Hostname: page-component-8448b6f56d-sxzjt Total loading time: 0 Render date: 2024-04-23T22:38:08.772Z Has data issue: false hasContentIssue false
  • English
  • Français

Preventing Ventilator-Associated Pneumonia in the United States: A Multicenter Mixed-Methods Study

Published online by Cambridge University Press:  02 January 2015

Sarah L. Krein ,
Christine P. Kowalski ,
Laura Damschroder ,
Jane Forman ,
Samuel R. Kaufman  and
Sanjay Saint
Sarah L. Krein*
Affiliation:
Department of Veterans Affairs Ann Arbor Health Services Research and Development Center of Excellence, Department of Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan
Christine P. Kowalski
Affiliation:
Department of Veterans Affairs Ann Arbor Health Services Research and Development Center of Excellence, Department of Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
Laura Damschroder
Affiliation:
Department of Veterans Affairs Ann Arbor Health Services Research and Development Center of Excellence, Department of Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
Jane Forman
Affiliation:
Department of Veterans Affairs Ann Arbor Health Services Research and Development Center of Excellence, Department of Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
Samuel R. Kaufman
Affiliation:
Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan Ann Arbor Department of Veterans Affairs–University of Michigan Patient Safety Enhancement Program, Ann Arbor, Michigan
Sanjay Saint
Affiliation:
Department of Veterans Affairs Ann Arbor Health Services Research and Development Center of Excellence, Department of Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan Ann Arbor Department of Veterans Affairs–University of Michigan Patient Safety Enhancement Program, Ann Arbor, Michigan
*
Veterans Affairs Ann Arbor Health Services Research and Development Center of Excellence, Veterans Affairs Ann Arbor Healthcare System, PO Box 130170, Ann Arbor, MI 48113 (skrein@umich.edu)
Get access Rights & Permissions [Opens in a new window]

Abstract

Objective.

To determine what practices are used by hospitals to prevent ventilator-associated pneumonia (VAP) and, through qualitative methods, to understand more fully why hospitals use certain practices and not others.

Design.

Mixed-methods, sequential explanatory study.

Methods.

We mailed a survey to the lead infection control professionals at 719 US hospitals (119 Department of Veterans Affairs [VA] hospitals and 600 non-VA hospitals), to determine what practices are used to prevent VAP. We then selected 14 hospitals for an in-depth qualitative investigation, to ascertain why certain infection control practices are used and others not, interviewing 86 staff members and visiting 6 hospitals.

Results.

The survey response rate was 72%; 83% of hospitals reported using semirecumbent positioning, and only 21% reported using subglottic secretion drainage. Multivariable analyses indicated collaborative initiatives were associated with the use of semirecumbent positioning but provided little guidance regarding the use of subglottic secretion drainage. Qualitative analysis, however, revealed 3 themes: (1) collaboratives strongly influence the use of semirecumbent positioning but have little effect on the use of subglottic secretion drainage; (2) nurses play a major role in the use of semirecumbent positioning, but they are only minimally involved with the use of subglottic secretion drainage; and (3) there is considerable debate about the evidence supporting subglottic secretion drainage, despite a meta-analysis of 5 randomized trials of subglottic secretion drainage that generally supported this preventive practice, compared with only 2 published randomized trials of semirecumbent positioning, one of which concluded that it was ineffective at preventing the development of VAP.

Conclusion.

Semirecumbent positioning is commonly used to prevent VAP, whereas subglottic secretion drainage is used far less often. We need to understand better how evidence related to prevention practices is identified, interpreted, and used to ensure that research findings are reliably translated into clinical practice.

Type
Original Article
Information
Infection Control & Hospital Epidemiology , Volume 29 , Issue 10 , October 2008 , pp. 933 - 940
Copyright
Copyright © The Society for Healthcare Epidemiology of America 2008

