CE Article and Journal Club Feature

NURSES IMPLEMENTATION OF GUIDELINES FOR VENTILATOR-ASSOCIATED PNEUMONIA FROM THE CENTERS FOR DISEASE CONTROL AND PREVENTION
By Carolyn L. Cason, RN, PhD, Tracy Tyner, RN, MSN, CEN, CCRN, Sue Saunders, RN, MSN, CCRN, and Lisa Broome, RN, MSN. From the School of Nursing, University of Texas at Arlington (CLC), Parkland Memorial Hospital, Dallas, Tex (TT), RHD Memorial Hospital, Dallas, Tex (SS), and Baylor Regional Hospital, Plano, Tex (LB).

BACKGROUND Ventilator-associated pneumonia accounts for 47% of infections in patients in intensive care units. Adherence to the best nursing practices recommended in the 2003 guidelines for the prevention of ventilator-associated pneumonia from the Centers for Disease Control and Prevention should reduce the risk of ventilator-associated pneumonia. OBJECTIVE To evaluate the extent to which nurses working in intensive care units implement best practices when managing adult patients receiving mechanical ventilation. METHODS Nurses attending education seminars in the United States completed a 29-item questionnaire about the type and frequency of care provided. RESULTS Twelve hundred nurses completed the questionnaire. Most (82%) reported compliance with hand-washing guidelines, 75% reported wearing gloves, half reported elevating the head of the bed, a third reported performing subglottic suctioning, and half reported having an oral care protocol in their hospital. Nurses in hospitals with an oral care protocol reported better compliance with hand washing and maintaining head-of-bed elevation, were more likely to regularly provide oral care, and were more familiar with rates of ventilator-associated pneumonia and the organisms involved than were nurses working in hospitals without such protocols. CONCLUSIONS The guidelines for the prevention of ventilator-associated pneumonia from the Centers for Disease Control and Prevention are not consistently or uniformly implemented. Practices of nurses employed in hospitals with oral care protocols are more often congruent with the guidelines than are practices of nurses employed in hospitals without such protocols. Signicant reductions in rates of ventilatorassociated pneumonia may be achieved by broader implementation of oral care protocols. (American Journal of Critical Care. 2007;16:28-38)

entilator-associated pneumonia (VAP) is the most common infectious complication among patients admitted to intensive care units (ICUs) and accounts for up to 47% of all infections among ICU
Corresponding author: Carolyn Cason, RN, PhD, University of Texas at Arlington, School of Nursing, 411 S Nedderman Dr, Pickard Hall, Arlington, TX 760190407 (e-mail: CLCason@uta.edu). To purchase reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 809-2273 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, reprints@aacn.org.

patients.1 When it occurs, VAP prolongs ICU length of stay and increases the risk of death in critically ill patients.1 The data summary for 1992 to 2004 from the National Nosocomial Infections Surveillance System Report reveals a median VAP rate of 2.2 to 14.7 cases per 1000 patient days of mechanical ventilation in adult ICUs.2 VAP continues to complicate the course of 8% to 28% of patients receiving mechanical ventilation.3 For patients receiving mechanical ventilation in whom VAP develops, the estimated mortality rate is between 20% and 70%.4-6
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An important precursor for the development of VAP is colonization of the oral cavity. The 2003 guidelines7 from the Centers for Disease Control and Prevention (CDC) reported that 63% of patients admitted to an ICU have oral colonization with a pathogen associated with VAP.7 Once in the ICU, 63% of patients admitted with an oral pathogen associated with VAP acquire an additional, second bacterial pathogen in the oral cavity. In 76% of VAP cases, the bacteria colonizing the mouth and lung are the same.7 The most prevalent bacteria are gram-negative Pseudomonas aeruginosa and enterobacteria and gram-positive Staphylococcus aureus.7 The 2003 CDC guidelines for the prevention of VAP include recommendations for nursing care. These recommendations, summarized in Table 1, provide the best current directives for practice. The research evidence for the rst 5 recommendations is strong and justies broadbased implementation of the recommendations in healthcare. Recommendations 6 and 7 are based on strong theoretical rationale and clinical or epidemiological studies that provide supporting evidence. To evaluate the extent to which ICU nurses implement these recommendations, we queried critical care nurses about the practices they use when caring for adult patients receiving mechanical ventilation. A national survey has not been completed since the CDC changed its guidelines in 2003.

Table 1 Guidelines for the prevention of ventilator-associated pneumonia from the Centers for Disease Control and Prevention: recommendations for nursing care7
1. Wash hands after contact with mucous membranes, respiratory secretions, or objects contaminated with respiratory secretions. Wash hands before and after contact with patient. 2. Educate healthcare workers about nosocomial bacterial pneumonias and infection control procedures used to prevent these pneumonias. 3. Wear gloves for handling respiratory secretions or objects contaminated with respiratory secretions. 4. Provide subglottic suctioning before deating the cuff of an endotracheal tube or before moving the tube. 5. Elevate the head of the bed to 30 to 45 if not contraindicated. 6. Develop and implement a comprehensive oral hygiene program to provide oropharyngeal cleaning and decontamination with or without an antiseptic agent. 7. Use chlorhexidine gluconate antiseptic rinse during the perioperative period in adult patients who undergo cardiac surgery.

