Brief description of previous research:
Preventable adverse patient events, including hospital-acquired infections, are responsible for 45,000 to 100,000 deaths annually, at a cost of $17 to $29 billion dollars (Kohn, Corrigan, & Donaldson, 1999). Ventilator-associated pneumonia (VAP) is the leading cause of nosocomial infections in critically ill adult patients around the world, surpassing central line-associated bloodstream infections and catheter-associated urinary tract infections (Center for Disease Control (CDC), 2000; Patel, Sathyaki, & Kilpadi, 1998). The incidence of VAP ranges from 4% to 42% of mechanically ventilated Intensive Care Unit (ICU) patients (Adnet, 2001; Akca et al., 2000; Bergmans et al., 1996; Beck-Sague et al., 1996; George et al., 1998; Ibrahim, Tracy, Hill, Fraser, & Kolleff, 2001; Legras et al., 1998; Memish Cunningham, Oni, & Djazmati, 2000).

Purpose/aim of the project:
To implement and measure strategies that will facilitate the adoption of a clinical practice guideline in order to decrease ventilator-associated pneumonia (VAP) incidence rates and ventilator days at Brooke Army Medical Center and Wilford Hall Medical Center . The focus of the guideline is to interrupt person-to-person transmission of bacteria and bacteria colonization using low cost standard of care strategies.

Expected outcome of the implementation/innovation:
Brooke Army Medical Center and Wilford Medical Center have four different types of intensive care units (burn, medical, surgical, and trauma). VAP rates for the burn unit, based on occupied bed days (OBD), are 48.5 /10,000 OBD for 2001 and 22.9/10,000 OBD for 1 st quarter 2002. The medical ICU VAP rates at BAMC for this same period ranged from 6.0 to 6.4, well within the rate limits of 3.8 to 9.0; WHMC ranged from 3.1 to 8.4. The surgical ICU VAP rates ranged from 22.2 to 38.2 at WHMC and 10.39 to 24.54 at BAMC. These rates should be between 7.7 and 14.9. However, the SICU rates exceed the 90 th percentile in some quarters . VAP rates for the trauma unit at BAMC ranged from 7.39 to 16.95. The NNIS median is 15.3 with a lower limit 10.7 and upper limit of 22.1.

VAP rates at Brooke Army Medical Center and Wilford Medical Center suggest a need for intervention. Therefore, the purpose of this study was to implement and test a clinical practice guideline (CPG) in order to decrease ventilator-associated pneumonia (VAP) incidence rates at Brooke Army Medical Center and Wilford Hall Medical Center.

Nature of the proposed change:
The implementation framework of applying CPG for VAP draws from two models. First, implementation strategies must consider barriers and facilitators to change involving the education intervention at the unit and organization level. The PRECEDE-PROCEED model (Green, 1999) evaluates the predisposing factors such as attitudes, beliefs and perceptions motivating a change as well as the enabling factors of resources, facilities, and skills at the unit and individual level. Reinforcing factors such as rewards, incentives, and positive feedback must be examined to place implementation strategies for the education intervention within a window of success (Green). Rogers (1995) model addresses the importance of ensuring change such as the education intervention in this study and associated implementation strategies:

1) translated with incremental complexity, 2) compatible with systems supportive of the change, 3) adaptable by staff to make the change reasonable for implementation (triability), 4) the change such as the education intervention of the VAP CPG holds an advantage for patients and staff, and 5) the change has observable benefits and decreases patients risk of pneumonia (observability). These models by Green and Rogers shape the framework for implementing the VAP CPG and understanding facilitators and barriers to compliance with the VAP CPG before, during, and after implementation. The PRECEDE-PROCEED models deliver focus of change at the organization level and the Roger’s model shapes the perspective at the staff member level. Combined, the two models facilitate an understanding of barriers to consider to successfully adopt the VAP CPG and compliance with the CPG.

The VAP CPG conceptual framework for this study is adopted from the Center for Disease Controls Guideline (CDC) for Prevention of Nosocomial Pneumonia (1994). The aim of the CDC guideline is to prevent infection, specifically nosocomial pneumonia. The CDC recognized four categories of intervention. These categories include modifying host risk for infection, treatment of related risks, interrupting person-to-person transmission of bacteria, and staff education (Tablan, Anderson, Arden, Breiman, Butler, & McNeil, 1994). The focus of this study was to interrupt person-to-person transmission of bacteria using staff education.

Steps/strategies of implementation of the project.

Methods used to evaluate effectiveness and outcomes.
Evaluation of the impact of the change will be patient outcomes and staff compliance rates.

Implications for continued use:
Use this systematic process as a template for development of other clinical practice guidelines.

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© 2002 UTHSCSA - School of Nursing
Last updated: 4 November 2004
By: Heather Cura