developing countries in comparison with the rest of the world. For example, the VAP mortality rate in India was found to be 37%,11 compared with only 4.6% in the United States.5 VAP is a preventable disease; however, translation of the findings from these studies in developing countries is challenging for several reasons,12 including lack of resources, shortage of staff, and lack of compliance with infection-control standards.3,13 In Jordan, very few studies have investigated VAP, although a study by Khuri-Bulos et al14 revealed a rate of 29 cases per 1,000 ventilator-days, and the rate of mortality related to VAP is 53%.15 Several factors contribute to the high level of VAP, including lack of resources, insufficient compliance with infection-control standards,16 and inadequate knowledge about VAP among health care providers.17 Professional organizations such as the Centers for Disease Control and Prevention and the American Thoracic Society released evidencebased guidelines to prevent VAP and improve mechanical ventilation outcomes. Studies report a significant reduction in the prevalence of VAP when these guidelines are applied correctly.18,19 However, nurses’ implementation of the VAP-prevention guidelines is uncertain,20 contributing to a high level of VAP. The extent to which educating nurses about VAP prevention can achieve a significant
0196-6553/© 2017 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajic.2017.04.009
ARTICLE IN PRESS S.M. Aloush / AJIC: American Journal of Infection Controlw ■■ (2017) ■■-■■
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improvement in their compliance and the amount of this improvement is still unclear. Thus, the aim of this study is to evaluate nurses’ compliance with VAP-prevention guidelines following an educational program and the factors that influence their compliance. METHODS
how to maintain consistency of the observations, and documentation. Advertisements about the study were placed in each of the participating hospitals. Nurses were told about the observations but not when they would be observed. Observations were deliberately conducted over a 6-month period (June-December 2016) during day and night shifts to minimize the Hawthorne effect.
Design
Educational course
This study was a randomized clinical trial (2-group posttest only design) in which participants were randomly assigned to either an experimental group or a control group. Participants in the control group underwent an intensive VAP education course, whereas the control group participants received nothing. Following the educational program, participants in both groups were observed. A nonparticipatory approach was used in which the observers documented the phenomena under investigation using a structured observation sheet.
The VAP-prevention guidelines course included 4 sessions of 2 hours per session. The first introduced mechanical ventilator management and VAP, and the remaining sessions covered the most upto-date guidelines. The guidelines included oral care, handwashing, suction, mechanical ventilator management, patient position, prophylactic use of antibiotics, peptic ulcer prophylaxis, and deep venous thrombosis prophylaxis. The sessions took place in classrooms at the researcher’s university. The educational strategies included classroom presentations, class discussion, and videotapes. The participants were provided with hard copies of the presentation’s slides.
Setting The study was conducted in the intensive care units (ICUs) of 5 hospitals in Jordan. The participating hospitals were selected from different geographic locations and different sectors. One of the ICUs has 5 beds, 2 have 6-10 beds, and 2 have a total bed capacity ≥11. The nurse to patient ratio in these hospitals varies from 1:1 to 1:2. Permission to conduct this study was obtained from the institutional review boards of the researcher’s university and the participating hospitals. Informed consent was obtained from all participants before the study. Participants G*power 3.1 software (Heinrich-Heine University of Dusseldorf, Dusseldorf, Germany) was used to calculate the required sample size. Based on a medium effect size ([d] = 0.6; α = 0.05; power = 0.8 based on 2 groups independent sample t test) the required sample size was estimated at 90. The study recruited a random sample of 120 participants from those nurses who agreed to participate; 60 were assigned to the experimental group and 60 to the control group, using a random-number generator. Participants in the experimental group underwent an intensive course in VAP-prevention guidelines, whereas the control group received nothing. Of participants in the control group, 17 withdrew from the study, whereas only 1 participant dropped out of the experimental group, resulting in 59 participants in the experimental group and 43 in the control group. The participants who dropped out of the study were of different ages, genders, and education levels. According to the continuing education departments in the participating hospitals, no VAP education courses had been given to the participants in any of those hospitals. Inclusion criteria All participants were registered nurses working full time in ICUs. Data collection The data collectors were knowledgeable ICU registered nurses who were not staff of the participating hospitals and who had at least 3 years of ICU experience. Each was involved in infection control activities at his or her own hospital. They received a short training course on the VAP-prevention guidelines. The course covered the development of VAP, the guidelines, the conduct of observations,
