Nurses implementation of guidelines for ventilator-associated pneumonia from the centers for disease control and prevention.

* BACKGROUND Ventilator-associated pneumonia accounts for 47% of infections in patients in intensive care units. Adherence to the best nursing practices recommended in the 2003 guidelines for the prevention of ventilator-associated pneumonia from the Centers for Disease Control and Prevention should reduce the risk of ventilator-associated pneumonia.

* OBJECTIVE To evaluate the extent to which nurses working in intensive care units implement best practices when managing adult patients receiving mechanical ventilation.

* METHODS Nurses attending education seminars in the United States completed a 29-item questionnaire about the type and frequency of care provided.

* RESULTS Twelve hundred nurses completed the questionnaire. Most (82%) reported compliance with hand-washing guidelines, 75% reported wearing gloves, half reported elevating the head of the bed, a third reported performing subglottic suctioning, and half reported having an oral care protocol in their hospital. Nurses in hospitals with an oral care protocol reported better compliance with hand washing and maintaining head-of-bed elevation, were more likely to regularly provide oral care, and were more familiar with rates of ventilator-associated pneumonia and the organisms involved than were nurses working in hospitals without such protocols.

* CONCLUSIONS The guidelines for the prevention of ventilator-associated pneumonia from the Centers for Disease Control and Prevention are not consistently or uniformly implemented. Practices of nurses employed in hospitals with oral care protocols are more often congruent with the guidelines than are practices of nurses employed in hospitals without such protocols. Significant reductions in rates of ventilator-associated pneumonia may be achieved by broader implementation of oral care protocols.

**********

Ventilator-associated pneumonia (VAP) is the most common infectious complication among patients admitted to intensive care units (ICUs) and accounts for up to 47% of all infections among ICU patients. (1) When it occurs, VAP prolongs ICU length of stay and increases the risk of death in critically ill patients. (1) The data summary for 1992 to 2004 from the National Nosocomial Infections Surveillance System Report reveals a median VAP rate of 2.2 to 14.7 cases per 1000 patient days of mechanical ventilation in adult ICUs. (2) VAP continues to complicate the course of 8% to 28% of patients receiving mechanical ventilation. (3) For patients receiving mechanical ventilation in whom VAP develops, the estimated mortality rate is between 20% and 70%. (4-6)

An important precursor for the development of VAP is colonization of the oral cavity. The 2003 guidelines (7) from the Centers for Disease Control and Prevention (CDC) reported that 63% of patients admitted to an ICU have oral colonization with a pathogen associated with VAP. (7) Once in the ICU, 63% of patients admitted with an oral pathogen associated with VAP acquire an additional, second bacterial pathogen in the oral cavity. In 76% of VAP cases, the bacteria colonizing the mouth and lung are the same. (7) The most prevalent bacteria are gram-negative Pseudomonas aeruginosa and enterobacteria and gram-positive Staphylococcus aureus. (7)

The 2003 CDC guidelines for the prevention of VAP include recommendations for nursing care. These recommendations, summarized in Table 1, provide the best current directives for practice. The research evidence for the first 5 recommendations is strong and justifies broad-based implementation of the recommendations in healthcare. Recommendations 6 and 7 are based on strong theoretical rationale and clinical or epidemiological studies that provide supporting evidence.

To evaluate the extent to which ICU nurses implement these recommendations, we queried critical care nurses about the practices they use when caring for adult patients receiving mechanical ventilation. A national survey has not been completed since the CDC changed its guidelines in 2003.

Background

For each recommendation presented in Table 1, a brief summary of the evidence is provided. More recently published evidence also is included because it augments and expands the foundation for the CDC guidelines and highlights areas in which evidence continues to be gathered.

CDC Guidelines

Decontamination of hands before and after contact with a patient, along with wearing gloves, is an important action in the prevention of VAP. (7) The CDC guidelines recommend using either antimicrobial soap or nonantimicrobial soap and water if hands are visibly soiled with body fluids. Alcohol-based waterless antiseptic agents, such as hand rubs, are also good alternatives for soaps. Hand rubs can and should be used before and after contact with a patient if hands are not visibly soiled. Gloves should be changed and hands washed between contacts with different patients.

The 2003 CDC guidelines recommend staff education about epidemiology and infection control practices related to the prevention of VAP. One recommended strategy is for staff to participate in interventions to prevent VAP. Knowing the VAP organisms prevalent in the unit is one component of the recommended staff education.