Background
For each recommendation presented in Table 1, a brief summary of the evidence is provided. More recently published evidence also is included because it augments and expands the foundation for the CDC guidelines and highlights areas in which evidence continues to be gathered.
CDC Guidelines

in the unit is one component of the recommended staff education. Critically ill patients often have a depressed level of consciousness and an impaired gag reex, leading to pooling of contaminated secretions in the posterior part of the oropharynx. Between 100 and 150 mL of secretions can accumulate within a 24-hour period. Microaspiration of these oropharyngeal secretions is a major risk factor for nosocomial pneumonia.7 Placement of an endotracheal tube provides a direct pathway for these organisms to enter the lungs. In 85% of cases,

CE

Decontamination of hands before and after contact with a patient, along with wearing gloves, is an important action in the prevention of VAP.7 The CDC guidelines recommend using either antimicrobial soap or nonantimicrobial soap and water if hands are visibly soiled with body uids. Alcohol-based waterless antiseptic agents, such as hand rubs, are also good alternatives for soaps. Hand rubs can and should be used before and after contact with a patient if hands are not visibly soiled. Gloves should be changed and hands washed between contacts with different patients. The 2003 CDC guidelines recommend staff education about epidemiology and infection control practices related to the prevention of VAP. One recommended strategy is for staff to participate in interventions to prevent VAP. Knowing the VAP organisms prevalent
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Notice to CE enrollees: A closed-book, multiple-choice examination following this article tests your understanding of the following objectives: 1. Describe the role of the CDC guidelines in relation to decreasing ventilator-associated pneumonia rates. 2. Recognize the key factors for the diagnosis of ventilator-associated pneumonia. 3. Understand the role of the CDC guidelines and nursing implications in helping to prevent ventilator-associated pneumonia. To read this article and take the CE test online, visit www.ajcconline.org and click CE Articles in This Issue.

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the microorganism that causes the nosocomial pneumonia previously has been detected in cultures of microorganisms from subglottic secretions.7 For these reasons, the CDC recommends that before an endotracheal tube cuff is deated or an endotracheal tube is repositioned, the area above the cuff should be suctioned. To reduce the risk of aspiration, the CDC recommends that patients receiving mechanical ventilation have the head of the bed elevated at an angle of 30 to 45 from horizontal unless contraindicated. Elevation of the head of the bed decreases the volume of gastric secretions, a change that reduces the risk for aspiration and VAP.8

In 76% of cases of ventilator-associated

pneumonia, the bacteria colonizing the mouth and the lung are the same.

The 2003 CDC guidelines changed the 1997 CDC guidelines9 by recommending implementation of a comprehensive oral hygiene program to prevent oropharyngeal colonization. Pathogens responsible for VAP in orally intubated patients are colonized in dental plaque and oral mucosa. The guidelines specify that an antiseptic agent be used as part of the oral hygiene program, but a specic agent, oral chlorhexidine gluconate rinse, is recommended solely for adults undergoing cardiac surgery. The guidelines do not specify the components of a comprehensive oral hygiene program, the optimal frequency of oral care, or the best way to remove dental plaque.
Recent Studies

Healthcare workers rarely exceed a 50% compliance rate with hand-washing guidelines.10 As workload and necessity for hand washing increases, compliance decreases.11 Educational hand-washing programs have boosted hand-washing compliance from 56% to 89%,10 but the lasting effects of such programs are unknown. Using alcohol-based hand rubs also improves hand hygiene practices among healthcare workers, but compliance rates continue to be low at about 67%.12 Educational interventions also can reduce VAP rates. Babcock et al13 and Cutler and Davis14 have shown that educational intervention on epidemiology and infection control reduces VAP rates. The 2003 CDC guidelines on elevation of the head of the bed do not appear to be routinely implemented among intubated patients. Grap et al,15 for example, took 506 measurements in 170 randomly chosen ICU
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patients and found a mean backrest elevation of 19. About 70% of the subjects were supine, and intubated patients had lower back-rest elevations than did nonintubated patients. Munro and Grap16(p27) provide the logic for comprehensive oral hygiene programs: Reducing the number of microorganisms in the mouth reduces the pool of organisms available for translocation to and colonization of the lung. Therefore, removal of organisms from the oral cavity by oral care interventions is a theoretically attractive method to reduce the risk for VAP. Oral care interventions that may play a role in the prevention of VAP include frequency of oral suctioning and decontamination and storage of the Yankauer suction device after use. Sole et al17 found that most suctioning equipment, including Yankauer suction devices and suction tubing, is colonized with a potential VAP pathogen within 24 hours of use. Although the primary origin of Pseudomonas in VAP appears to be endogenous, some cases of VAP have been linked to contaminated devices or environments such as sinks, faucets, and tap water.7 Currently, no standard exists for storing Yankauer suction devices after use or for which rinse solution to use for decontamination and cleansing of Yankauer devices. The multisite study reported by Sole et al18 in 2003 is the most recent report of nurses oral care practices. They reported the following: More than half of hospitals do not have specic policies for oral care of intubated patients. In the hospitals without an oral care protocol, not 1 patient out of 139 had his or her oral cavity assessed or his or her teeth brushed, and less than 50% of the patients had their teeth and mouth swabbed.14 A total of 75% of ICU nurses provide oral suctioning every 4 hours, 7% provide it every 8 to 12 hours, and 18% remove patients oral secretions by suctioning only as needed. Cutler and Davis14 found that 45% of 139 patients had their mouths suctioned, but no patients received oropharyngeal suctioning. A total of 71% of nurses store the suctioning device in its original or protective packaging; 19% leave the device uncovered. A total of 33% of nurses use sterile isotonic sodium chloride solution to rinse the Yankauer device after use and 36% use tap water. Rinsing only if visible mucus is present was reported by 14% of nurses, and 7% did not rinse the device at all. With new technology, single-use disposable suction devices are becoming more popular; 11% of nurses use such disposable devices as part of their oral suctioning practice. A total of 45% of nurses replace the Yankauer device every 24 hours; 40% replace the device only as needed.
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Most nurses (91%-96%) report using an antiseptic solution as part of oral care.19,20 In the United States, 20% of nurses report using oral chlorhexidine gluconate rinse for oral care.19 In the United Kingdom, 50% report doing so.20 Recent surveys21,22 reveal that oral care tends to be provided between 4 and 5 times daily.