Observation sheet A 9-item structured observation sheet was developed based on VAP-prevention guidelines from the American Thoracic Society,21 the Centers for Disease Control and Prevention,22 and the Institute for Health Care and Improvement.23 The observation sheet had 2 parts: demographic characteristics and the 9 VAP-prevention guidelines items with 3 options per item: “done correctly and completely” gained 2 marks, “done but not completely or not accurately” only 1 mark, and “not done” gained no marks. During the observations, for each guideline the data collector documented “done completely and accurately” if the nurse correctly applied an intervention consistent with the updated VAP-prevention guidelines at every opportunity to do so. If the nurse demonstrated an intervention not based on the guidelines, or missed an opportunity to do perform an intervention, the data collector recorded “done but not completely or incorrectly.” If the nurse failed to apply the guidelines at all in any of the opportunities to do so, “not done” was recorded. The highest score on the observation sheet was 18 and the lowest zero. A panel of 3 experts in infection control and 3 critical-care nurses validated the content of the observation sheet. Items that were found not to be nursing responsibilities were deleted on the recommendation of the panel. A pilot study was conducted to identify obstacles that might be encountered, but no necessary changes were found. Observations Participants were required to provide their work schedule each month to facilitate the observations. A data collector attended each ICU/critical care unit in the participating hospitals, asking participants for the demographic data before observing them and completing the observation sheet. Each nurse was observed for an entire shift. After the observation was completed, the nurse was informed of the fact. A monthly rotation of observers between the participating hospitals was made to minimize bias. Observations were made during both day and night shifts. Different methods were used during the observations to evaluate the nurses’ compliance with the VAP-prevention guidelines (Table 1). Statistical analysis SPSS version 21 (IBM-SPSS Inc, Armonk, NY) was used to analyze the study data. Descriptive statistics were used to evaluate the par-
ARTICLE IN PRESS
Document at least 1 assessment for the cuff pressure during 1 shift observation The nurse strictly applied the guidelines in 2 random checkup episodes during 1 shift observation Direct observation at the ventilated patient bedside
Direct observation at the ventilated patient bedside
Use normal saline irrigation during endotracheal suctioning (reverse code item) Assess the cuff pressure of the endotracheal tube (must be maintained 20-25 cm water) Position mechanically ventilated patients on semiflower position
Nurse progressive notes
Direct observation at the ventilated patient bedside Direct observation at the ventilated patient bedside Use sterile gloves to perform endotracheal tube suctioning Wash hands after performing endotracheal suctioning
Wash hands before performing endotracheal suctioning
Wash hands before and after contact with the patient
Direct observation at the ventilated patient bedside
Wash hand each time before and after contact with the patient in all the opportunities to do so Wash hands each time before suctioning the patient in all the opportunities to do so Put sterile gloves on in the all the opportunities to do so Wash hands each time after suctioning the patient in all the opportunities to do so Never use normal saline during suctioning in all the suctioning events
Perform and document at least 1 assessment episode during 1 shift
Definition of compliance (done accurate and complete) Assessment technique
Direct observation at the ventilated patient bedside and nurse progressive notes Direct observation at the ventilated patient bedside and from the nursing progressive note Direct observation at the ventilated patient bedside Perform oral care for patient on mechanical ventilator with chlorhexidine solution Perform a daily assessment of patient readiness to extubation (weaning)
VAP prevention guideline
Table 1 Performance assessment of compliance with ventilator-associated pneumonia (VAP) prevention guidelines
Perform at least 1 oral cleaning with chlorhexidine during shift
S.M. Aloush / AJIC: American Journal of Infection Controlw ■■ (2017) ■■-■■