Critically ill patients often have a depressed level of consciousness and an impaired gag reflex, leading to pooling of contaminated secretions in the posterior part of the oropharynx. Between 100 and 150 mL of secretions can accumulate within a 24-hour period. Microaspiration of these oropharyngeal secretions is a major risk factor for nosocomial pneumonia. (7) Placement of an endotracheal tube provides a direct pathway for these organisms to enter the lungs. In 85% of cases, the microorganism that causes the nosocomial pneumonia previously has been detected in cultures of microorganisms from subglottic secretions. (7) For these reasons, the CDC recommends that before an endotracheal tube cuff is deflated or an endotracheal tube is repositioned, the area above the cuff should be suctioned.

To reduce the risk of aspiration, the CDC recommends that patients receiving mechanical ventilation have the head of the bed elevated at an angle of 30[degrees] to 45[degrees] from horizontal unless contraindicated. Elevation of the head of the bed decreases the volume of gastric secretions, a change that reduces the risk for aspiration and VAP. (8)

The 2003 CDC guidelines changed the 1997 CDC guidelines (9) by recommending implementation of a comprehensive oral hygiene program to prevent oropharyngeal colonization. Pathogens responsible for VAP in orally intubated patients are colonized in dental plaque and oral mucosa. The guidelines specify that an antiseptic agent be used as part of the oral hygiene program, but a specific agent, oral chlorhexidine gluconate rinse, is recommended solely for adults undergoing cardiac surgery. The guidelines do not specify the components of a comprehensive oral hygiene program, the optimal frequency of oral care, or the best way to remove dental plaque.

Recent Studies

Healthcare workers rarely exceed a 50% compliance rate with hand-washing guidelines. (10) As workload and necessity for hand washing increases, compliance decreases. (11) Educational hand-washing programs have boosted hand-washing compliance from 56% to 89%, (10) but the lasting effects of such programs are unknown. Using alcohol-based hand rubs also improves hand hygiene practices among healthcare workers, but compliance rates continue to be low at about 67%. (12)

Educational interventions also can reduce VAP rates. Babcock et al (13) and Cutler and Davis (14) have shown that educational intervention on epidemiology and infection control reduces VAP rates.

The 2003 CDC guidelines on elevation of the head of the bed do not appear to be routinely implemented among intubated patients. Grap et al, (15) for example, took 506 measurements in 170 randomly chosen ICU patients and found a mean backrest elevation of 19[degrees]. About 70% of the subjects were supine, and intubated patients had lower back-rest elevations than did nonintubated patients.

Munro and Grap (16(p27)) provide the logic for comprehensive oral hygiene programs: "Reducing the number of microorganisms in the mouth reduces the pool of organisms available for translocation to and colonization of the lung. Therefore, removal of organisms from the oral cavity by oral care interventions is a theoretically attractive method to reduce the risk for VAP." Oral care interventions that may play a role in the prevention of VAP include frequency of oral suctioning and decontamination and storage of the Yankauer suction device after use. Sole et al (7) found that most suctioning equipment, including Yankauer suction devices and suction tubing, is colonized with a potential VAP pathogen within 24 hours of use. Although the primary origin of Pseudomonas in VAP appears to be endogenous, some cases of VAP have been linked to contaminated devices or environments such as sinks, faucets, and tap water. (7) Currently, no standard exists for storing Yankauer suction devices after use or for which rinse solution to use for decontamination and cleansing of Yankauer devices.

The multisite study reported by Sole et al (18) in 2003 is the most recent report of nurses' oral care practices. They reported the following:

* More than half of hospitals do not have specific policies for oral care of intubated patients, in the hospitals without an oral care protocol, not 1 patient out of 139 had his or her oral cavity assessed or his or her teeth brushed, and less than 50% of the patients had their teeth and mouth swabbed. (14)

* A total of 75% of ICU nurses provide oral suctioning every 4 hours, 7% provide it every 8 to 12 hours, and 18% remove patients' oral secretions by suctioning only as needed. Cutler and Davis (14) found that 45% of 139 patients had their mouths suctioned, but no patients received oropharyngeal suctioning.

* A total of 71% of nurses store the suctioning device in its original or protective packaging; 19% leave the device uncovered.

* A total of 33% of nurses use sterile isotonic sodium chloride solution to rinse the Yankauer device after use and 36% use tap water. Rinsing only if visible mucus is present was reported by 14% of nurses, and 7% did not rinse the device at all. With new technology, single-use disposable suction devices are becoming more popular; 11% of nurses use such disposable devices as part of their oral suctioning practice.

* A total of 45% of nurses replace the Yankauer device every 24 hours; 40% replace the device only as needed.

