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Preventing ventilator-associated pneumonia—a mixed-method study to find behavioral leverage for better protocol adherence

Published online by Cambridge University Press:  31 August 2018

Aline Wolfensberger ,
Marie-Theres Meier ,
Lauren Clack ,
Peter W. Schreiber  and
Hugo Sax
Aline Wolfensberger*
Affiliation:
Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zürich, University of Zurich, Zurich, Switzerland
Marie-Theres Meier
Affiliation:
Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zürich, University of Zurich, Zurich, Switzerland
Lauren Clack
Affiliation:
Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zürich, University of Zurich, Zurich, Switzerland
Peter W. Schreiber
Affiliation:
Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zürich, University of Zurich, Zurich, Switzerland
Hugo Sax
Affiliation:
Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zürich, University of Zurich, Zurich, Switzerland
*
Author for correspondence: Aline Wolfensberger, MD, Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Rämistrasse 100 CH-8091 Zurich, Switzerland. E-mail: aline.wolfensberger@usz.ch
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Abstract

Objective

Preventing ventilator-associated pneumonia (VAP) is an important goal for intensive care units (ICUs). We aimed to identify the optimal behavior leverage to improve VAP prevention protocol adherence.

Design

Mixed-method study using adherence measurements to assess 4 VAP prevention measures and qualitative analysis of semi-structured focus group interviews with frontline healthcare practitioners (HCPs).

Setting

The 6 ICUs in the 900-bed University Hospital Zurich in Zurich, Switzerland.

Patients and participants

Adherence to VAP prevention measures were assessed in patients with a device for invasive ventilation (ie, endotracheal tube, tracheostomy tube). Participants in focus group interviews included a convenience samples of ICU nurses and physicians.

Results

Between February 2015 and July 2017, we measured adherence to 4 protocols: bed elevation showed adherence at 27% (95% confidence intervals [CI], 23%–31%); oral care at 41% (95% CI, 36%–45%); sedation interruption at 81% (95% CI, 74%–85%); and subglottic suctioning at 88% (95% CI, 83%–92%). Interviews were analyzed first inductively according a grounded theory approach then deductively against the behavior change wheel (BCW) framework. Main behavioral facilitators belonged to the BCW component ‘reflective motivation’ (ie, perceived seriousness of VAP and self-efficacy to prevent VAP). The main barriers belonged to ‘physical capability’ (ie, lack of equipment and staffing and side-effects of prevention measures). Furthermore, 2 primarily technical approaches (ie, ‘restructuring environment’ and ‘enabling HCP’) emerged as means to overcome these barriers.

Conclusions

Our findings suggest that technical, rather than education-based, solutions should be promoted to improve VAP prevention. This theory-informed mixed-method approach is an effective means of guiding infection prevention efforts.

Type
Original Article
Information
Infection Control & Hospital Epidemiology , Volume 39 , Issue 10 , October 2018 , pp. 1222 - 1229
Copyright
© 2018 by The Society for Healthcare Epidemiology of America. All rights reserved 

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