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Table 2 Participants’ baseline characteristics
Variable Gender Female Male Nurse to patient ratio 1:1 1:2 Level of education 3-y diploma Bachelor’s degree Master’s degree Position Staff nurse In-charge nurse Head nurse Experience, y 1-5 6-10 11-20 Working unit Medical/surgical intensive care unit Coronary care unit Number of bed in unit 1-5 6-10 ≤11
No. of nurses (%) (N = 102) 28 (27.5) 74 (72.5) 58 (57) 44 (43) 12 (12) 85 (83) 5 (5) 78 (76) 21 (21) 3 (3) 46 (45) 45 (44) 11 (11) 64 (63) 38 (37) 23 (23) 56 (55) 22 (22)
ticipants’ compliance scores. An independent sample t test was used to compare the differences in the compliance scores between the experimental and control groups. RESULTS ICU nurses from 5 Jordanian hospitals participated in the study. Their mean age was 31 ± 5.6 years. There was no statistically significant difference in the baseline characteristics of the experimental group and the control group (Table 2). Of the 120 nurses who began, 17 (28%) dropped out of the control group but only 1 participant dropped from the experimental group. Participants who dropped out were of different ages, years of experience, and genders. The overall compliance scores for VAP-prevention guidelines were moderate. The mean compliance score for the experimental group was 14.1 ± 4.4 compared with the control group mean of 12.8 ± 3.7. Although the participants in the experimental group scored higher, the difference was not statistically significant (t [100] = –1.43; P = .15). Factors influencing compliance in the entire group There was a statistically significant difference in compliance across the number of beds per unit and the nurse to patient ratio groups. Participants working in units with fewer beds and a 1:1 nurse to patient ratio had statistically significant higher compliance scores than those in units with more beds and a 1:2 nurse to patient ratio (Table 3). DISCUSSION This study found that the difference in the compliance with VAPprevention guidelines between nurses in the experimental group and those in the control group was less than expected. These findings disagreed with those from previous studies, which revealed a significant improvement in nurses’ compliance following education and training. 24,25 Factors other than the nurses’ level of knowledge influence their compliance with the guidelines; in our study, nurses’ workload appeared to be a major factor. Nurses
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Table 3 Factors that influence nurses’ compliance scores Nurses’ compliance score Variable Gender Male Female Nurse to patient ratio 1:1 1:2
Mean ± standard deviation
t
P value
13.4 ± 4.1 13.6 ± 4.2
–0.18
.68
14.6 ± 3.7 12.1 ± 4.3
3.2
CONCLUSIONS .00
F Level of education Diploma Bachelor’s degree Master’s degree Position in department Staff In-charge Head nurse Years of experience, y 1-5 6-10 11-20 Number of beds 1-5 6-10 ≤11
the control group to reduce the dropout rate. Finally, the rate of VAP/ 1,000 ventilator-days could not be measured in any of the participating hospitals because there were insufficient data. Future researchers are recommended to conduct their observations in hospitals that have adequate data.
12.9 ± 2.2 13.5 ± 4.4 15.8 ± 3.2
0.87
.42
13.6 ± 4.3 13.1 ± 3.8 16.0 ± 0.0
0.64
.53
12.7 ± 4.2 14.2 ± 3.9 14.4 ± 5.3
1.77
.18
15.5. ± 3.2 14.6 ± 4.3 12.7 ± 4.1
4.65
.01
This study revealed that the effectiveness of education about VAPprevention guidelines may be limited by some confounding factors such as nurses’ heavy workload. Policies in clinical settings must be revised to reduce the workloads, especially in critical care settings, to improve compliance with VAP-prevention guidelines and to enhance the effectiveness of VAP education.
References
working in units with lower bed capacity and having to take care of only 1 patient at a time demonstrated higher compliance than those in units with higher bed capacity and having to take care of 2 patients at a time. These findings agree with other studies that have highlighted excessive workload as a major barrier to compliance with the VAP-prevention guidelines. Future studies should investigate more factors that may influence nurses’ compliance with the guidelines. Strengths and limitations A major strength of the study is that participants were randomly assigned to the study groups, minimizing bias. Another strength is the observational technique used to assess compliance, which prevented subjectivity of assessment and enhanced reliability. A limitation of the study that prevents generalizability of the findings is that it was conducted only on Jordanian nurses. Future studies should include nurses from different countries. Another possible limitation is that compliance in the study groups was not measured before the educational program. However, we believe that the random assignment of the participants to groups and the absence of any statistically significant differences among them act as baselines to help overcome this barrier. Moreover, the data collectors