Most nurses (91%-96%) report using an antiseptic solution as part of oral care. (19,20) In the United States, 20% of nurses report using oral chlorhexidine gluconate rinse for oral care. (19) In the United Kingdom, 50% report doing so. (20) Recent surveys (21,22) reveal that oral care tends to be provided between 4 and 5 times daily.

Purpose

The primary purpose of this study was to identify the gap between what is known and what nurses report as their care practices. Knowing the differences between recommended and reported practices permits development, implementation, and evaluation of strategies that have the potential to improve care and care outcomes. The study had 3 objectives:

1. to describe the extent to which nurses' report care practices that match the CDC guidelines for the prevention of VAP;

2. in those areas in which the evidence is not sufficiently strong to support recommendations, to describe nurses' prevailing care practices; and

3. to explore the relationships between care practices and the demographic characteristics of the nurse respondents.

Methods

Design

This study was a cross-sectional survey of nurses who attended either the 2005 American Association of Critical-Care Nurses National Teaching Institute (NTI) or selected training programs offered by Barbara Clark Mims Associates (BCMA). A university-based institutional review board approved the study. The Critical Care Expo Educational Committee granted permission to conduct the study at the 2005 NTI, and the owner of BCMA granted permission to collect data from attendees at seminars conducted across the United States between April 18 and May 12, 2005. The population of interest was critical care nurses who provide care for adult patients receiving mechanical ventilation and who work in the United States in an acute care setting.

Instrument

The Oral Care of Ventilated Patients Questionnaire is an investigator-designed instrument to gather information from critical care nurses on current care practices for adult patients receiving mechanical ventilation. It was adapted, with permission, from the Suctioning Techniques and Airway Management Practices instrument created by Sole et al. (23) The survey includes questions about the CDC guidelines (frequency of hand washing, knowledge of VAP rates and organisms, wearing gloves, subglottic suctioning, elevation of the head of the bed, presence of oral care protocols, and use of oral chlorhexidine gluconate rinse), questions to provide information about current oral care practices, and demographic questions. Questions about current oral care practices were based on the research literature and addressed use and frequency of tooth brushing; use and frequency of swabbing; frequency of oral care and oral suctioning; storage, rinsing, and replacement of suction devices; and use of antiseptic oral rinse agents.

Content validation of the adapted survey was obtained by using a panel of 3 persons: an infection control nurse, an infection control physician, and a nationally recognized nurse with expertise in pulmonary and ventilator topics. Each person was familiar with the CDC guidelines, and each received a copy of Table 1 and a summary of the research published since the release of the CDC guidelines. Each commented on the adequacy of the match between the guidelines and the questions on the survey. No additional items were suggested, and no items were suggested for deletion or revision.

The survey was then distributed to 9 nurses (3 from each of 3 hospitals) employed in a variety of ICU settings to evaluate readability and time to complete. None of these 9 nurses had questions or concerns about the questions, and they were able to complete the survey within 5 minutes. Three of these nurses completed the survey again 1 week later, and their responses were highly similar to those from the first time they completed the survey.

Procedure

At NTI, data were collected in 2 ways: during a morning lecture sponsored by a vendor and at the vendor's exhibit. One of us distributed and collected surveys from nurses visiting the exhibit. At BCMA Critical Care Educational Seminars, each of 4 speakers distributed surveys.

Each speaker received instructions for distribution and collection of the surveys. To reduce bias related to new knowledge of VAP acquired during the lecture or seminar, speakers distributed and collected all surveys before discussion of VAP-related topics. Each speaker placed the completed surveys into envelopes and returned these sealed envelopes to us.

A cover sheet on each survey instructed respondents to protect anonymity by placing no identifying information on the survey. Respondents also were informed that completion and return of the surveys implied their consent to participate. As a recruitment incentive to participate in the study, each cover sheet contained a name and address form. Respondents who completed and returned the form automatically became eligible to win a stethoscope. The name and address forms were collected and stored separately from the completed surveys.

Completed surveys were scanned into an electronic data file. We used SPSS for Windows, Version 12.0 (SPSS Inc, Chicago, Ill) to describe the characteristics of the respondents and their responses (counts, frequencies, and percentages for nominal data and measures of central tendency and dispersion for better than nominal data). To explore differences in care practices associated with demographic data, we used [chi square] and multinomial regression analyses. (24) For the multinominal regression analyses, we used as predictor variables the presence or absence of a hospital protocol, participation in quality improvement projects related to infection control, sex, age, years of critical care experience, certification in critical care, highest educational degree, type of employing unit, size of hospital, and teaching or nonteaching hospital. Outcome (or dependent) variables were frequency of hand washing, wearing gloves, and subglottic suctioning and degree of elevation of the head of the bed.

