Our study describes the knowledge, adherence and practices of nurses and ICPs regarding the VAP bundle. We highlight several key findings: first, the existence of a knowledge gap among both nurses and ICP regarding VAP prevention strategies; second, poor adherence to specific components of the VAP bundle, and third, lack of education and formal training were identified as the main barriers to VAP bundle adherence.
In general, all participants had difficulty answering the knowledge questionnaire, with a mean of 5.25 (range 3–8) points. Most correct responses were on questions directly related to nursing care (e.g., bed positioning, suctioning of secretions, and oral antisepsis). Questions regarding the use of airway humidifiers and frequency of ventilator circuit changes were incorrectly answered most of the time. One possible explanation for this, also observed in a prior study [8], is that other healthcare personnel such as respiratory therapists are assigned to maintain, assess, and care for humidifiers and ventilator tubings. As a result, the ICU nurses are less familiar with their maintenance. This suggests that components of the VAP bundle related to airway and ventilation should be frequently taught to nursing staff in the ICU to address this specific knowledge gap.
Our nurses with longer experience in the ICU (i.e. > 4 years) were more likely to have undergone VAP bundle training. However, their knowledge (score of 6 points) appeared similar to less experienced nurses (data not shown), which differs from published data [6]. In one study [8] for example, the average knowledge level was higher among more experienced ICU nurses (> 1 year experience) and those holding a special degree in emergency and intensive care. Retention of ICU nurses so they gain experience is particularly problematic in private hospitals in the Philippines where turnover is high because of lower wages, fewer opportunities for career development, better financial incentives abroad, and the prospect of migration [9]. Consequently, providing incentives for both recruitment and long-term retention of these nurses have to be addressed, so that knowledge of hospital specific initiatives such as the VAP bundles of care is cultivated over time.
Majority of respondents reported high rates of self-adherence with the VAP bundle—head of bed elevation was easiest to comply with, while spontaneous breathing trials and DVT prophylaxis were the most difficult. The reluctance to perform breathing trials was related to fear of potential adverse events such as precipitating patient discomfort or shortness of breath [10], as well as lack of training and specific guidelines. Similarly, compliance with DVT prophylaxis was not uniformly followed. We speculate that this modest compliance with the bundle components is rooted in lack of formal training, and absence of specific guidance regarding implementation, as the SGD highlighted the same issues—informal handover of knowledge, and irregular or inconsistent training.
The lack of education and training were consistently identified as the principal reasons precluding proper implementation of the VAP bundle. Several studies have shown the impact of educational interventions. In a 2-year study among healthcare workers in a 20 bed medical intensive care unit (MICU) [11], for example, educational programs and reminders were implemented to increase compliance to VAP prevention strategies. A 3-h mandatory slide presentation on the epidemiology and pathophysiology of VAP and preventive measures was given to the MICU healthcare workers, followed by an interactive discussion. This presentation was repeated for new employees. Reminders were also displayed on the MICU computer screensavers. The median composite score throughout the study (baseline, 1 month, 6 months, 12 months and 24 months) significantly increased after continuous implementation of the program for all healthcare workers in the ICU (p < 0.0001) from a baseline of 2, to as high as 5 points, over time. The rate of VAP decreased by 51%, after the intervention (p < 0.0001) [11]. The success of this intervention highlights the importance of regular and consistent education and feedback, which is currently lacking in our institution.
Our study has several limitations. Our sample size was small and not all ICU nurses participated in the study. Our assessment of knowledge was based solely on one validated questionnaire, and our period of direct observation was limited. We also did not directly co-relate VAP bundle adherence with VAP rates. Nevertheless, this is the first study to determine baseline knowledge, adherence, and implementation practices of key personnel directly involved with implementation of the VAP bundle.