A European survey of nosocomial infection control and hospital-acquired pneumonia prevention practices
Introduction
Despite numerous advances in its comprehension and prevention,1 ventilator-associated pneumonia (VAP) remains the most frequent nosocomial infection in the intensive care unit (ICU). It places a huge burden on both patient safety and healthcare services and resources. Patient safety is obviously affected because occurrence of a nosocomial infection influences patient outcome with attributable morbidity and mortality. Healthcare costs are considerably increased because of prolonged stay2 and additional use of healthcare resources to treat nosocomial infections (antibiotics, isolation measurements, staff, etc).
Any nosocomial infection prevention and VAP in particular, is an evolving and dynamic process that encompasses structural, organisational, technical and medical aspects. Such diversity is not always addressed in recommendations and guidelines that tend to focus on medical and technical aspects, those addressed in clinical trials. Structural and organisational aspects of nosocomial infection prevention are often overlooked in clinical trials because difficult to evaluate and modify. Nonetheless, they have been shown to affect care and patient outcome. Bloodstream infection and cross-transmission of methicillin-resistant Staphylococcus aureus for example, may be prevented by the use of single rooms.3 Understaffing is also a recurrent problem in ICU that has been proved to increase NI4 but also length of mechanical ventilation in weaning of COPD patients.5
Numerous guidelines and recommendations on VAP and its prevention are available.6 Although these recommendations encompass both pharmacological and non-pharmacological aspects, they do not take into account country and ICU specificities. Selective digestive decontamination is an astute example of a VAP prevention measure that is supported by strong evidence and that is paradoxically not widely applied. Indeed, this practice is mostly used in ICUs with very low rates of multidrug resistant bacteria. Elsewhere in Europe, where prevalence of such microorganisms is much higher, this practice is not often applied. Data indicate an overall non-adherence rate of 37.0% among intensive care unit practitioners regarding published recommendations for the VAP prevention.7 Among reasons for non-adherence, unavailability and costs were reasons often put forward. Because this study interviewed a very small number of physicians,7 we were interested in knowing on a much broader scale organizational and structural nosocomial infection control measures provided in European ICUs, how ICU staff complied with VAP prevention practices, how these practices differed among European countries and if practices differed between nurses and physician. Results of this study have been presented in part as an abstract.8
Section snippets
Methods
We elected to develop a simple, short, closed-ended questionnaire using items appropriate for gathering data on current practices regarding VAP prevention. A panel of European ICU physicians, interested in VAP prevention, developed a web-based questionnaire (http://www.vapaway.eu/newsflash/vapaway-questionnaire.html) to address the question of compliance to VAP prevention guidelines by ICU staff. The questionnaire was developed by extracting non-pharmacological (with the exception of oral rinse
Results
The website questionnaire was accessible worldwide during 14 months (October 2007 through December 2008), period during which 2117 questionnaires were answered. We report here the 1561 (675 nurses and 886 physicians) answers coming from European ICU staff of 13 countries. Table 1 displays the numbers of questionnaires completed per country. There was a median of 118.0 (64.5–155.5) respondents per country, with 43.0 (16.0–75.5) nurses per country and 73.0 (25.5–107.5) physicians. Rates for each
Discussion
This is to date the largest questionnaire on VAP prevention ever performed on European ICU staff. Main results can be summarized as follows:
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Overall adherence rate to recommendations was 72%, and nurses and physicians had very similar rates of adherence; providing a strong agreement between nurses and physicians attitude toward VAP prevention.
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If responders offered similar answers for organisational aspects, compliance to structural aspects (single patient room noticeably) showed wide disparities
Conclusion
This survey provides for the first time a picture of VAP prevention practices in Europe. Although the overall rate of adherence was high (72%), important disparities were noted among measures but also among countries. The detailed analysis of these differences offers opportunities for improvement per country and indicates direction of research and implementation programs for healthcare authorities.
Authors' contribution
JDR, GC, CH, JP, MQ, SR, AT designed the study, established the questionnaire and tested it.
JDR and MB analyzed the data; and JDR, GC, CH, JP, MQ, SR, AT interpreted the data.
JDR drafted the manuscript and GC, CH, JP, MQ, SR, AT provided substantial scientific input to the manuscript. All authors approved the final version of the manuscript.
Funding of the study
The study was funded by an unrestricted educational grant from Covidien. JDR, on behalf of all authors declares having had full access to the data and that the sponsor had no involvement in the study design, interpretation of the data, writing of the report, nor in the decision to submit the paper for publication.
Conflict of interest
All authors (except MB) have received funding for speaking, advisory board membership and travel from Covidien. MB is employed by Covidien.
Acknowledgements
None.
References (32)
- et al.
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) - et al.
Influence of tracheal suctioning systems on health care workers gloves and equipment contamination: a comparison of closed and open systems
Am J Infect Control
(2011) - et al.
Southern european intensive care nurses' knowledge of evidence-based guidelines for preventing ventilator-associated pneumonia
Med Intensiva
(2011) - et al.
Ventilator-associated pneumonia
Am J Respir Crit Care Med
(2002) - et al.
Multicenter prospective study of ventilator-associated pneumonia during acute respiratory distress syndrome. Incidence, prognosis, and risk factors. ARDS Study Group
Am J Respir Crit Care Med
(2000) - et al.
Single rooms may help to prevent nosocomial bloodstream infection and cross-transmission of methicillin-resistant Staphylococcus aureus in intensive care units
Intensive Care Med
(2007) - et al.
The role of understaffing in central venous catheter-associated bloodstream infections
Infect Control Hosp Epidemiol
(1996) - et al.
Influence of the quality of nursing on the duration of weaning from mechanical ventilation in patients with chronic obstructive pulmonary disease
Crit Care Med
(November 1995) - et al.
Defining, treating and preventing hospital acquired pneumonia: European perspective
Intensive Care Med
(2009) - et al.
Vapaway project: a european audit of vap prevention practices
Intensive Care Med
(2008)
Why Don't physicians follow clinical practice guidelines?: a framework for improvement
JAMA
Control and outcome of a large outbreak of colonization and infection with glycopeptide-intermediate Staphylococcus aureus in an intensive care unit
Clin Infect Dis
Emergence of a new antibiotic resistance mechanism in India, Pakistan, and the UK: a molecular, biological, and epidemiological study
Lancet Infect Dis
Availability of an alcohol solution can improve hand disinfection compliance in an intensive care unit
Am J Respir Crit Care Med
Characteristics and outcomes in adult patients receiving mechanical ventilation: a 28-day international study
Jama
Feasibility and effects of the semirecumbent position to prevent ventilator-associated pneumonia: a randomized study
Crit Care Med
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