Results

Description of the Sample

A total of 1596 surveys were distributed (750 at NTI and 846 at BCMA seminars); 1285 were returned (607 from NTI and 678 from BCMA seminars) for an 81% return rate. Eighty-five surveys were discarded because they were less then 30% completed, completed by nonnurses, or completed by nurses working outside the United States, working in a long-term care facility with ventilator-dependent patients, or working in an area other than an adult acute care ICU (eg, pediatric ICU, postanesthesia care unit, emergency room, medical/surgical unit). Thus, the study included responses from 1200 critical care nurses for a final response rate of 75%.

Nurses completing the survey reflected the national trends regarding nurses' ages and years of experience. The mean age of respondents was 43 (SD 9, range 21-68) years. As shown in Table 2, the mean years of experience was 14 (SD 9, range 1-45). The majority of respondents (52%) held baccalaureate degrees in nursing. About a third (37%) held CCRN certification. Although respondents worked in various specialty units, the largest percentage (42%) worked in general medical/surgical ICUs. About half (54%) worked at teaching hospitals. With the exception of Wyoming and Rhode Island, respondents resided in all states within the United States. Although more respondents resided in the Western region, respondents did not differ in terms of age or years of experience across all regions.

Practice of CDC Guidelines

Table 3 presents the percentage of critical care nurses who reported practice as recommended by the CDC guidelines. Most (82%) reported washing their hands between patients, and most (77%) reported always wearing gloves to provide oral care. About a third (36%) reported always suctioning secretions from under a patient's tongue before deflating the cuff of an endotracheal tube. Another third (32%) reported this practice as a respiratory therapy intervention. As for elevation of the head of the bed to 30[degrees] to 45[degrees] from horizontal, 34% of nurses reported maintaining that elevation for 75% of the day, and 52% reported maintaining that elevation for 100% of the day.

Knowledge of the VAP rates and causative organisms in their units was taken as a reflection of nurses' knowledge of the epidemiology of VAP and infection control practices. Only 32% knew the VAP rate for their unit, and only 50% knew the primary causative VAP organism for their unit.

Only 56% of nurses responded that their hospital had a written oral care protocol. Respondents working in teaching hospitals were significantly more likely to have oral care protocols than were respondents working in nonteaching facilities ([chi square] = 15.7, df = 6, P = .02).

Of the 116 respondents who identified themselves as working in a cardiovascular ICU, 31% reported using chlorhexidine gluconate rinse for oral care. Across all types of ICUs, 26% of respondents reported using chlorhexidine gluconate.

Prevailing Oral Care Practices

Tables 4 and 5 summarize the prevailing self-reported practices regarding oral care and contrasts them with the practices reported by Sole et al (18) in their 2003 multisite study. Compared with the percentages reported by Sole et al, more nurses in this study reported brushing patients' teeth, and they reported doing so more frequently than reported by Sole and colleagues (Table 4). A larger percentage of respondents in this study than in the study by Sole and colleagues also reported swabbing the oral cavity of patients receiving mechanical ventilation. However, a larger percentage (27%) of respondents in this study reported suctioning only as needed, whereas only 18% of the respondents in the study by Sole and colleagues reported suctioning only as needed.

Table 5 suggests that (compared with the results reported by Sole et al) a larger percentage of nurses are cleansing the Yankauer suction device after each use, and a larger percentage of them use tap water when they rinse the device. The results on practices for storing suction devices also suggest that practices have improved since the 2003 study.

Association Between Care Practices and Demographic Characteristics of Respondents

The multinominal regression analyses yielded good fits (significance values close to 1.0) for frequency of hand washing ([chi square] = 354, df = 452, P = 1.0) and degree of elevation of the head of the bed ([chi square] = 498, df = 565, P = .98). The analysis of the use of gloves to give oral care ([chi square] = 325, df = 339, P = .70) and the analysis of use of subglottic suctioning ([chi square] = 372, df = 333, P = .06) yielded poor fits, suggesting no clear relationships between these 2 practices and respondents' demographic characteristics.