were not staff of the participating hospitals. This might have influenced the data because the participants saw them as outsiders. Future researchers are recommended to recruit data collectors from both the participating hospitals and other hospitals to enhance the reliability of observations. In addition, the observations could not be covert because the participants were requested to provide some information before the observation. This might have influenced the data because it possibly triggered the Hawthorne effect. For future studies, we recommended conducting covert observations using cameras and to videotape nurses during their work. Furthermore, the study was conducted over a 6-month period, which might have increased the dropout rate, especially in the control group. A shorter period of observation might be better. A modification in the design of future studies might include providing the same educational course at the end of the study for participants in
1. Mooney JJ, Raimundo K, Chang E, Broder MS. Hospital cost and length of stay in idiopathic pulmonary fibrosis. J Med Econ 2017;doi:10.1080/13696998 .2017.1282864. 2. Yap V, Perlman JM. Neurologic complications of mechanical ventilation. Manual of neonatal respiratory care. Springer; 2017. p. 695-9. 3. Hamill ME, Reed CR, Fogel SL, Bradburn EH, Powers KA, Love KM, et al. Contact isolation precautions in trauma patients: an analysis of infectious complications. Surg Infect (Larchmt) 2017;doi:10.1089/sur.2015.094. 4. Rodrigues ME, Lopes SP, Pereira CR, Azevedo NF, Lourenço A, Henriques M, et al. Polymicrobial ventilator-associated pneumonia: fighting in vitro Candida albicans-Pseudomonas aeruginosa biofilms with antifungal-antibacterial combination therapy. PLoS ONE 2017;12:e0170433. 5. Spalding MC, Cripps MW, Minshall CT. Ventilator-associated pneumonia: new definitions. Crit Care Clin 2017. http://dx.doi.org/10.1016/j.ccc.2016.12.009 6. van Oort PM, Nijsen T, Weda H, Knobel H, Dark P, Felton T, et al. BreathDx– molecular analysis of exhaled breath as a diagnostic test for ventilator–associated pneumonia: protocol for a European multicentre observational study. BMC Pulm Med 2017;17:1. 7. Khan RM, Aljuaid M, Aqeel H, Aboudeif MM, Elatwey S, Shehab R, et al. Introducing the comprehensive unit-based safety program for mechanically ventilated patients in Saudi Arabian intensive care units. Ann Thoracic Med 2017;12:11. 8. Porhomayon J, Pourafkari L. Ventilator associated pneumonia and the role of tapered endotracheal tube with subglottic suctioning. J Crit Care 2017. http://dx.doi.org/10.1016/j.jcrc.2017.01.009 9. Arabi Y, Al-Shirawi N, Memish Z, Anzueto A. Ventilator-associated pneumonia in adults in developing countries: a systematic review. Int J Infect Dis 2008;12:505-12. 10. El-Saed A, Al-Jardani A, Althaqafi A, Alansari H, Alsalman J, Al Maskari Z, et al. Ventilator-associated pneumonia rates in critical care units in 3 Arabian Gulf countries: a 6-year surveillance study. Am J Infect Control 2016;44. 11. Garg V, Chari V, Paul A, Raval B, Maiti S. A study of ventilator associated pneumonia (VAP) in intensive care unit (ICU) setting. Indian J Appl Res 2017;7. 12. Chacko B, Thomas K, David T, Paul H, Jeyaseelan L, Peter JV. Attributable cost of a nosocomial infection in the intensive care unit: a prospective cohort study. World J Crit Care Med 2017;6:79-84. 13. Khan HA, Baig FK, Mehboob R. Nosocomial infections: epidemiology, prevention, control and surveillance. Asian Pac J Trop Biomed 2017. http://dx.doi.org/10.1016/ j.apjtb.2017.01.019 14. Khuri-Bulos NA, Shennak M, Agabi S, Saleh S, Al Rawashdeh S, Al Ghanem S, et al. Nosocomial infections in the intensive care units at a university hospital in a developing country: comparison with National Nosocomial Infections Surveillance intensive care unit rates. Am J Infect Control 1999;27:547-52. 15. Samrah S, Bashtawi Y, Hayajneh W, Almomani B, Momany S, Khader Y. Impact of colistin-initiation delay on mortality of ventilator-associated pneumonia caused by A. baumannii. J Infect Dev Countries 2016;10:1129-34. 16. AL-Rawajfah OM. Infection control practices among intensive care unit registered nurses: a Jordanian national study. Nurs Crit Care 2014;21:e20-7. 17. Hassan ZM, Wahsheh MA. Knowledge level of nurses in Jordan on ventilatorassociated pneumonia and preventive measures. Nurs Crit Care 2016. doi:10.1111/nicc.12273. 18. Bassi GL, Senussi T, Xiol EA. Prevention of ventilator-associated pneumonia. Curr Opin Infect Dis 2017;30:214-20. 19. Rizwan M, Ikram A, Zaman G, Satti L, Ahmed P. Surveillance of device-associated infections in intensive care units of a tertiary care hospital. J Hosp Infect 2017;95:101-2. 20. Jahansefat L, Vardanjani MM, Bigdelian H, Massoumi G, Khalili A, Mardani D. Exploration of knowledge of, adherence to, attitude and barriers toward evidence-based guidelines (EBGs) for prevention of ventilator-associated pneumonia (VAP) in healthcare workers of pediatric cardiac intensive care units (PCICUs): A Quali-Quantitative survey. Health Sci 2016;5:67-73.
