American Journal of Infection Control 42 (2014) 923-5

Contents lists available at ScienceDirect

American Journal of Infection Control American Journal of

Infection Control

journal homepage: www.ajicjournal.org

Brief report

Critical care nurses knowledge of measures to prevent

ventilator-associated pneumonia
Hsin-Lan Lin RN a, b, Chih-Cheng Lai MD c, Li-Yu Yang PhD d, *
a
Department of Nursing, Chi Mei Medical Center, Liouying, Tainan, Taiwan
b
Department of Nursing, Min-Hwei College of Health Care Management, Tainan, Taiwan
c
Department of Intensive Care Medicine, Chi Mei Medical Center, Liouying, Tainan, Taiwan
d
School of Nursing, Kaohsiung Medical University, Kaohsiung, Taiwan

Key Words: We queried critical care nurses at a hospital about their level of knowledge of interventions designed to
Critical care nurses prevent ventilator-associated pneumonia (VAP). The mean score was 7.87
1.36 (65.6%) among 133
Knowledge questionnaires. Multivariate analysis revealed that intensive care unit (ICU) license (P .03) and ranking
Ventilator-associated pneumonia
of registered nurses (RNs) (P .041) were signicantly associated with higher knowledge level
(8 correct answers of 12 items) of respondents. This surveillance study revealed that noneICU-licensed
nurses and junior RNs lack the knowledge necessary to prevent VAP in critical care settings.
Copyright 2014 by the Association for Professionals in Infection Control and Epidemiology, Inc.
Published by Elsevier Inc. All rights reserved.

In 2004, the Institute for Healthcare Improvement introduced
bundled care as a structured protocol for preventing the develop-
ment of pneumonia in mechanically ventilated patients.1,2 As with
other quality-improvement interventions, the know how is the rst
step.3 However, few studies have investigated the level of
knowledge of evidence-based guidelines for the prevention of
ventilator-associated pneumonia (VAP) among critical care
nurses.3-8 Moreover, all of the studies were conducted in western
countries.3-8 Therefore, we investigated the level of knowledge of
VAP prevention among critical care nurses in Taiwan.
MATERIAL
This study was carried out at a regional teaching hospital in
southern Taiwan with 5 acute intensive care units (ICUs) (63 total
beds) and a 20-bed subacute respiratory care center. A multiple
choice questionnaire based on the study by Labeaus et al7 was
designed to assess knowledge of VAP prevention.1 The question-
naire consisted of 12 items with 4 possible answers and only 1
correct answer. The content was validated by 1 infection control
physician, 2 chest physicians, and 2 senior nurses with expertise in
VAP. After these experts reviewed the adequacy of the match
* Address correspondence to Li-Yu Yang, PhD, School of Nursing, Kaohsiung
Medical University, 100, Shih-Chuan 1st Road, Kaohsiung 80708, Taiwan.
E-mail address: a885019@kmu.edu.tw (L.-Y. Yang).
Financial Disclosures: None.
Conict of interest: None to report.
between local guidelines and the questions, the reviewers did not
suggest any further revision or deletion of the 12 items. All of the
150 critical care nurses received the questionnaire, but only 142
responded. Nine surveys were considered invalid. Demographic
data collected included age, sex, academic degree, serving location,
whether nurses served as a team member or team leader, ICU
license, ranking of registered nurses (RNs), and years of critical care
experience. Ethics approval was obtained from the Institutional
Review Board of the Chi Mei Medical Center.
Continuous variables are expressed as means
SDs, and
categorical variables were compared using the chi-square test. All
signicant variables in the univariate analyses were included in
a multiple logistic regression model to identify the independent
factors associated with nurses level of knowledge of preventing
VAP.
RESULTS
Overall, 133 questionnaires were identied as valid, which
translates into a nal response rate of 88.6%. Nurses who provided
valid responses ranged in age from 20-35 years old, and 92% were
women. The average number of years working in critical care
settings was 4.1, and most of the critical care nurses served in the
medical ICU or surgical ICU. Only 23 (17.3%) nurses were classied
as team leaders, and 29 (21.8%) nurses were ranked as senior RNs,
including RN 3 and RN 4.
The percentage of nurses who answered each item is shown in
Table 1. The top 3 queries to which nurses answered correctly were

0196-6553/$36.00 - Copyright 2014 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.ajic.2014.05.012
924 H.-L. Lin et al. / American Journal of Infection Control 42 (2014) 923-5