The analysis on hand washing yielded significant (P = .05) likelihood ratio tests for presence of a written oral care protocol, participation in improvement projects related to infection control, sex of respondent, and type of critical care unit. Respondents working in hospitals with an oral care protocol in place reported that they more often washed their hands (always and frequently) than did respondents who worked in hospitals without an oral care protocol. Respondents who had not recently participated in improvement projects related to infection control more often reported that they washed their hands (always and frequently) than did respondents who had participated in such improvement projects. Female respondents more often reported that they washed their hands (always and frequently) than did male respondents. Respondents who worked in surgical (trauma and neurology) units more often reported that they washed their hands (always and frequently) than did respondents working in medical units.

The analysis on degree of elevation of the head of the bed yielded significant (P = .05) likelihood ratio tests for presence of a written oral care protocol, age of respondent, number of years of critical care practice, and holding certification in critical care. Respondents working in hospitals with an oral care protocol in place reported that they kept the head of the bed elevated at 30[degrees] to 45[degrees] from horizontal 75% or more of the time, whereas respondents working in hospitals without an oral care protocol did not. Older respondents and those with more years of critical care experience reported that they kept the head of the bed elevated at 30[degrees] to 45[degrees] from horizontal 75% or more of the time, whereas younger respondents and those with fewer years of critical care experience did not do so. Respondents without certification reported that they kept the head of the bed elevated at 30[degrees] to 45[degrees] from horizontal 75% or more of the time, whereas respondents with certification did not do so.

Conclusions, Discussion, and Recommendations

According to these nurses' self-reports, evidence-based and best practices as recommended in the CDC guidelines for the prevention of VAP are not consistently and uniformly implemented. Of concern, 18% of nurses reported not always washing their hands between patients, and 23% reported not using gloves when providing oral care. A self-reported hand-washing rate of 82% may be an overestimate of actual compliance; in the study by Grap and Munro (25) in 1997, 90% of nurses surveyed reported compliance with hand washing, but when the nurses were observed, only 22% were actually compliant. The seemingly counterintuitive finding regarding the relationship between hand-washing responses and participation in infection control projects may stem from heightened awareness to increase hand-washing frequency among those participating in such projects.

The gap between what we know and the way we practice continues to be larger than desired. Clearly, nurses' compliance with recommendations about hand washing and wearing gloves must be improved. Although subglottic suctioning is often an intervention used by both nurses and respiratory therapists, only 69% of nurses reported providing this intervention that reduces the risk of VAP. Even fewer nurses reported maintaining elevation of the head of the bed if not contraindicated.

Even though the CDC does not specify the components to be included in an oral hygiene program, the results of this study suggest that having a protocol in place improves care provided by nurses. Yet in this study only 56% of respondents reported working in hospitals that have oral care protocols.

Limitations

This descriptive study had at least 4 primary limitations. First, we did not complete a formal assessment of the reliability of the survey. Consequently, we have no way of knowing how much or in what direction responses would differ if respondents completed the survey a second time. Because most respondents were attending lectures or seminars related to VAP, most likely the results paint a more positive picture than what actually exists.

Second, our survey was distributed at educational seminars only, and this method of distribution may have introduced a selection bias. Because education appears to play a role in influencing clinical practice, we might assume that because our survey respondents were actively involved in educational advancement, they may be more knowledgeable about practice guidelines and thus more likely than others to adhere to the CDC VAP prevention guidelines. As a result, it is difficult to determine if our findings can be generalized to a larger population such as those nurses who do not attend educational seminars.

Third, we have only self-reported results. We attempted to minimize the potential for response bias by providing anonymity and instructing participants to record what they actually do in practice versus what is recommended, but, as mentioned, the results of this study most likely overestimate compliance with recommended practices. The finding that recent participation in improvement projects related to infection control was associated with lower self-reported compliance with hand washing may be attributable to heightened awareness due to participation in such projects.

Last, we did not institute a fail-safe method to prevent participants from completing the survey more than once. We operated under the assumption that because of personal time constraints, most participants would not submit another survey if they had previously completed one.

Recommendations

Whether nursing actions reduce VAP rates remains an empirical question that requires further research. However, the results of this study suggest that best practices for the prevention of VAP are not consistently or uniformly implemented. A gap persists between what we know and the ways in which we provide care. To address this gap, we offer the following recommendations.

Hospitals should implement protocols for preventing VAP that include each of the practices recommended by the CDC. Units implementing prevention protocols should evaluate the effects of nursing actions on VAP rates and disseminate the results.