Heathcare workers rarely exceed a

50% compliance rate with guidelines for hand washing.

Purpose
The primary purpose of this study was to identify the gap between what is known and what nurses report as their care practices. Knowing the differences between recommended and reported practices permits development, implementation, and evaluation of strategies that have the potential to improve care and care outcomes. The study had 3 objectives: 1. to describe the extent to which nurses report care practices that match the CDC guidelines for the prevention of VAP; 2. in those areas in which the evidence is not sufciently strong to support recommendations, to describe nurses prevailing care practices; and 3. to explore the relationships between care practices and the demographic characteristics of the nurse respondents.

Methods
Design

This study was a cross-sectional survey of nurses who attended either the 2005 American Association of Critical-Care Nurses National Teaching Institute (NTI) or selected training programs offered by Barbara Clark Mims Associates (BCMA). A university-based institutional review board approved the study. The Critical Care Expo Educational Committee granted permission to conduct the study at the 2005 NTI, and the owner of BCMA granted permission to collect data from attendees at seminars conducted across the United States between April 18 and May 12, 2005. The population of interest was critical care nurses who provide care for adult patients receiving mechanical ventilation and who work in the United States in an acute care setting.
Instrument

information from critical care nurses on current care practices for adult patients receiving mechanical ventilation. It was adapted, with permission, from the Suctioning Techniques and Airway Management Practices instrument created by Sole et al.23 The survey includes questions about the CDC guidelines (frequency of hand washing, knowledge of VAP rates and organisms, wearing gloves, subglottic suctioning, elevation of the head of the bed, presence of oral care protocols, and use of oral chlorhexidine gluconate rinse), questions to provide information about current oral care practices, and demographic questions. Questions about current oral care practices were based on the research literature and addressed use and frequency of tooth brushing; use and frequency of swabbing; frequency of oral care and oral suctioning; storage, rinsing, and replacement of suction devices; and use of antiseptic oral rinse agents. Content validation of the adapted survey was obtained by using a panel of 3 persons: an infection control nurse, an infection control physician, and a nationally recognized nurse with expertise in pulmonary and ventilator topics. Each person was familiar with the CDC guidelines, and each received a copy of Table 1 and a summary of the research published since the release of the CDC guidelines. Each commented on the adequacy of the match between the guidelines and the questions on the survey. No additional items were suggested, and no items were suggested for deletion or revision. The survey was then distributed to 9 nurses (3 from each of 3 hospitals) employed in a variety of ICU settings to evaluate readability and time to complete. None of these 9 nurses had questions or concerns about the questions, and they were able to complete the survey within 5 minutes. Three of these nurses completed the survey again 1 week later, and their responses were highly similar to those from the rst time they completed the survey.
Procedure

The Oral Care of Ventilated Patients Questionnaire is an investigator-designed instrument to gather

At NTI, data were collected in 2 ways: during a morning lecture sponsored by a vendor and at the vendors exhibit. One of us distributed and collected surveys from nurses visiting the exhibit. At BCMA Critical Care Educational Seminars, each of 4 speakers distributed surveys. Each speaker received instructions for distribution and collection of the surveys. To reduce bias related to new knowledge of VAP acquired during the lecture or seminar, speakers distributed and collected all surveys before discussion of VAP-related topics. Each speaker placed the completed surveys into envelopes and returned these sealed envelopes to us.
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A cover sheet on each survey instructed respondents to protect anonymity by placing no identifying information on the survey. Respondents also were informed that completion and return of the surveys implied their consent to participate. As a recruitment incentive to participate in the study, each cover sheet contained a name and address form. Respondents who completed and returned the form automatically became eligible to win a stethoscope. The name and address forms were collected and stored separately from the completed surveys. Completed surveys were scanned into an electronic data le. We used SPSS for Windows, Version 12.0 (SPSS Inc, Chicago, Ill) to describe the characteristics of the respondents and their responses (counts, frequencies, and percentages for nominal data and measures of central tendency and dispersion for better than nominal data). To explore differences in care practices associated with demographic data, we used 2 and multinomial regression analyses.24 For the multinominal regression analyses, we used as predictor variables the presence or absence of a hospital protocol, participation in quality improvement projects related to infection control, sex, age, years of critical care experience, certication in critical care, highest educational degree, type of employing unit, size of hospital, and teaching or nonteaching hospital. Outcome (or dependent) variables were frequency of hand washing, wearing gloves, and subglottic suctioning and degree of elevation of the head of the bed.