Table 1 Table 2
Nurses answers to questions about knowledge of prevention of VAP Respondent characteristics associated with high knowledge level (8 correct an-
swers of 12 items) based on the multivariate logistic regression
Number of % of
Item respondents respondents Ratio of respondents
1. The denition of VAP, based on ATS guidelines with high scores
Pneumonia that occurs 48 hours after 110 82.7* Number of (8 correct answers Odds ratio (95% P
endotracheal intubation Characteristics respondents of 12 items) (%) condence interval) value
Pneumonia that occurs within 48 hours after 8 6.0 ICU license
endotracheal intubation No 17 29.4 1 (reference)
Pneumonia that occurs 24 hours after 8 6.0 Yes 116 66.4 9.99 (2.234-44.677) .03
endotracheal intubation Ranking of RN
I do not know 7 5.3 RN, RN 1, 29 52.9 1 (reference)
2. Which one is not a clinical feature of VAP? and RN 2
Fever, productive cough, dyspnea, and rales 16 12 RN 3 and RN 104 93.1 3.243 (1.051-10.005) .041
Chest radiography shows increased 7 5.3 4
inltration or consolidation
ICU, intensive care unit; RN, registered nurse.
Clinical pulmonary infection score <5 94 70.7*
I do not know 16 12.0
3. Oral versus nasal route for endotracheal
intubation item 7 (recommended patients position; n 130, 97.7%), item 6
Nasal route is recommended 15 11.3 (when to perform the weaning process; n 127, 95.6%), and item 8
Oral route is recommended 63 47.4* (sedative and analgesic agents; n 126, 94.7%). In contrast, item 10
Both routes are recommended 37 27.8
(use of endotracheal tubes with subglottic suction; n 8, 6.0%),
I do not know 18 13.5
4. What is the pathogenesis of VAP? item 4 (pathogenesis of VAP; n 31, 23.3%), and item 5 (possible
Via ventilator circuit 95 71.4 pathogens causing VAP; n 60, 45.1%) have the lowest ratio of
Via other patients 1 0.8 correct response.
Via oral ora translocation 31 23.3*
Overall, the mean score was 7.87
1.36 (65.6%). By using the
I do not know 6 4.5
5. Which pathogen does not cause VAP? average scores as the cutoff value, we divided the respondents into
Staphylococcus aureus 29 21.8 2 subgroups, which included respondents with high scores
Clostridium difcile 60 45.1* (8 correct answers of 12 items) and low scores (7 correct
Enterobacteriaceae 24 18.1 answers of 12 items), for further analysis. In the univariate analysis,
I do not know 20 15.0
the high scores group was more likely to be found among nurses
6. When can we perform the weaning process?
Dopamine > 5 mcg/kg/min 2 1.5 aged >30 years, team leaders, senior RNs (RNs 3 and 4), nurses in
Fraction of inspired oxygen <50% and positive 127 95.6* acute ICUs, and ICU-licensed nurses than among nurses &30 years,
end-expiratory pressure <8 cm H2O nonteam leaders, junior RNs (RN, RN 1, RN 2), nurses in the respi-
Persistent irritability 3 2.3
ratory care center, and noneICU-licensed nurses (all P < .05).
I do not know 1 0.8
7. What is the recommended position for
Results of the multivariate analysis disclosed that ICU license
ventilated patients? (P .03) and ranking of RNs (P .041) were signicantly associated
Semirecumbent position 130 97.7* with high scores of respondents (Table 2).
Trendelenburg position 0 0
Prone position 2 1.5
I do not know 1 0.8 DISCUSSION
8. Use of sedative and analgesic agents
Keep SAS within 1-2 5 3.7 Several interesting ndings emerged from this study on the
Daily sedation vacation 126 94.7*
level of nurses knowledge of VAP prevention in the ICU in southern
Give analgesic agents after the use of sedative 1 0.8
agents
Taiwan. First, although the mean score on the 12-item question-
I do not know 1 0.8 naire was relatively low (7.87, 65.6%), it was markedly higher than
9. Use of peptic ulcer prophylaxis the mean scores on similar questionnaires reported in studies
Can prevent VAP 47 35.3 conducted in western countries.4,8,9 The higher scores achieved by
Use only for high-risk patients 76 57.1*
the critical care nurses in our hospital might be attributed to the
Should not use for ventilated patients 1 0.8
I do not know 9 6.8 recent implementation of the ventilator bundle for prevention of
10. Which intervention can prevent VAP? VAP in the ICU at the Chi Mei Medical Center. Another reason for
Use of endotracheal tube with subglottic 8 6.0* the higher mean score might be because of the modications we
suction
made to the questionnaire used in previous studies.4,8,9 Neverthe-