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21. ATS. Guidelines for the Management of Adults with Hospital-acquired, Ventilator-associated, and Healthcare-associated Pneumonia. Am J Resp Care Med 2005;171:388-416. 22. Hughes JM, Cardo DM, Cohen ML. Guidelines for preventing health-careassociated pneumonia, 2003 recommendations of the CDC and the Healthcare Infection Control Practices Advisory Committee. Respir Care 2004;49:926-39. 23. IHI. How-to Guide: Prevent Ventilator-Associated Pneumonia. Cambridge (MA): Institute for Healthcare Improvement; 2012. Available from: www.ihi.org. Accessed February 1, 2017.
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24. Akdogan O, Ersoy Y, Kuzucu C, Gedik E, Togal T, Yetkin F. Assessment of the effectiveness of a ventilator associated pneumonia prevention bundle that contains endotracheal tube with subglottic drainage and cuff pressure monitorization. Braz J Infect Dis 2017 Feb 11. [Epub ahead of print]. 25. Kellough J, Perkins K, Sullivan H, Walker C, Rogers C. Ventilator care bundles and their effectiveness in reducing the incident of ventilatorassociated pneumonia in intensive care units; 2016. Available from: http:// scholarworks.moreheadstate.edu/scholarship_posters/14. Accessed February 1, 2017.
Contents lists available at ScienceDirect
AJIC: American Journal of Infection Controlw
American Journal of Infection Control
j o u r n a l h o m e p a g e : w w w. a j i c j o u r n a l . o r g
Major Article
Does educating nurses with ventilator-associated pneumonia prevention guidelines improve their compliance? Sami M. Aloush * Adult Health Nursing Department, Faculty of Nursing, Al albayt University, Mafraq, Jordan
Key Words: Nosocomial infection Mechanical ventilator Evidence based guidelines
Background: This study aimed to compare the compliance with ventilator-associated pneumonia (VAP)prevention guidelines between nurses who underwent an intensive educational program and those who did not, and to investigate other factors that influence nurses’ compliance. Method: A 2-group posttest design was used to examine the effect of the VAP-prevention guidelines education on nurses’ compliance. Participants were randomly assigned to experimental and control groups. Results: The overall nurses’ compliance scores were moderate. There was no statistically significant difference in compliance between the nurses who received VAP education and those who did not (t[100] = –1.43; P = .15). The number of beds in the unit and the nurse–patient ratio were found to influence nurses’ compliance. Conclusion: Education in VAP-prevention guidelines will not improve nurses’ compliance unless other confounding factors, such as their workload, are controlled. It is imperative to reduce nurses’ workload to improve their compliance and enhance the effectiveness of education. © 2017 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
Mechanical ventilators are widely used as a respiratory assistance device. Although a significant proportion of critically ill patients need mechanical ventilators as a life-saving measure, their use is associated with a variety of complications. These include increased cost of care, 1 increased consumption of resources, comorbidity,2 and nosocomial infection.3 Ventilator-associated pneumonia (VAP) is considered among the most common nosocomial infections. It is an infection of the lung that occurs 48 hours after insertion of an endotracheal tube,4 and studies have reported that 27% of intubated patients develop VAP during hospitalization.5 VAP results in a significant increase in the cost of care,6 prolonged hospitalization,5 an extended number of days in need of the mechanical ventilator,7 and a significant increase in the rate of mortality.8 The prevalence of VAP varies across the world. In the United States, the incidence is as low as 3-5 cases per 1,000 ventilator-days,5 but this increases to 41 cases per 1,000 ventilator-days in Tunisia.9 The cost of care for each episode of VAP is $40,000.7 In the Middle
* Address correspondence to Sami Aloush, PhD, MSN, RN, Adult Health Nursing Department, Faculty of Nursing, Al albayt University, PO Box 130040, Mafraq 25113, Jordan. E-mail address: [email protected]. Conflicts of interest: None to report.