Table 2 Demographic characteristics of respondents (n = 1200)*

Characteristic Years of experience 0-2 3-5 6-10 11-20 >20 Level of nursing education Diploma Associate degree Bachelors degree Masters degree Doctorate Hold CCRN certication Type of intensive care unit General Coronary care Surgery/trauma Medical/pulmonary Cardiovascular surgery Other Critical care educator Neurological/neurosurgical Work in teaching hospital Size of hospital, No. of beds <100 100-499 >500 Region of the United States West South Mid-Atlantic Midwest Northeast Southwest No. 144 173 204 381 285 114 310 625 122 5 446 498 153 141 119 116 78 53 33 653 208 675 273 364 247 231 197 42 32 % 12 14 17 32 24 10 26 52 10 <1 37 42 13 12 10 10 6 4 3 54 17 56 23 30 21 19 16 4 3

Results
Description of the Sample

A total of 1596 surveys were distributed (750 at NTI and 846 at BCMA seminars); 1285 were returned (607 from NTI and 678 from BCMA seminars) for an 81% return rate. Eighty-five surveys were discarded because they were less then 30% completed, completed by nonnurses, or completed by nurses working outside the United States, working in a long-term care facility with ventilator-dependent patients, or working in an area other than an adult acute care ICU (eg, pediatric ICU, postanesthesia care unit, emergency room, medical/surgical unit). Thus, the study included responses from 1200 critical care nurses for a nal response rate of 75%. Nurses completing the survey reected the national trends regarding nurses ages and years of experience. The mean age of respondents was 43 (SD 9, range 2168) years. As shown in Table 2, the mean years of experience was 14 (SD 9, range 1-45). The majority of respondents (52%) held baccalaureate degrees in nursing. About a third (37%) held CCRN certication. Although respondents worked in various specialty
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*Because of missing data and rounding, percentages do not all total 100.

units, the largest percentage (42%) worked in general medical/surgical ICUs. About half (54%) worked at teaching hospitals. With the exception of Wyoming and Rhode Island, respondents resided in all states within the United States. Although more respondents resided in the Western region, respondents did not differ in terms of age or years of experience across all regions.
Practice of CDC Guidelines

Table 3 presents the percentage of critical care nurses who reported practice as recommended by the CDC guidelines. Most (82%) reported washing their hands between patients, and most (77%) reported always wearing gloves to provide oral care. About a third (36%) reported always suctioning secretions from under a patients tongue before deating the cuff of an endotracheal tube. Another third (32%) reported this practice as a respiratory therapy intervention. As for
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Table 3 Nurses adherence to recommended guidelines from the Centers for Disease Control and Prevention (n = 1200)*
Nursing practice Hand washing between patients Always Frequently Sometimes Rarely Use of gloves for oral care Always Frequently Sometimes Rarely Perform subglottic suctioning Respiratory therapy intervention Always Frequently Sometimes Rarely/not at all Maintains head of bed elevation at 30 to 45 0% of the day 25% of the day 50% of the day 75% of the day 100% of the day Education Participation in infection control projects Last quarter In the past year Never Ventilator-associated pneumonia in their unit Does not know the infection rate Does not know the infecting organism Employer has written oral hygiene protocol Yes No Unsure Uses chlorhexidine gluconate antiseptic rinse in cardiovascular intensive care unit No. 978 200 16 2 921 233 38 3 390 427 139 96 118 % 82 17 1 <1 77 19 3 <1 32 36 12 8 10

Table 4 Prevailing self-reported oral care practices*

No. (%) of % reported respondents by Sole et (n = 1200) al18 594 (50) 228 (19) 32 (3) 328 (27) 2 (<1) 193 (16) 593 (49) 274 (23) 126 (10) 558 (46) 424 (35) 115 (10) 78 (6) 19 (2) 309 (26) 458 (38) 324 (27) 20 (2) 51 (4) 45 (4) NR 75 7 18 NR 5 34 20 41 NR 72 24 3 1 20 NR NR NR NR NR

Practice Frequency of oral suctioning Every 2 hours Every 4 hours Every 8-12 hours Only as needed Rarely or not at all Frequency of tooth brushing Every 4 hours Every 8-12 hours Rarely or not at all Only as needed Frequency of swabbing Every 2 hours Every 4 hours Every 8-12 hours Only as needed Rarely or not at all Antiseptic rinse solution Chlorhexidine gluconate Mouthwash Hydrogen peroxide Other None Dont know

3 45 112 410 622

<1 4 9 34 52

189 441 528

16 37 44

*Because of missing data and rounding, percentages do not all total 100. Abbreviation: NR, not reported.

809 603

68 50

669 300 205 372

56 25 17 31

in teaching hospitals were signicantly more likely to have oral care protocols than were respondents working in nonteaching facilities (2 = 15.7, df = 6, P = .02). Of the 116 respondents who identied themselves as working in a cardiovascular ICU, 31% reported using chlorhexidine gluconate rinse for oral care. Across all types of ICUs, 26% of respondents reported using chlorhexidine gluconate.
Prevailing Oral Care Practices

*Because of missing data and rounding, percentages do not all total 100.

elevation of the head of the bed to 30 to 45 from horizontal, 34% of nurses reported maintaining that elevation for 75% of the day, and 52% reported maintaining that elevation for 100% of the day. Knowledge of the VAP rates and causative organisms in their units was taken as a reection of nurses knowledge of the epidemiology of VAP and infection control practices. Only 32% knew the VAP rate for their unit, and only 50% knew the primary causative VAP organism for their unit. Only 56% of nurses responded that their hospital had a written oral care protocol. Respondents working

Tables 4 and 5 summarize the prevailing selfreported practices regarding oral care and contrasts them with the practices reported by Sole et al18 in their 2003 multisite study. Compared with the percentages reported by Sole et al, more nurses in this study reported brushing patients teeth, and they reported doing so more frequently than reported by Sole and colleagues (Table 4). A larger percentage of respondents in this study than in the study by Sole and colleagues also reported swabbing the oral cavity of patients receiving mechanical ventilation. However, a larger percentage (27%) of respondents in this study reported suctioning only as needed, whereas only 18% of the respondents in the study by Sole and colleagues reported suctioning only as needed.
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Table 5 Prevailing practices for suction devices*

