Theme Issue Editorial
Ventilator-associated pneumonia: Improving outcomes through guideline implementation

https://doi.org/10.1016/j.jcrc.2007.11.013Get rights and content

Abstract

Ventilator-associated pneumonia (VAP) is associated with increased duration of mechanical ventilation and increased risk of death for critically ill patients. Although scientific advances have the potential to improve the outcomes of critically ill patients who are at risk of or who have VAP, the translation of research knowledge on effective strategies to prevent, diagnose, and treat VAP is not uniformly applied in practice in the intensive care unit. Knowledge about VAP may be used more effectively at the bedside by a systematic process of knowledge translation through implementation of clinical practice guidelines. Unfortunately, there remain large gaps in our understanding of guideline implementation in the intensive care unit, specifically as it applies to guidelines for the prevention, diagnosis, and treatment of VAP.

Introduction

Ventilator-associated pneumonia (VAP) continues to be a common cause of morbidity and mortality in the critically ill patient despite extensive research evidence on how to prevent, diagnose, and treat it [1], [2]. Furthermore, research knowledge on effective strategies to prevent, diagnose, and treat VAP is not uniformly applied to practice in the intensive care unit (ICU) [3]. This is supported by a recent Canada-wide survey that revealed that practices proven to prevent VAP are used inconsistently [4]. The reasons for this discrepancy are unclear, and important opportunities for improvement remain.

Currently, there are large gaps in our understanding of knowledge translation (KT) in the ICU, specifically as it applies to the prevention, diagnosis, and treatment of VAP. We postulate that VAP knowledge may be used more effectively at the bedside through a systematic process of KT that incorporates knowledge about clinician preferences and behavior change theory. We define a systematic process of KT as the one that uses evidence-based clinical practice guidelines (CPGs) (henceforth referred to as guidelines) and includes a guideline implementation strategy that addresses understood barriers to clinicians' adherence to guidelines, and capitalizes on the facilitators.

In an effort to bridge the gap between development and implementation of guidelines for the prevention, diagnosis, and treatment of VAP, we will discuss (1) an overview of guidelines, guideline implementation strategies, and their effectiveness outside the ICU; (2) an overview of guideline implementation in the ICU; (3) an overview of our understanding of behavior change and clinician adherence to guidelines in the ICU; (4) current knowledge about VAP guideline implementation in the ICU; and (5) a framework for implementation of a VAP guideline in the ICU. Because the data on the effect of different KT interventions are sparse, we will focus primarily on clinician behavior change and processes of care.

Section snippets

Guidelines and guideline implementation strategies outside the ICU

Significant gaps remain in the transfer of research evidence into clinical practice [5]. As many as 50% of patients do not receive care according to best evidence, and up to 25% of care is either not necessary or harmful [6]. This has resulted in inappropriate use of drugs and technology in health care [7].

Outside the ICU, guideline implementation can improve processes of care but variably impact outcomes of care. The degree of improvement depends on the setting, target clinician and patient

Guideline implementation in the ICU: the ICU organization and culture

Optimal strategies to implement and facilitate clinician adherence to guidelines in the ICU remain unknown. The evidence that guidelines improve care in the critically ill is limited to well-defined clinical situations, and in these, guidelines variably improve the processes [18], [19], [20], [21], [22], outcomes [23], [24], and costs [19], [24] of critical care. Studies that evaluated the implementation of guidelines in the ICU used different study designs, with modest and inconsistent effects

Behavior change and clinician adherence to guidelines in the ICU

There are many influences on clinical decision making, including patient and clinician factors, research evidence, and health care organization [36]. Cognitive, behavioral, and administrative factors have also been shown to influence research uptake in the ICU [37]. Individual cognitive influences comprise knowledge, attitudes, and heuristics. Behavioral and administrative influences consist of current practice patterns, organizational culture, and incentives or disincentives. Similar factors

Current state of knowledge of implementation of VAP guidelines in the ICU

Without effective methods to implement guidelines at the local level, clinical practice will not change [47]. Single-center observational studies in university-affiliated ICUs [48], [49], [50] and one observational multicenter study including community ICUs [51] suggest that use of educational programs alone to implement guidelines for the prevention of VAP may be useful to reduce the incidence of VAP. There was both lack of uniformity in the way the educational strategies were implemented

Framework for implementation of VAP guidelines in the ICU

Behavior change theory can provide a framework within which we can integrate potentially effective guideline implementation strategies to help optimize implementation and clinician adherence to VAP guidelines in the ICU. Psychologic theories apply to interventions directed at individuals and teams and are categorized as motivational, action, and stages of change [52]. Advantages of the stages of change model are that they differentiate motivation and action steps and can be applied to medical

Summary

Health care professionals and decision makers have not marshaled a system-wide approach or system-wide resources to reduce the burden of VAP. Most initiatives use only a few of the interventions, and none have been rigorously tested [58], [59]. An important barrier to the implementation of VAP knowledge is the lack of information on optimal strategies to transfer knowledge in the ICU. One approach to VAP guideline implementation is an active educational strategy combined with a reminder and

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    Dr Sinuff is supported by a Canadian Institutes for Health Research Clinician Scientist Award. Dr Cook holds a Research Chair of the Canadian Institutes for Health Research.

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