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

1.Richards, MJ, Edwards, JR, Culver, DH, Gaynes, RP. Nosocomial infections in combined medical-surgical intensive care units in the United States. Infect Control Hosp Epidemiol 2000;21:510–515.CrossRefGoogle ScholarPubMed
2.Safdar, N, Dezfulian, C, Collard, HR, Saint, S. Clinical and economic consequences of ventilator-associated pneumonia: a systematic review. Crit Care Med 2005;33:2184–2193.CrossRefGoogle ScholarPubMed
3.Tablan, OC, Anderson, LJ, Besser, R, Bridges, C, Hajjeh, R. Guidelines for preventing health-care-associated pneumonia, 2003: recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee. MMWR Recomm Rep 2004;53(RR-3):1–36.Google ScholarPubMed
4.Dodek, P, Keenan, S, Cook, D, et al.Evidence-based clinical practice guideline for the prevention of ventilator-associated pneumonia. Ann Intern Med 2004;141:305–313.Google Scholar
5.Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med 2005;171:388–416.Google Scholar
6.Collard, HR, Saint, S, Matthay, MA. Prevention of ventilator-associated pneumonia: an evidence-based systematic review. Ann Intern Med 2003;138:494–501.Google Scholar
7.Berwick, DM, Calkins, DR, McCannon, CJ, Hackbarth, AD. The 100,000 Lives Campaign: setting a goal and a deadline for improving health care quality. JAMA 2006;295:324–327.Google Scholar
8.Resar, R, Pronovost, P, Haraden, C, Simmonds, T, Rainey, T, Nolan, T. Using a bundle approach to improve ventilator care processes and reduce ventilator-associated pneumonia. Jt Comm J Qual Patient Saf 2005;31:243–248.Google Scholar
9.Youngquist, P, Carroll, M, Farber, M, et al.Implementing a ventilator bundle in a community hospital. Jt Comm J Qual Patient Saf 2007;33:219–225.Google Scholar
10.Krein, SL, Olmsted, RN, Hofer, TP, et al.Translating infection prevention evidence into practice using quantitative and qualitative research. Am J Infect Control 2006;34:507–512.Google Scholar
11.Krein, S, Hofer, T, Kowalski, C, et al.Use of central venous catheter-related bloodstream infection prevention practices by US hospitals. Mayo Clin Proc 2007;82:672–678.CrossRefGoogle ScholarPubMed
12.Saint, S, Kowalski, CP, Kaufman, SR, et al.Preventing hospital-acquired urinary tract infection in the United States: a national study. Clin Infect Dis 2008;46:243–250.Google Scholar
13.Sandelowski, M. Combining qualitative and quantitative sampling, data collection, and analysis techniques in mixed-method studies. Res Nurs Health 2000;23:246–255.Google Scholar
14.Ivankova, NV, Creswell, JW, Stick, SL. Using mixed-methods sequential explanatory design: from theory to practice. Field Methods 2006;18:3–20.Google Scholar
15.National Center for Health Workforce Analysis Bureau of Health Professions, Health Resources and Services Administration, Department of Health and Human Services. Area Resource File (ARF). Fairfax, VA: Quality Resource Systems (QRS), Inc.; 2003.Google Scholar
16.Needleman, J, Buerhaus, P, Mattke, S, Stewart, M, Zelevinsky, K. Nurse-staffing levels and quality of care in hospitals. N Engl J Med 2002;346:1715–1722.Google Scholar
17.Putnam, W, Twohig, PL, Burge, FI, Jackson, LA, Cox, JL. A qualitative study of evidence in primary care: what the practitioners are saying. CMAJ 2002;166:1525–1530.Google Scholar
18.Kane, RL, Shamliyan, T, Mueller, C, Duval, S, Wilt, TJ. Nurse staffing and quality of patient care. Evid Rep Technol Assess (Full Rep) 2007; (151):1–115.Google ScholarPubMed
19.Mason, J. Qualitative researching. Thousand Oaks, CA: Sage Publications; 2002.Google Scholar
20.Sandelowski, M, Barroso, J. Writing the proposal for a qualitative research methodology project. Qual Health Res 2003;13:781–820.Google Scholar
21.Forman, J, Damschroder, LJ. Qualitative content analysis. In: Jacoby, L, Siminoff, L, eds. Empirical Research for Bioethics: A Primer. Oxford, UK: Elsevier Publishing; 2008:39–62.Google Scholar
22.Ovretveit, J, Bate, P, Cleary, P, et al.Quality collaboratives: lessons from research. Qual Saf Health Care 2002;11:345–351.Google Scholar
23.Wilson, T, Berwick, DM, Cleary, PD. What do collaborative improvement projects do? Experience from seven countries. Jt Comm J Qual Saf 2003;29:85–93.Google Scholar
24.Pronovost, P, Needham, D, Berenholtz, S, et al.An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med 2006;355:2725–2732.CrossRefGoogle ScholarPubMed
25.Wachter, RM, Pronovost, PJ. The 100,000 Lives Campaign: a scientific and policy review. Jt Comm J Qual Patient Saf 2006;32:621–627.Google Scholar
26.Ricart, M, Lorente, C, Diaz, E, Kollef, MH, Rello, J. Nursing adherence with evidence-based guidelines for preventing ventilator-associated pneumonia. Crit Care Med 2003;31:2693–2696.Google Scholar
27.Cason, CL, Tyner, T, Saunders, S, Broome, L. Nurses' implementation of guidelines for ventilator-associated pneumonia from the Centers for Disease Control and Prevention. Am J Crit Care 2007;16:28–36.Google Scholar
28.Grap, MJ, Munro, CL, Bryant, S, Ashtiani, B. Predictors of backrest elevation in critical care. Intensive Crit Care Nurs 2003;19:68–74.Google Scholar
29.American Association of Critical-Care Nurses Practice Alert. Ventilator Associated Pneumonia. Available at: http://www.aacn.org/AACN/practiceAlert.nsf/vwdoc/pa2. Accessed January 3, 2008.Google Scholar
30.Rello, J, Lorente, C, Bodi, M, Diaz, E, Ricart, M, Kollef, MH. Why do physicians not follow evidence-based guidelines for preventing ventilator-associated pneumonia? A survey based on the opinions of an international panel of intensivists. Chest 2002;122:656–661.Google Scholar
31.Kaynar, AM, Mathew, JJ, Hudlin, MM, et al.Attitudes of respiratory therapists and nurses about measures to prevent ventilator-associated pneumonia: a multicenter, cross-sectional survey study. Respir Care 2007;52:1687–1694.Google Scholar
32.Dezfulian, C, Shojania, K, Collard, HR, Kim, HM, Matthay, MA, Saint, S. Subglottic secretion drainage for preventing ventilator-associated pneumonia: a meta-analysis. Am J Med 2005;118:11–18.Google Scholar
33.van Nieuwenhoven, CA, Vandenbroucke-Grauls, C, van Tiel, FH, et al.Feasibility and effects of the semirecumbent position to prevent ventilator-associated pneumonia: a randomized study. Crit Care Med 2006;34:396–402.Google Scholar
34.Drakulovic, MB, Torres, A, Bauer, TT, Nicolas, JM, Nogue, S, Ferrer, N. Supine body position as a risk factor for nosocomial pneumonia in mechanically ventilated patients: a randomised trial. Lancet 1999;354:1851–1858.Google Scholar
35.Forman, J, Creswell, JW, Damschroder, L, Kowalski, CP, Krein, SL. Qualitative research methods: key features and insights gained by their use in infection prevention research. Am J Infect Control 2008. In press.Google Scholar