We recommend that all hospitals institute educational training programs for their staff to heighten awareness of VAP prevention and to improve adherence to the evidence-based guidelines provided by the CDC. In addition, we recommend that hospitals encourage staff involvement in educational advancement and performance improvement projects. Because of the importance of hand washing in the prevention of VAP, we recommend consideration of such improvement projects as the following:

* placement and use of alternatives to antimicrobial soap as a means of improving hand-washing rates and evaluating the effects on VAP rates,

* unit-based studies that identify circumstances and situations in which hand-washing rates increase and decrease,

* observational studies of healthcare workers to determine actual practices in hand washing, and

* performance reviews that include information on rates of hand washing.

Similar projects could be undertaken for use of gloves while giving oral care, use of subglottic suctioning, and elevation of the head of the bed.

The CDC guidelines recommend development and implementation of a comprehensive oral hygiene program to provide oropharyngeal cleansing and decontamination with or without an antiseptic agent. The results of this and other studies suggest that having an oral care protocol improves the likelihood that oral care is provided. Accordingly, we recommend that all ICUs develop and implement an oral hygiene protocol based on the best available research evidence. We recommend that units conduct systematic evaluations of the benefits associated with use of the protocols and disseminate the findings.

ACKNOWLEDGMENTS

We appreciate the collaboration provided by the 2005 American Association of Critical-Care Nurses Critical Care Expo Educational Committee and our colleagues at Sage Products and Barbara Clark Mires Associates. We thank Dr Mary. Lou Sole and colleagues for sharing their Suctioning Techniques and Airway Management Practices survey instrument and the content experts who reviewed our adaptation: Barbara Clark Mims, Patti Grant, Dr David Allen, ICU staff nurses at Parkland Memorial Hospital, Baylor Hospital of Plano, and RHD Memorial Hospital. The staff of the Center for Nursing Research, School of Nursing, University of Texas at Arlington helped with data management and analyses. We send a special thank you to all the nurses who volunteered their time to complete our survey.

FINANCIAL DISCLOSURES

Financial support for our project included a generous Littman stethoscope donation from 3M (St Paul, Minn) and exhibit space from Sage Products (Cary, Ill) at the 2005 Critical Care Expo.

Notice to CE enrollees:

A closed-book, multiple-choice examination following this article tests your understanding of the following objectives:

1. Describe the role of the CDC guidelines in relation to decreasing ventilator-associated pneumonia rates.

2. Recognize the key factors for the diagnosis of ventilator-associated pneumonia.

3. Understand the role of the CDC guidelines and nursing implications in helping to prevent ventilator-associated pneumonia.

By Carolyn L. Cason, RN, PhD, Tracy Tyner, RN, MSN, CEN, CCRN, Sue Saunders, RN, MSN, CCRN, and Lisa Broome, RN, MSN. From the School of Nursing, University of Texas at Arlington (CLC), Parkland Memorial Hospital, Dallas, Tex (TT), RHD Memorial Hospital, Dallas, Tex (SS), and Baylor Regional Hospital, Plano, Tex (LB).

Corresponding author: Carolyn Cason, RN, PhD, University of Texas at Arlington, School of Nursing, 411 S Nedderman Dr, Pickard Hall, Arlington, TX 760190407 (e-mail: [e-mail]).

REFERENCES

(1.) Luna CM, Blanzaco D, Niederman MS, et al. Resolution of ventilator-associated pneumonia: prospective evaluation of the Clinical Pulmonary Infection Score as an early clinical predictor of outcome. Crit Care Med. 2003;31:676-682.

(2.) Centers for Disease Control and Prevention. CDC National Nosocomial Infections Surveillance (NNIS) System Report, data summary from January 1992 through June 2004, issued October 2004. Am J Inject Control. 2004;32:470-485.

(3.) Chastre J, Fagon JY. Ventilator-associated pneumonia. Am J Respir Crit Care Med. 2002;165:867-903.

(4.) Craven DE, Steger KA. Ventilator-associated bacterial pneumonias: challenges in diagnosis, treatment, and prevention. New Horiz. 1998;6(2 suppl):S30-S45.

(5.) Lode H, Raffenberg M, Erbes R, Geerdes-Fengea H, Mauch M. Nosocomial pneumonia: epidemiology, pathogenesis, diagnosis, treatment and preventions. Curr Opin Infect Dis. 2000;13:377-384.

(6.) Kollef MH. The prevention of ventilator-associated pneumonia. N Engl J Med. 1999;340:627-633.

(7.) Tablan OC, Anderson LJ, Besser R, et al. Guidelines for preventing health-care-associated pneumonia, 2003: recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee. MMWR Recomm Rep. March 26, 2004;53(RR-3):1-36.

(8.) Myrianthefs PM, Kalafati M, Samara I, Baltopoulos GJ. Nosocomial pneumonia. Crit Care Nurs Q. 2004;27:241-257.

