ARTICLE IN PRESS

American Journal of Infection Control ■■ (2017) ■■-■■

Contents lists available at ScienceDirect

American Journal of Infection Control American Journal of

Infection Control

journal homepage: www.ajicjournal.org

Brief Report

Evidence-based guidelines for prevention of ventilator-associated pneumonia:Evaluationof

intensive careunitnurses’ adherence
Muhammad W. Darawad PhD, RN *, Mohammad Abu Sa’aleek MSN, RN, Taghreed Shawashi MSN,
RN
School of Nursing, The University of Jordan, Amman, Jordan

Key Words: Using self-reported questionnaires, this descriptive study assessed nurses’ adherence to ventilator- associated pneumonia (VAP)
Jordan VAP guidelines, which was found to be 81.3%. Although items concerning infection control achieved the highest scores, items concerning the
ICU nurses’ adherence suctioning process achieved the lowest scores. Participants’ score of VAP care knowledge had a significant positive correlation with
their score of VAP guidelines adherence. Addressing the strength and weakness domains that affect nurses’ adherence is crucial for
health care administrators at different managerial levels, which may help in executing differ- ent strategies to improve nurses’
adherence to VAP strategies.
© 2017 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier
Inc. All rights reserved.

Ventilator-associated pneumonia (VAP) is among the most wide- spread health
care-associated infections in intensive care units (ICUs) and accounted for 50% of all
health care-associated infections.1 Further, VAP has been connected to longer length
of stay and higher mortality and morbidity rates.2 Indeed, nurses and health care pro-
viders (HCPs) play a crucial role in infection control in ICUs. However, not all HCPs are
compliant with the recommended handwashing guidelines.3 The Society for
Healthcare Epidemiology of America4 and the Institute for Healthcare Improvement5
have published guide- lines for VAP prevention that are termed the VAP
bundle. Nevertheless, lack of knowledge may be considered a barrier to
implementing and adhering to such guidelines.6 Despite the use of VAP bundles in
clinical practice, nonadherence behavior still exists.7 Adherence to evidence-based
guidelines for preventing VAP has not been previously studied within the Jordanian
context. Therefore, this study aimed to assess Jordanian nurses’ level of adherence to
VAP guidelines.
METHODS
To answer research questions, this study adopted a descriptive cross-sectional
design using self-reported questionnaires. The study
was conducted in 3 medium- and large-sized hospitals that were randomly selected
from hospitals representing different health care sectors in the middle region of
Jordan. A stratified random sam- pling was used to select registered nurses to
participate in this study. Participants had to be registered nurses with a bachelor’s
degree, provide direct nursing care, and work in an ICU for at least 3 months. Besides
collecting demographic data, this study assessed nurses’ general knowledge of
evidence-based VAP guidelines using 10 multiple-choice questions8,9 and
nurses’ adherence to evidence- based guidelines for VAP prevention using 15 yes-
or-no items.7,9
This study was conducted considering all ethical implications, starting with
obtaining ethical approval from the Scientific Re- search Committee at the
School of Nursing of The University of Jordan and the institutional review boards
at the targeted hospi- tals. During frequent visits to the targeted hospitals, data
collectors interviewed potential participants and invited them for voluntary
participation. Those who accepted participation were given the study package in a closed
envelope that contained a cover letter and the self-administered questionnaires. Data
collection took place over 3 months during March-May 2017. Finally, using the
Statistical Package for Social Sciences version 21 (IBM-SPSS Inc, Armonk, NY), data
analysis was conducted applying descriptive statistics, a series of independent sample
t tests, 1-way analysis of variance, and Pearson correlation coefficient test.

RESULTS
* Address correspondence to Muhammad W. Darawad, PhD, RN, School of Nursing, The University of
Jordan, Amman, 11942 Jordan.
A total of 260 questionnaires were distributed, out of which 224 were returned
E-mail address: m.darawad@ju.edu.jo (M.W. Darawad). Conflicts (response rate, 86%). However, 16 were incomplete,
of interest: None to report.

