Elsevier

Journal of Infection

Volume 65, Issue 4, October 2012, Pages 285-291
Journal of Infection

A European survey of nosocomial infection control and hospital-acquired pneumonia prevention practices

https://doi.org/10.1016/j.jinf.2012.06.016Get rights and content

Summary

Objectives

We aimed to examine organizational, structural and routine infection control measures provided by European ICUs and staff practices in ventilator-associated pneumonia prevention in relation with current recommendations.

Methods

European ICU staffs were invited to complete a web-based 20 closed-item questionnaire.

Results

675 nurses and 886 physicians from 13 countries answered the questionnaire. Median number of respondents per country was 118.0 (64.5–155.5). Availability and organizational aspects of infection control revealed wide variations between countries. Among them, single-patient rooms was the aspect with the lowest availability (median availability 38%), but the largest variation ranging from 15 to 84%. Self-reported median adherence rate to recommendations was 72% (34.5–83.0) with a strong correlation between nurses and physicians responses (r² = 0.96; p < 0.0001). Sub-glottic drainage (31%), and infrequent ventilatory-circuit change (24%) were the measures with the lowest adherence rate whereas preferential use of oral intubation (90%) and of NIV (84%) and use of HMEs (82%) were the three with the highest rate. Organization of infection control was consistently self-reported. Disparities among countries were more frequent for specific actions regarding airway management, and even moreso for controversial issues (subglottic drainage, closed-suction systems).

Conclusion

This European survey shows a 72% overall adherence rate to VAP prevention measures; with strong agreements between physician and nurses but considerable differences among countries for availability and organization aspects of infection control, providing healthcare authorities with figures for future programs.

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:

  • -

    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.

  • -

    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.

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