(9.) Centers for Disease Control and Prevention Guidelines for prevention of nosocomial pneumonia. MMWR Recomm Rep. January 3, 1997;46(RR-1):1-79.

(10.) Creedon S. Healthcare workers hand decontamination practices: compliance with recommended guidelines. J Adv Nurs. 2005;51:208-216.

(11.) Galway R, Harrod ME, Crisp J, et al. Central venous access and handwashing: variability in policies and practices. Paediatr Nurs. 2003;15:14-18.

(12.) Picheansathian W. A systematic review on the effectiveness of alcohol-based solutions for hand hygiene. Int J Nurs Pract. 2004;10:3-9.

(13.) Babcock H, Zack J, Garrison T. et al. An educational intervention to reduce ventilator-associated pneumonia in an integrated health system: a comparison of effects. Chest. 2004; 125:2224-2231.

(14.) Cutler CJ, Davis N. improving oral care in patients receiving mechanical ventilation. Am J Crit Care. 2005;14:389-394.

(15.) Grap MJ, Munro CL, Bryant S, Ashtiani B. Predictors of backrest elevation in critical care. Intensive Crit Care Nurs. 2003;19:68-74.

(16.) Munro CL, Grap, MJ. Oral health and care in the intensive care unit: state of the science. Am J Crit Care. 2004;13:25-33.

(17.) Sole ML, Poalillo FE, Byers JF, Ludy JE. Bacterial growth in secretions and on suctioning equipment of orally intubated patients: a pilot study. Am J Crit Care. 2002;11:141-149.

(18.) Sole ML, Byers JF, Ludy JE, Zhang Y, Banta CM, Brummel K. A multisite survey of suctioning techniques and airway management practices. Am J Crit Care. 2003;12:220-230.

(19.) Binkley C, Furr LA, Carrico R, McCurren C. Survey of oral care practices in US intensive care units. Am J Infect Control. 2004;32:161-169.

(20.) Jones H, Newton JT, Bower EJ. A survey of the oral care practices of intensive care nurses. Intensive Crit Care Nurs. 2004;20:69-76.

(21.) Hanneman SK, Gusick GM. Frequency of oral care in positioning of patients in critical care: a replication study. Ant J Crit Care. 2005;14:378-386.

(22.) Grap MJ, Munro CL, Ashtiani B, Bryant S. Oral care interventions in critical care: frequency and documentation. Am J Crit Care. 2003;12:113-118.

(23.) Sole ML, Byers JF, Ludy JE. STAMP Survey: Suctioning Techniques and Airway Management Practices. Orlando, Fla: University of Central Florida, School of Nursing; 2001.

(24.) Stevens J. Applied Multivariate Statistics for the Social Sciences. 3rd ed. Mahwah, NJ: Lawrence Erlbaum Assoc; 1996.

(25.) Grap MJ, Munro CL. Ventilator-associated pneumonia: clinical significance and implications for nursing. Heart Lung. 1997;26:419-429.

Table 1 Guidelines for the prevention of ventilator-associated
pneumonia from the Centers for Disease Control and
Prevention: recommendations for nursing care (7)

1. Wash hands after contact with mucous membranes, respiratory
secretions, or objects contaminated with respiratory
secretions. Wash hands before and after contact with
patient.

2. Educate healthcare workers about nosocomial bacterial
pneumonias and infection control procedures used to prevent
these pneumonias.

3. Wear gloves for handling respiratory secretions or
objects contaminated with respiratory secretions.

4. Provide subglottic suctioning before deflating the cuff
of an endotracheal tube or before moving the tube.

5. Elevate the head of the bed to 30[degrees] to 45[degrees] if
not contraindicated.

6. Develop and implement a comprehensive oral hygiene
program to provide oropharyngeal cleaning and decontamination
with or without an antiseptic agent.

7. Use chlorhexidine gluconate antiseptic rinse during the
perioperative period in adult patients who undergo cardiac
surgery.

Table 2 Demographic characteristics of respondents
(n = 1200) *

Characteristic                    No.     %

Years of experience
  0-2                             144     12
  3-5                             173     14
  6-10                            204     17
  11-20                           381     32
  >20                             285     24

Level of nursing education
  Diploma                         114     10
  Associate degree                310     26
  Bachelor's degree               625     52
  Master's degree                 122     10
  Doctorate                         5     <1

Hold CCRN certification           446     37

Type of intensive care unit
  General                         498     42
  Coronary care                   153     13
  Surgery/trauma                  141     12
  Medical/pulmonary               119     10
  Cardiovascular surgery          116     10
  Other                            78      6
  Critical care educator           53      4
  Neurological/neurosurgical       33      3

Work in teaching hospital         653     54

Size of hospital, No. of beds
  <100                            208     17
  100-499                         675     56
  >500                            273     23

Region of the United States
  West                            364     30
  South                           247     21
  Mid-Atlantic                    231     19
  Midwest                         197     16
  Northeast                        42      4
  Southwest                        32      3

* Because of missing data and rounding, percentages
do not all total 100.