No. (%) of % reported respondents by Sole et (n = 1200) al18

Practice Cleansing of Yankauer suction device Rarely or not at all Only if visible mucus present After each use Dispose after each use Rinsing of Yankauer suction device Tap water Sterile water Sterile isotonic sodium chloride solution Do not rinse Storage of Yankauer suction device Original package, anywhere except bed Not in original package, anywhere except bed In bed (in or out of original package) Other No response Replacement of Yankauer suction device As needed Every 12 hours Every 24 hours Every 48 hours Every 72 hours Rarely or not at all

40 (3) 398 (33) 722 (60) 34 (3)

6 14 33 11

689 (57) 209 (17) 296 (25) 17 (1)

36 NR 33 6

888 (74) 204 (17) 39 (3) 37 (3) 32 (3)

71 NR 14 5 NR

The analysis on hand washing yielded signicant (P = .05) likelihood ratio tests for presence of a written oral care protocol, participation in improvement projects related to infection control, sex of respondent, and type of critical care unit. Respondents working in hospitals with an oral care protocol in place reported that they more often washed their hands (always and frequently) than did respondents who worked in hospitals without an oral care protocol. Respondents who had not recently participated in improvement projects related to infection control more often reported that they washed their hands (always and frequently) than did respondents who had participated in such improvement projects. Female respondents more often reported that they washed their hands (always and frequently) than did male respondents. Respondents who worked in surgical (trauma and neurology) units more often reported that they washed their hands (always and frequently) than did respondents working in medical units.

264 (22) 161 (13) 608 (51) 42 (4) 38 (3) 45 (4)

40 NR 45 4 1 NR

Only 56% of those surveyed reported that their hospital has a written protocol for oral care.
The analysis on degree of elevation of the head of the bed yielded significant (P = .05) likelihood ratio tests for presence of a written oral care protocol, age of respondent, number of years of critical care practice, and holding certication in critical care. Respondents working in hospitals with an oral care protocol in place reported that they kept the head of the bed elevated at 30 to 45 from horizontal 75% or more of the time, whereas respondents working in hospitals without an oral care protocol did not. Older respondents and those with more years of critical care experience reported that they kept the head of the bed elevated at 30 to 45 from horizontal 75% or more of the time, whereas younger respondents and those with fewer years of critical care experience did not do so. Respondents without certification reported that they kept the head of the bed elevated at 30 to 45 from horizontal 75% or more of the time, whereas respondents with certication did not do so.

*Because of missing data and rounding, percentages do not all total 100. Abbreviation: NR, not reported.

Table 5 suggests that (compared with the results reported by Sole et al) a larger percentage of nurses are cleansing the Yankauer suction device after each use, and a larger percentage of them use tap water when they rinse the device. The results on practices for storing suction devices also suggest that practices have improved since the 2003 study.
Association Between Care Practices and Demographic Characteristics of Respondents

The multinominal regression analyses yielded good ts (signicance values close to 1.0) for frequency of hand washing (2 = 354, df = 452, P = 1.0) and degree of elevation of the head of the bed (2 = 498, df = 565, P = .98). The analysis of the use of gloves to give oral care (2 = 325, df = 339, P = .70) and the analysis of use of subglottic suctioning (2 = 372, df = 333, P = .06) yielded poor fits, suggesting no clear relationships between these 2 practices and respondents demographic characteristics.
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Conclusions, Discussion, and Recommendations

According to these nurses self-reports, evidencebased and best practices as recommended in the CDC guidelines for the prevention of VAP are not consistently and uniformly implemented. Of concern, 18%
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of nurses reported not always washing their hands between patients, and 23% reported not using gloves when providing oral care. A self-reported hand-washing rate of 82% may be an overestimate of actual compliance; in the study by Grap and Munro25 in 1997, 90% of nurses surveyed reported compliance with hand washing, but when the nurses were observed, only 22% were actually compliant. The seemingly counterintuitive nding regarding the relationship between hand-washing responses and participation in infection control projects may stem from heightened awareness to increase hand-washing frequency among those participating in such projects.

Most nurses surveyed did not know the rate of ventilator-associated pneumonia in their unit.
The gap between what we know and the way we practice continues to be larger than desired. Clearly, nurses compliance with recommendations about hand washing and wearing gloves must be improved. Although subglottic suctioning is often an intervention used by both nurses and respiratory therapists, only 69% of nurses reported providing this intervention that reduces the risk of VAP. Even fewer nurses reported maintaining elevation of the head of the bed if not contraindicated. Even though the CDC does not specify the components to be included in an oral hygiene program, the results of this study suggest that having a protocol in place improves care provided by nurses. Yet in this study only 56% of respondents reported working in hospitals that have oral care protocols.
Limitations

actively involved in educational advancement, they may be more knowledgeable about practice guidelines and thus more likely than others to adhere to the CDC VAP prevention guidelines. As a result, it is difcult to determine if our findings can be generalized to a larger population such as those nurses who do not attend educational seminars. Third, we have only self-reported results. We attempted to minimize the potential for response bias by providing anonymity and instructing participants to record what they actually do in practice versus what is recommended, but, as mentioned, the results of this study most likely overestimate compliance with recommended practices. The nding that recent participation in improvement projects related to infection control was associated with lower self-reported compliance with hand washing may be attributable to heightened awareness due to participation in such projects. Last, we did not institute a fail-safe method to prevent participants from completing the survey more than once. We operated under the assumption that because of personal time constraints, most participants would not submit another survey if they had previously completed one.
Recommendations

Whether nursing actions reduce VAP rates remains an empirical question that requires further research. However, the results of this study suggest that best practices for the prevention of VAP are not consistently or uniformly implemented. A gap persists between what we know and the ways in which we provide care. To address this gap, we offer the following recommendations.