Keep the cuff pressure of endotracheal tube 36 27.1
<20 mm Hg
less, the mean score in this study indicates that critical care nurses
Change ventilator circuit weekly 66 49.6 at our hospital lack the knowledge necessary to prevent VAP in the
I do not know 23 17.3 ICU, indicating that additional training is needed.
11. Which solution is recommended for oral care? Second, we found that the degree of knowledge regarding the
0.12% chlorhexidine 95 71.4*
core aspects of VAP prevention among our nurses differed greatly
Normal saline 11 8.3
Povidone-iodine 23 17.3 from that among nurses in other countries. For example, although
I do not know 4 3.0 about 97% of the study subjects correctly answered that patients
12. Frequency of oral care receiving ventilator support should be maintained in a semi-
Once daily 0 0
recumbent position, a nding consistent with a previous study,8
At least once per shift 124 93.2*
Following suction 9 6.8
only 6% were familiar with subglottic endotracheal tube suction.
I do not know 0 0 The main reason for this nding is that subglottic suctioning de-
vices are not used in our hospital.
ATS, American Thoracic Society; SAS, Sedation-Agitation Scale; VAP, ventilator-
associated pneumonia. Third, we found that only ICU license and ranking of RNs were
*Indicates the correct answer. independently associated with the level of knowledge about VAP
 H.-L. Lin et al. / American Journal of Infection Control 42 (2014) 923-5
among critical care nurses. That is, noneICU-licensed critical care
nurses and nurses with a junior ranking were more likely to be less
knowledgeable about prevention of VAP than ICU-licensed nurses
and higher ranking RNs. Hospital administrators, therefore, should
implement mandatory VAP education programs for critical care
nurses who do not have an ICU license and for junior-level nurses.
In conclusion, knowledge of VAP prevention among critical care
nurses at the Chi Mei Medical Center is inadequate, especially among
noneICU-licensed nurses and nurses with a low RN rank. Although
knowledge is only one of the components effecting behavior change,
it remains essential to nd the nurse without adequate knowledge
to educate them. However, further large-scale studies should be
warranted to better understand this issue before policymaking.
References
1. Liu WL, Lin HL, Lai CC, Hsueh PR. A multidisciplinary team care bundle for
reducing ventilator-associated pneumonia at a hospital in southern Taiwan.
J Microbiol Immunol Infect 2013;46:313-4.
2. OGrady NP, Murray PR, Ames N. Preventing ventilator-associated pneumonia:
does the evidence support the practice? JAMA 2012;307:2534-9.
925
3. Subramanian P, Choy KL, Gobal SV, Mansor M, Ng KH. Impact of education on
ventilator-associated pneumonia. Singapore Med J 2013;54:281-4.
4. Jasson M, Ala-Kokko T, Ylipalosaari P, Syrjala H, Kygas H. Critical care nurses
knowledge of adherence to and barriers towards evidence-based guidelines for
the prevention of ventilator-associated pneumoniaea survey study. Intensive
Crit Care Nurs 2013;29:216-27.
5. Llaurad M, Labeau S, Vandijck D, Rello J, Rosa A, Riera A, et al, Investigadores del
Estudio EVIDENCE, Colaboradores del PROCORNEU (Programa Corporativo
Neumona CIBERES). Southern European intensive care nurses knowledge of
evidence-based guidelines for preventing ventilator-associated pneumonia]
[Spanish]. Med Intensiva 2011;35:6-12.
6. Labeau S, Vandijck D, Rello J, Adam S, Rosa A, Wenisch C, et al. Evidence-based
guidelines for the prevention of ventilator-associated pneumonia of a
knowledge test among European intensive care nurses. J Hosp Infect 2008;70:
180-5.
7. Labeau S, Vandijck DM, Claes B, Van Aken P, Blot SI, Executive board of the
Flemish Society for Critical Care Nurses. Critical care nurses knowledge of
evidence-based guidelines for preventing ventilator-associated pneumonia: an
evaluation questionnaire. Am J Crit Care 2007;16:371-7.
8. Blot SI, Labeau S, Vandijck D, Van Aken P, Claes B, Executive Board of the Flemish
Society for Critical Care Nurses. Evidence-based guidelines for the prevention of
ventilator-associated pneumonia of a knowledge test among intensive care
nurses. Intensive Care Med 2007;33:1463-7.
9. Akin Korhan E, Hakverdioglu Yont G, Parlar Kilic S, Uzelli D. Knowledge level of
intensive care nurses on prevention of ventilator-associated pneumonia. Nurs
Crit Care 2014;19:26-33.