Table 3 Nurses' adherence to recommended guidelines
from the Centers for Disease Control and Prevention
(n = 1200) *

Nursing practice                                No.     %

Hand washing between patients
  Always                                        978     82
  Frequently                                    200     17
  Sometimes                                      16      1
  Rarely                                          2     <1

Use of gloves for oral care
  Always                                        921     77
  Frequently                                    233     19
  Sometimes                                      38      3
  Rarely                                          3     <1

Perform subglottic suctioning
  Respiratory therapy intervention              390     32
  Always                                        427     36
  Frequently                                    139     12
  Sometimes                                      96      8
  Rarely/not at all                             118     10

Maintains head of bed elevation at
30[degrees] to 45[degrees]
  0% of the day                                   3     <1
  25% of the day                                 45      4
  50% of the day                                112      9
  75% of the day                                410     34
  100% of the day                               622     52

Education
  Participation in infection control
  projects
    Last quarter                                189     16
    In the past year                            441     37
    Never                                       528     44
  Ventilator-associated pneumonia in
  their unit
    Does not know the infection rate            809     68
    Does not know the infecting organism        603     50

Employer has written oral hygiene
protocol
  Yes                                           669     56
  No                                            300     25
  Unsure                                        205     17

Uses chlorhexidine gluconate antiseptic         372     31
rinse in cardiovascular intensive care unit

* Because of missing data and rounding, percentages do not
all total 100.

Table 4 Prevailing self-reported oral care practices *

                                 No. (%) of      % reported
                                 respondents     by Sole et
Practice                         (n = 1200)       al (18)

Frequency of oral suctioning
  Every 2 hours                   594 (50)           NR
  Every 4 hours                   228 (19)           75
  Every 8-12 hours                 32 (3)             7
  Only as needed                  328 (27)           18
  Rarely or not at all              2 (<1)           NR

Frequency of tooth brushing
  Every 4 hours                   193 (16)            5
  Every 8-12 hours                593 (49)           34
  Rarely or not at all            274 (23)           20
  Only as needed                  126 (10)           41

Frequency of swabbing
  Every 2 hours                   558 (46)           NR
  Every 4 hours                   424 (35)           72
  Every 8-12 hours                115 (10)           24
  Only as needed                   78 (6)             3
  Rarely or not at all             19 (2)             1

Antiseptic rinse solution
  Chlorhexidine gluconate         309 (26)           20
  Mouthwash                       458 (38)           NR
  Hydrogen peroxide               324 (27)           NR
  Other                            20 (2)            NR
  None                             51 (4)            NR
  Don't know                       45 (4)            NR

* Because of missing data and rounding, percentages do
not all total 100.

Abbreviation: NR, not reported.

Table 5 Prevailing practices for suction devices *

                                    No. (%) of      % reported
                                    respondents     by Sole et
Practice                            (n = 1200)       al (18)

Cleansing of Yankauer suction
device
  Rarely or not at all                40 (3)             6
  Only if visible mucus present      398 (33)           14
  After each use                     722 (60)           33
  Dispose after each use              34 (3)            11

Rinsing of Yankauer suction
device
  Tap water                          689 (57)           36
  Sterile water                      209 (17)           NR
  Sterile isotonic sodium            296 (25)           33
    chloride solution
  Do not rinse                        17 (l)             6

Storage of Yankauer suction
device
  Original package, anywhere         888 (74)           71
    except bed
  Not in original package,           204 (17)           NR
    anywhere except bed
  In bed (in or out of original       39 (3)            14
    package)
  Other                               37 (3)             5
  No response                         32 (3)            NR

Replacement of Yankauer suction
device
  As needed                          264 (22)           40
  Every 12 hours                     161 (13)           NR
  Every 24 hours                     608 (51)           45
  Every 48 hours                      42 (4)             4
  Every 72 hours                      38 (3)             1
  Rarely or not at all                45 (4)            NR

* Because of missing data and rounding, percentages
do not all total 100.

Abbreviation: NR, not reported.