Implementation of best practices for

preventing ventilator-associated pneumonia is inadequate and inconsistent.

This descriptive study had at least 4 primary limitations. First, we did not complete a formal assessment of the reliability of the survey. Consequently, we have no way of knowing how much or in what direction responses would differ if respondents completed the survey a second time. Because most respondents were attending lectures or seminars related to VAP, most likely the results paint a more positive picture than what actually exists. Second, our survey was distributed at educational seminars only, and this method of distribution may have introduced a selection bias. Because education appears to play a role in inuencing clinical practice, we might assume that because our survey respondents were

Hospitals should implement protocols for preventing VAP that include each of the practices recommended by the CDC. Units implementing prevention protocols should evaluate the effects of nursing actions on VAP rates and disseminate the results. We recommend that all hospitals institute educational training programs for their staff to heighten awareness of VAP prevention and to improve adherence to the evidence-based guidelines provided by the CDC. In addition, we recommend that hospitals encourage staff involvement in educational advancement and performance improvement projects. Because of the
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importance of hand washing in the prevention of VAP, we recommend consideration of such improvement projects as the following: placement and use of alternatives to antimicrobial soap as a means of improving hand-washing rates and evaluating the effects on VAP rates, unit-based studies that identify circumstances and situations in which hand-washing rates increase and decrease, observational studies of healthcare workers to determine actual practices in hand washing, and performance reviews that include information on rates of hand washing. Similar projects could be undertaken for use of gloves while giving oral care, use of subglottic suctioning, and elevation of the head of the bed. The CDC guidelines recommend development and implementation of a comprehensive oral hygiene program to provide oropharyngeal cleansing and decontamination with or without an antiseptic agent. The results of this and other studies suggest that having an oral care protocol improves the likelihood that oral care is provided. Accordingly, we recommend that all ICUs develop and implement an oral hygiene protocol based on the best available research evidence. We recommend that units conduct systematic evaluations of the benets associated with use of the protocols and disseminate the ndings.
ACKNOWLEDGMENTS We appreciate the collaboration provided by the 2005 American Association of Critical-Care Nurses Critical Care Expo Educational Committee and our colleagues at Sage Products and Barbara Clark Mims Associates. We thank Dr Mary Lou Sole and colleagues for sharing their Suctioning Techniques and Airway Management Practices survey instrument and the content experts who reviewed our adaptation: Barbara Clark Mims, Patti Grant, Dr David Allen, ICU staff nurses at Parkland Memorial Hospital, Baylor Hospital of Plano, and RHD Memorial Hospital. The staff of the Center for Nursing Research, School of Nursing, University of Texas at Arlington helped with data management and analyses. We send a special thank you to all the nurses who volunteered their time to complete our survey. FINANCIAL DISCLOSURES Financial support for our project included a generous Littman stethoscope donation from 3M (St Paul, Minn) and exhibit space from Sage Products (Cary, Ill) at the 2005 Critical Care Expo.

REFERENCES 1. Luna CM, Blanzaco D, Niederman MS, et al. Resolution of ventilatorassociated pneumonia: prospective evaluation of the Clinical Pulmonary Infection Score as an early clinical predictor of outcome. Crit Care Med. 2003;31:676-682. 2. Centers for Disease Control and Prevention. CDC National Nosocomial Infections Surveillance (NNIS) System Report, data summary from January 1992 through June 2004, issued October 2004. Am J Infect Control. 2004;32:470-485. 3. Chastre J, Fagon JY. Ventilator-associated pneumonia. Am J Respir Crit Care Med. 2002;165:867-903. 4. Craven DE, Steger KA. Ventilator-associated bacterial pneumonias: challenges in diagnosis, treatment, and prevention. New Horiz. 1998;6(2 suppl):S30-S45. 5. Lode H, Raffenberg M, Erbes R, Geerdes-Fengea H, Mauch M. Nosocomial pneumonia: epidemiology, pathogenesis, diagnosis, treatment and preventions. Curr Opin Infect Dis. 2000;13:377-384. 6. Kollef MH. The prevention of ventilator-associated pneumonia. N Engl J Med. 1999;340:627-633. 7. Tablan OC, Anderson LJ, Besser R, et al. Guidelines for preventing health-care-associated pneumonia, 2003: recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee. MMWR Recomm Rep. March 26, 2004;53(RR-3):1-36. 8. Myrianthefs PM, Kalafati M, Samara I, Baltopoulos GJ. Nosocomial pneumonia. Crit Care Nurs Q. 2004;27:241-257. 9. Centers for Disease Control and Prevention Guidelines for prevention of nosocomial pneumonia. MMWR Recomm Rep. January 3, 1997;46(RR-1):1-79. 10. Creedon S. Healthcare workers hand decontamination practices: compliance with recommended guidelines. J Adv Nurs. 2005;51:208-216. 11. Galway R, Harrod ME, Crisp J, et al. Central venous access and handwashing: variability in policies and practices. Paediatr Nurs. 2003;15:14-18. 12. Picheansathian W. A systematic review on the effectiveness of alcoholbased solutions for hand hygiene. Int J Nurs Pract. 2004;10:3-9. 13. Babcock H, Zack J, Garrison T, et al. An educational intervention to reduce ventilator-associated pneumonia in an integrated health system: a comparison of effects. Chest. 2004;125:2224-2231. 14. Cutler CJ, Davis N. Improving oral care in patients receiving mechanical ventilation. Am J Crit Care. 2005;14:389-394. 15. Grap MJ, Munro CL, Bryant S, Ashtiani B. Predictors of backrest elevation in critical care. Intensive Crit Care Nurs. 2003;19:68-74. 16. Munro CL, Grap, MJ. Oral health and care in the intensive care unit: state of the science. Am J Crit Care. 2004;13:25-33. 17. Sole ML, Poalillo FE, Byers JF, Ludy JE. Bacterial growth in secretions and on suctioning equipment of orally intubated patients: a pilot study. Am J Crit Care. 2002;11:141-149. 18. Sole ML, Byers JF, Ludy JE, Zhang Y, Banta CM, Brummel K. A multisite survey of suctioning techniques and airway management practices. Am J Crit Care. 2003;12:220-230. 19. Binkley C, Furr LA, Carrico R, McCurren C. Survey of oral care practices in US intensive care units. Am J Infect Control. 2004;32:161-169. 20. Jones H, Newton JT, Bower EJ. A survey of the oral care practices of intensive care nurses. Intensive Crit Care Nurs. 2004;20:69-76. 21. Hanneman SK, Gusick GM. Frequency of oral care in positioning of patients in critical care: a replication study. Am J Crit Care. 2005;14:378-386. 22. Grap MJ, Munro CL, Ashtiani B, Bryant S. Oral care interventions in critical care: frequency and documentation. Am J Crit Care. 2003;12:113-118. 23. Sole ML, Byers JF, Ludy JE. STAMP Survey: Suctioning Techniques and Airway Management Practices. Orlando, Fla: University of Central Florida, School of Nursing; 2001. 24. Stevens J. Applied Multivariate Statistics for the Social Sciences. 3rd ed. Mahwah, NJ: Lawrence Erlbaum Assoc; 1996. 25. Grap MJ, Munro CL. Ventilator-associated pneumonia: clinical significance and implications for nursing. Heart Lung. 1997;26:419-429.