East, mechanically ventilated patients have twice the risk of developing VAP as in the Western world,10 and overall VAP results in significantly higher mortality in developing countries in comparison with the rest of the world. For example, the VAP mortality rate in India was found to be 37%,11 compared with only 4.6% in the United States.5 VAP is a preventable disease; however, translation of the findings from these studies in developing countries is challenging for several reasons,12 including lack of resources, shortage of staff, and lack of compliance with infection-control standards.3,13 In Jordan, very few studies have investigated VAP, although a study by Khuri-Bulos et al14 revealed a rate of 29 cases per 1,000 ventilator-days, and the rate of mortality related to VAP is 53%.15 Several factors contribute to the high level of VAP, including lack of resources, insufficient compliance with infection-control standards,16 and inadequate knowledge about VAP among health care providers.17 Professional organizations such as the Centers for Disease Control and Prevention and the American Thoracic Society released evidencebased guidelines to prevent VAP and improve mechanical ventilation outcomes. Studies report a significant reduction in the prevalence of VAP when these guidelines are applied correctly.18,19 However, nurses’ implementation of the VAP-prevention guidelines is uncertain,20 contributing to a high level of VAP. The extent to which educating nurses about VAP prevention can achieve a significant
0196-6553/© 2017 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajic.2017.04.009
ARTICLE IN PRESS S.M. Aloush / AJIC: American Journal of Infection Controlw ■■ (2017) ■■-■■
2
improvement in their compliance and the amount of this improvement is still unclear. Thus, the aim of this study is to evaluate nurses’ compliance with VAP-prevention guidelines following an educational program and the factors that influence their compliance. METHODS
how to maintain consistency of the observations, and documentation. Advertisements about the study were placed in each of the participating hospitals. Nurses were told about the observations but not when they would be observed. Observations were deliberately conducted over a 6-month period (June-December 2016) during day and night shifts to minimize the Hawthorne effect.
Design
Educational course
This study was a randomized clinical trial (2-group posttest only design) in which participants were randomly assigned to either an experimental group or a control group. Participants in the control group underwent an intensive VAP education course, whereas the control group participants received nothing. Following the educational program, participants in both groups were observed. A nonparticipatory approach was used in which the observers documented the phenomena under investigation using a structured observation sheet.
The VAP-prevention guidelines course included 4 sessions of 2 hours per session. The first introduced mechanical ventilator management and VAP, and the remaining sessions covered the most upto-date guidelines. The guidelines included oral care, handwashing, suction, mechanical ventilator management, patient position, prophylactic use of antibiotics, peptic ulcer prophylaxis, and deep venous thrombosis prophylaxis. The sessions took place in classrooms at the researcher’s university. The educational strategies included classroom presentations, class discussion, and videotapes. The participants were provided with hard copies of the presentation’s slides.
Setting The study was conducted in the intensive care units (ICUs) of 5 hospitals in Jordan. The participating hospitals were selected from different geographic locations and different sectors. One of the ICUs has 5 beds, 2 have 6-10 beds, and 2 have a total bed capacity ≥11. The nurse to patient ratio in these hospitals varies from 1:1 to 1:2. Permission to conduct this study was obtained from the institutional review boards of the researcher’s university and the participating hospitals. Informed consent was obtained from all participants before the study. Participants G*power 3.1 software (Heinrich-Heine University of Dusseldorf, Dusseldorf, Germany) was used to calculate the required sample size. Based on a medium effect size ([d] = 0.6; α = 0.05; power = 0.8 based on 2 groups independent sample t test) the required sample size was estimated at 90. The study recruited a random sample of 120 participants from those nurses who agreed to participate; 60 were assigned to the experimental group and 60 to the control group, using a random-number generator. Participants in the experimental group underwent an intensive course in VAP-prevention guidelines, whereas the control group received nothing. Of participants in the control group, 17 withdrew from the study, whereas only 1 participant dropped out of the experimental group, resulting in 59 participants in the experimental group and 43 in the control group. The participants who dropped out of the study were of different ages, genders, and education levels. According to the continuing education departments in the participating hospitals, no VAP education courses had been given to the participants in any of those hospitals. Inclusion criteria All participants were registered nurses working full time in ICUs. Data collection The data collectors were knowledgeable ICU registered nurses who were not staff of the participating hospitals and who had at least 3 years of ICU experience. Each was involved in infection control activities at his or her own hospital. They received a short training course on the VAP-prevention guidelines. The course covered the development of VAP, the guidelines, the conduct of observations,