0196-6553/© 2017 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.ajic.2017.11.020
 ARTICLE IN PRESS
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Table 1
Participants’ responses regarding adherence to ventilator-associated pneumonia guide- lines (N = 208)
Item
Adequate hand hygiene between patients
Semirecumbent positioning of the patient (30°-45°)
Used catheter and gloves are disposed of in a manner that
prevents contamination from secretions
Sterility of suction catheter maintained until inserted into airway 189 (90.9)
Sedation protocol (sedation vacation and assess readiness to extubate)
Maintenance of adequate pressure in the endotracheal-tube cuff
Presuctioning hyperoxygenation
Enteral feeding protocol/avoidance of gastric over distension
Protection ofduring
secretions patient’s eyes and central venous catheter from
suctioning
Face mask wearing during suctioning
Removal of nasogastric tube as soon as clinically feasible
Use of protective gowns during suctioning
Sodium chloride instillation
Continuous subglottic suctioning
Two nurses perform suctioning
leaving a total of 208 complete questionnaires. Participants were mainly women
(58.2%; n = 121), had a bachelor’s degree (92.8%; n = 193), were from educational
hospitals (44.2%; n = 92), and worked in a mixed ICU (59.1%; n = 123). Their mean age
was 27.7 ± 4.5 years, and years of experience was 4.8 ± 3.8 years in nursing and 3.3 ±
3.4 years in ICUs. Most of them reported working with either 2 (41.8%; n = 87) or
more (41.4%; n = 86) patients per shift. Also, most of them reported having a suction
policy (83.7%; n = 174) and only 114 (54.8%) reported having previous VAP
training. Finally, partici- pants’ score of VAP care knowledge was 43% (4.3 ± 1.7
out of 10) and their score of VAP guidelines adherence was 81.3% (12.2 ± 2.4 out of
15).
Investigating the individual items of VAP guidelines adherence (Table 1)
revealed that most items (12 out of 15) were above 70%, with none below 50%.
Comparing between items revealed that infection control measures achieved
higher scores, with the item that had the highest adherence rate being “Adequate hand
hygiene between patients” (94.2%; n = 196) followed by “Semirecumbent
positioning of the patient (30-45 degrees)” (92.3%; n = 192) and “Used catheter
and gloves are disposed of in a manner that prevents contamination from
secretions” (91.8%; n = 191). Con- versely, the items concerning the suctioning
process achieved the lowest scores. The item with the lowest adherence rate was
“Two nurses perform suctioning” (57.7%; n = 120) preceded by “Contin- uous
subglottic suctioning” (61.5%; n = 128) and “Sodium chloride instillation” (63%; n
= 131).
None of the categorical demographic variables had a signifi- cant difference in
participants’ VAP guidelines adherence. Similarly, none of the continuous
demographic variables had significant cor- relation with participants’ VAP
guidelines adherence (Table 2). However, participants’ score of VAP care knowledge
had a significant positive correlation (r = .175; P = .012) with their score of VAP guide-
lines adherence.
Table 2
Pearson correlation between adherence to ventilator-associated pneumonia (VAP) guidelines and demographic variables
Years of experience in
Variable Age
Adherence to VAP Guidelines 0.037
*Correlation significant at the .05 level (2-tailed).
DISCUSSION
n (%) This study assessed Jordanian nurses’ level of adherence to VAP guidelines, an
196 (94.2) issue that has not been previously addressed within the Jordanian context. It is
192 (92.3) noteworthy that Jordanian nurses had a relatively high level of adherence to VAP
guidelines (81.3%), which
191 (91.8)
is close to the rate of 84% among nurses in other countries.9-11So, Jordanian critical
care nurses are in line with the international lit-
188 (90.4) erature as far as having an acceptable VAP adherence rate, which is a positive sign
that is hopefully reflected in patient outcomes because adherence to a VAP
187 (89.9) bundle is an effective way to reduce VAP rates.11 One major limitation is that there
178 (85.6)
177 (85.1)
is little evidence of a link between self-report and actual practice.
172 (82.7) Examiningthe individualVAP strategiesreveled thatnurseswere
171 (82.2) mostly adherent to hand hygiene (94.2%), semirecumbent position- ing of patients
158 (76)
(92.3%), and disposal of used suction catheters and gloves (91.8%). Lower rates of
147 (70.7)
131 (63)
those items were reported in other studies where hand hygiene had a rate of only
128 (61.5) 32.8%,12 and patient positioning had a rate of 76.4%.7 Therefore, it seems that
120 (57.7) Jordani- an nurses had better adherence to infection control standards
compared with the literature.13,14
Conversely, the VAP strategies that had the lowest nurses’ adherence were
related to how nurses perform suctioning (57.7%), continuous subglottic suctioning
(61.5%), and sodium chloride installation (63%), which were all related to the
suction process and were similar to the literature, where Jansson et al9 reported
even lower rates for those strategies (46.5%, 27.7%, and 68.3%, respectively).
Of concern is that total VAP care knowledge was correlated with VAP
guidelines adherence, which indicates that nurses with better knowledge of VAP
care bundles tend to be more adherent to VAP guidelines. This confirms a
previous conclusion by Sedwick et al2 who stated that nurses can significantly
improve patients’ outcomes by the use of VAP evidence-based practice, which
is recommended to be conducted during the execution of clinical practice
guidelines with continuous education after implementation.
CONCLUSIONS
Addressing the strength and weakness domains that affect nurses’ adherence is crucial
for health care administrators at different man- agerial levels, which may help in
planning, developing, and executing different strategies to improve nurses’
adherence to VAP strate- gies. Furthermore, the results of this study highlight the
importance of continuing education about VAP prevention strategies, which would
promote positive patient outcomes. The present study opens the door for future
research using more rigorous research methods such as mixed methodology.
Acknowledgments
The authors wish to thank all nurses who participated in this study. Also the
authors aregratefulfor theuniversityof Jordan for the funding of this study.
Years of experience in Years of experience in Total VAP care
nursing current hospital intensive care unit knowledge
0.073 0.067 0.091 0.175*
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