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JOURNAL CLUB ARTICLE DISCUSSION POINTS

In a journal club, research articles are reviewed and critiqued. General and specic questions help to aid journal club participants in probing the quality of the research study, the appropriateness of the study design and methods, the validity of the conclusions, and the implications for practice. When critically appraising this issues journal club article, Nurses Implementation of Guidelines for Ventilator-Associated Pneumonia From the Centers for Disease Control and Prevention, consider the questions and discussion points listed below.
Study Synopsis: This study used a survey to assess critical care nurses use of evidence-based practices related to the care of mechanically ventilated patients based on the Centers for Disease Control and Prevention (CDC) guidelines for prevention of ventilator-associated pneumonia (VAP). Surveys were completed by 1200 nurses who attended several continuing education programs including AACNs National Teaching Institute. The results revealed that most respondents reported compliance with hand hygiene (82%) and wearing gloves when indicated (75%). However, only 52% reported elevating the head of the patients bed, 36% reported the use of suctioning prior to endotracheal cuff deation, and only 56% reported a written policy for oral care, demonstrating inconsistent use of the CDC guidelines. Yet compared with prior research, more participants reported use of oral care, cleansing of the Yankauer suction device after use, and practices for storing suction devices. These ndings indicate some improvement in practice changes. A. Description of the Study What was the purpose of the research? How does the study incorporate use of evidencebased practice? B. Literature Evaluation What previous research has been conducted on nurses knowledge related to prevention of VAP? How does the current study add to the literature? C. Sample How was the study sample obtained? How representative was the sample of nurses working in critical care settings? D. Methods and Design Describe the study methods. How was the survey tool developed? What methods were used to recruit study participants? thors wished to make a more signicant contribution to critical care. So we discussed ways in which [we might] capture a larger and more national audience. Dr Cason reports that collecting data at the National Teaching Institute proved benecial for promoting response rates to the survey. Tracy Tyner, RN, MSN, CEN, CCRN, a coauthor of the article, adds: We had implemented a VAP protocol in our MICU [medical intensive care unit] and there had been lots of discussion regarding its implications at our hospital. We had a dramatic drop in our VAP rates, so when the idea of looking at nursing practice in relation to VAP CDC guidelines was discussed, we thought it would be very appropriate and clinically useful information for all ICU nurses. The authors report that some study results were a bit surprising. Sue Saunders, RN, MSN, CCRN, relates that the most surprising finding of the study was how many people were unaware of their VAP rates and organisms in their individual units. For Tyner, however, many of the study results were not unexpected. I was curious to nd out how many nurses who thought they were providing adequate VAP prevention care were actually providing care according to guidelines, she says. Bottom line: what is perceived as adequate care does not always meet recommended guidelines. I was glad to see that the percent of tooth brushing [had gone] up since the survey by Sole and colleagues [39% to 66% at least every 12 hours]. I was a little surprised to see that 86% of nurses say they keep the head of bed elevated 30 to 45 for at least 75% of the day. This may be true, which means the word has gotten out regarding its efcacy, but I think we need to consider the possibility that the head of bed height may be [inaccurate] based on prior studies and estimating backrest elevation.... I cant say I was surprised that only 56% of nurses reported that their hospital has an oral care protocol. I think this was the most important nding in our study, because it is something that can easily be remedied and has components that have been proven to reduce VAP. Implications for Practice: Dr Cason suggests that there are several major implications of the study results for nurses. Nurses can and should implement care that decreases VAP rates: wash their hands, suction before deation or movement of the [endotracheal] tube, elevate the head of the bed, and provide oral care on a systematic, routine basis, she notes. Saunders adds: One of the implications is how important nursing education is, [but also] that continuing nursing education at the hospital level can contribute more than just general nursing orientation and BCLS [basic cardiac life support] courses. Currently, most institutions are downsizing their education departments, and I think this study can show in small part how important education is. Tyner concludes: Based on our survey results, respondents who had an oral care protocol in place reported nursing practice that was more consistent with recommended CDC guidelines for VAP prevention. The take-home point is that every hospital should implement a VAP prevention protocol that includes an oral care component.
Journal Club feature commentary is provided by Ruth Kleinpell.