Observation sheet A 9-item structured observation sheet was developed based on VAP-prevention guidelines from the American Thoracic Society,21 the Centers for Disease Control and Prevention,22 and the Institute for Health Care and Improvement.23 The observation sheet had 2 parts: demographic characteristics and the 9 VAP-prevention guidelines items with 3 options per item: “done correctly and completely” gained 2 marks, “done but not completely or not accurately” only 1 mark, and “not done” gained no marks. During the observations, for each guideline the data collector documented “done completely and accurately” if the nurse correctly applied an intervention consistent with the updated VAP-prevention guidelines at every opportunity to do so. If the nurse demonstrated an intervention not based on the guidelines, or missed an opportunity to do perform an intervention, the data collector recorded “done but not completely or incorrectly.” If the nurse failed to apply the guidelines at all in any of the opportunities to do so, “not done” was recorded. The highest score on the observation sheet was 18 and the lowest zero. A panel of 3 experts in infection control and 3 critical-care nurses validated the content of the observation sheet. Items that were found not to be nursing responsibilities were deleted on the recommendation of the panel. A pilot study was conducted to identify obstacles that might be encountered, but no necessary changes were found. Observations Participants were required to provide their work schedule each month to facilitate the observations. A data collector attended each ICU/critical care unit in the participating hospitals, asking participants for the demographic data before observing them and completing the observation sheet. Each nurse was observed for an entire shift. After the observation was completed, the nurse was informed of the fact. A monthly rotation of observers between the participating hospitals was made to minimize bias. Observations were made during both day and night shifts. Different methods were used during the observations to evaluate the nurses’ compliance with the VAP-prevention guidelines (Table 1). Statistical analysis SPSS version 21 (IBM-SPSS Inc, Armonk, NY) was used to analyze the study data. Descriptive statistics were used to evaluate the par-
ARTICLE IN PRESS
Document at least 1 assessment for the cuff pressure during 1 shift observation The nurse strictly applied the guidelines in 2 random checkup episodes during 1 shift observation Direct observation at the ventilated patient bedside
Direct observation at the ventilated patient bedside
Use normal saline irrigation during endotracheal suctioning (reverse code item) Assess the cuff pressure of the endotracheal tube (must be maintained 20-25 cm water) Position mechanically ventilated patients on semiflower position
Nurse progressive notes
Direct observation at the ventilated patient bedside Direct observation at the ventilated patient bedside Use sterile gloves to perform endotracheal tube suctioning Wash hands after performing endotracheal suctioning
Wash hands before performing endotracheal suctioning
Wash hands before and after contact with the patient
Direct observation at the ventilated patient bedside
Wash hand each time before and after contact with the patient in all the opportunities to do so Wash hands each time before suctioning the patient in all the opportunities to do so Put sterile gloves on in the all the opportunities to do so Wash hands each time after suctioning the patient in all the opportunities to do so Never use normal saline during suctioning in all the suctioning events
Perform and document at least 1 assessment episode during 1 shift
Definition of compliance (done accurate and complete) Assessment technique
Direct observation at the ventilated patient bedside and nurse progressive notes Direct observation at the ventilated patient bedside and from the nursing progressive note Direct observation at the ventilated patient bedside Perform oral care for patient on mechanical ventilator with chlorhexidine solution Perform a daily assessment of patient readiness to extubation (weaning)
VAP prevention guideline
Table 1 Performance assessment of compliance with ventilator-associated pneumonia (VAP) prevention guidelines
Perform at least 1 oral cleaning with chlorhexidine during shift
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Table 2 Participants’ baseline characteristics
Variable Gender Female Male Nurse to patient ratio 1:1 1:2 Level of education 3-y diploma Bachelor’s degree Master’s degree Position Staff nurse In-charge nurse Head nurse Experience, y 1-5 6-10 11-20 Working unit Medical/surgical intensive care unit Coronary care unit Number of bed in unit 1-5 6-10 ≤11
No. of nurses (%) (N = 102) 28 (27.5) 74 (72.5) 58 (57) 44 (43) 12 (12) 85 (83) 5 (5) 78 (76) 21 (21) 3 (3) 46 (45) 45 (44) 11 (11) 64 (63) 38 (37) 23 (23) 56 (55) 22 (22)