E.

Results What were the ndings of the research? Discuss the results in terms of the evidence-based practice guideline recommendations. What factors were found to affect hand washing and head of bed elevation practices? F. Clinical Signicance What are the implications of this study for clinical nursing? Information From the Authors: Carolyn Cason, RN, lead author of the article, provided additional information about the study. She reported that the study team included several staff nurses and students enrolled in graduate programs who were interested in studying VAP rates. She notes: I suggested that we do a local survey but my coauPhD,

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CE Test Test ID A071601: Nurses Implementation of Guidelines for Ventilator-Associated Pneumonia From the Centers for Disease Control and Prevention. Learning objectives: 1. Describe the role of the CDC guidelines in relation to decreasing ventilator-associated pneumonia rates. 2. Recognize the key factors for the diagnosis of ventilator-associated pneumonia. 3. Understand the role of the CDC guidelines and nursing implications in helping to prevent ventilator-associated pneumonia.
1. Ventilator-associated pneumonia (VAP) accounts for what percentage of infections among patients in the intensive care unit (ICU)? a. 47% c. 65% b. 45% d. 75% 2. Which of the following are the 2 most common pathological organisms in VAP? a. Klebsiella pneumoniae and Staphylococcus epidermidis b. Pseudomonas aeruginosa and Staphylococcus aureus c. Escherichia coli and Candida albicans d. Streptococcus pneumoniae and Acinetobacter 3. Due to decreased levels of consciousness in critically ill patients, pooling of secretions can accumulate to what extent within a 24-hour period? a. Between 50 and 150 mL b. Between 100 and 150 mL c. Between 25 and 75 mL d. Between 150 and 200 mL 4. What is one Centers for Disease Control and Prevention (CDC) recommendation for endotracheal tube cuff deflation or endotracheal tube repositioning? a. Deflate the cuff and reposition as needed b. Hyperventilate the patient prior to repositioning or extubating c. Suction above the cuff prior to deflating the cuff d. Vigorous oral care prior to deflating the cuff 5. As identified in the CDC recommendations, which of the following best describes the rationale for maintaining head-of-bed elevation between 30 and 45? a. It allows the patient to see family, staff, and visitors more clearly. b. It prevents pressure ulcers on the patients lower back. c. It prevents patients from reaching up and inadvertently extubating themselves. d. It decreases the volume of gastric secretions, thereby reducing the risk of aspiration. 6. Which of the following best describes the specific agent that is recommended for adult cardiovascular surgery patients who are mechanically ventilated in the ICU? a. Half-strength hydrogen peroxide solution with normal saline b. Commercially prepared mouthwashes c. Chlorhexadine gluconate rinses d. Saline rinses 7. What are 2 ways the critical care nurse can decrease the chance of VAP frequencies with oral care? a. Frequent oral suctioning and decontamination and storage of suction devices Test Answers: Mark only one box for your answer to each question. You may photocopy this form. b. Use of oral swabs and suctioning of oral mucosa every 4 hours c. Brushing patients teeth with antimicrobial toothpaste and frequent rinsing d. Allowing patients family to suction when needed and to report the number of times the patient was suctioned 8. Questions included in the study survey (the Oral Care of Ventilated Patients Questionnaire) were based on which of these 3 current oral care practices? a. Frequency of tooth brushing, oral care, and use of antiseptic oral rinse agents b. Frequency of oral suctioning, repositioning of endotracheal tube, and wearing of gloves c. Frequency of hand washing, wearing of gloves, and replacement of suction devices d. Use of disposable suction devices, frequency of oral swabbing, and subglottic suctioning 9. The overall outcome variables in the survey were identified as which of the following? a. Hand washing, subglottic suctioning, and degree of the head of the bed b. Subglottic suctioning, use of oral rinse agents, and use of soap and water versus alcoholbased hand washing c. Alcohol-based hand washing, head of bed elevation, and amount of sedation used for the patient d. Identification of causative organisms, frequency of oral care, and use of oral rinse agents 10. Based on the survey results, who was more likely to wash their hands always or frequently? a. Nurses on noncritical care units or extended care ventilator units b. Staff in critical care units where no oral care protocol was in place c. Staff working in hospitals with an oral care protocol in place d. Staff working in hospitals without an oral care protocol in place 11. Of the respondents in the survey, what was the percentage of nurses who reported not using gloves during suctioning? a. 38% c. 65% b. 42% d. 23% 12. Which of the following is not a recommendation from the CDC for decreasing VAP rates in hospitals? a. Continue current practices in VAP prevention b. Institute educational training programs for staff to heighten awareness of VAP prevention c. Implement protocols for preventing VAP that include practices recommended by the CDC d. Develop and implement comprehensive oral hygiene programs to provide oropharyngeal cleansing and decontamination with or without antiseptic agents

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Test ID: A071601 Form expires: January 1, 2009. Contact hours: 1.5 Fee: $11 Passing score: 9 correct (75%) Category: A Test writer: Todd M. Grivetti, RN, BSN, CCRN

Program evaluation
Objective 1 was met Objective 2 was met Objective 3 was met Content was relevant to my nursing practice K My expectations were met K This method of CE is effective for this content K The level of difficulty of this test was: K easy K medium K difficult To complete this program, it took me hours/minutes. Yes K K K No K K K K K K

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