ticipants’ compliance scores. An independent sample t test was used to compare the differences in the compliance scores between the experimental and control groups. RESULTS ICU nurses from 5 Jordanian hospitals participated in the study. Their mean age was 31 ± 5.6 years. There was no statistically significant difference in the baseline characteristics of the experimental group and the control group (Table 2). Of the 120 nurses who began, 17 (28%) dropped out of the control group but only 1 participant dropped from the experimental group. Participants who dropped out were of different ages, years of experience, and genders. The overall compliance scores for VAP-prevention guidelines were moderate. The mean compliance score for the experimental group was 14.1 ± 4.4 compared with the control group mean of 12.8 ± 3.7. Although the participants in the experimental group scored higher, the difference was not statistically significant (t [100] = –1.43; P = .15). Factors influencing compliance in the entire group There was a statistically significant difference in compliance across the number of beds per unit and the nurse to patient ratio groups. Participants working in units with fewer beds and a 1:1 nurse to patient ratio had statistically significant higher compliance scores than those in units with more beds and a 1:2 nurse to patient ratio (Table 3). DISCUSSION This study found that the difference in the compliance with VAPprevention guidelines between nurses in the experimental group and those in the control group was less than expected. These findings disagreed with those from previous studies, which revealed a significant improvement in nurses’ compliance following education and training. 24,25 Factors other than the nurses’ level of knowledge influence their compliance with the guidelines; in our study, nurses’ workload appeared to be a major factor. Nurses
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Table 3 Factors that influence nurses’ compliance scores Nurses’ compliance score Variable Gender Male Female Nurse to patient ratio 1:1 1:2
Mean ± standard deviation
t
P value
13.4 ± 4.1 13.6 ± 4.2
–0.18
.68
14.6 ± 3.7 12.1 ± 4.3
3.2
CONCLUSIONS .00
F Level of education Diploma Bachelor’s degree Master’s degree Position in department Staff In-charge Head nurse Years of experience, y 1-5 6-10 11-20 Number of beds 1-5 6-10 ≤11
the control group to reduce the dropout rate. Finally, the rate of VAP/ 1,000 ventilator-days could not be measured in any of the participating hospitals because there were insufficient data. Future researchers are recommended to conduct their observations in hospitals that have adequate data.
12.9 ± 2.2 13.5 ± 4.4 15.8 ± 3.2
0.87
.42
13.6 ± 4.3 13.1 ± 3.8 16.0 ± 0.0
0.64
.53
12.7 ± 4.2 14.2 ± 3.9 14.4 ± 5.3
1.77
.18
15.5. ± 3.2 14.6 ± 4.3 12.7 ± 4.1
4.65
.01
This study revealed that the effectiveness of education about VAPprevention guidelines may be limited by some confounding factors such as nurses’ heavy workload. Policies in clinical settings must be revised to reduce the workloads, especially in critical care settings, to improve compliance with VAP-prevention guidelines and to enhance the effectiveness of VAP education.
References
working in units with lower bed capacity and having to take care of only 1 patient at a time demonstrated higher compliance than those in units with higher bed capacity and having to take care of 2 patients at a time. These findings agree with other studies that have highlighted excessive workload as a major barrier to compliance with the VAP-prevention guidelines. Future studies should investigate more factors that may influence nurses’ compliance with the guidelines. Strengths and limitations A major strength of the study is that participants were randomly assigned to the study groups, minimizing bias. Another strength is the observational technique used to assess compliance, which prevented subjectivity of assessment and enhanced reliability. A limitation of the study that prevents generalizability of the findings is that it was conducted only on Jordanian nurses. Future studies should include nurses from different countries. Another possible limitation is that compliance in the study groups was not measured before the educational program. However, we believe that the random assignment of the participants to groups and the absence of any statistically significant differences among them act as baselines to help overcome this barrier. Moreover, the data collectors were not staff of the participating hospitals. This might have influenced the data because the participants saw them as outsiders. Future researchers are recommended to recruit data collectors from both the participating hospitals and other hospitals to enhance the reliability of observations. In addition, the observations could not be covert because the participants were requested to provide some information before the observation. This might have influenced the data because it possibly triggered the Hawthorne effect. For future studies, we recommended conducting covert observations using cameras and to videotape nurses during their work. Furthermore, the study was conducted over a 6-month period, which might have increased the dropout rate, especially in the control group. A shorter period of observation might be better. A modification in the design of future studies might include providing the same educational course at the end of the study for participants in
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