infection control and hospital epidemiology august 2014, vol. 35, no.

original article

Strategies to Enhance Adoption of Ventilator-Associated Pneumonia

Prevention Interventions: A Systematic Literature Review

Jente M. Goutier, BSc;1 Christine G. Holzmueller, BLA;1 Kelsey C. Edwards, BA;1 Michael Klompas, MD, MPH;2
Kathleen Speck, BS, MPH;1 Sean M. Berenholtz, MD, MHS1,3

background. Ventilator-associated pneumonia (VAP) is among the most lethal of all healthcare-associated infections. Guidelines sum-
marize interventions to prevent VAP, but translating recommendations into practice is an art unto itself.
objective. Summarize strategies to enhance adoption of VAP prevention interventions.
methods. We conducted a systematic literature review of articles in the MEDLINE database published between 2002 and 2012. We
selected articles on the basis of specific inclusion criteria. We used structured forms to abstract implementation strategies and inserted
them into the “engage, educate, execute, and evaluate” framework.
results. Twenty-seven articles met our inclusion criteria. Engagement strategies included multidisciplinary teamwork, involvement of
local champions, and networking among peers. Educational strategies included training sessions and developing succinct summaries of the
evidence. Execution strategies included standardization of care processes and building redundancies into routine care. Evaluation strategies
included measuring performance and providing feedback to staff.
conclusion. We summarized and organized practical implementation strategies in a framework to enhance adoption of recommended
evidence-based practices. We believe this work fills an important void in most clinical practice guidelines, and broad use of these strategies
may expedite VAP reduction efforts.
Infect Control Hosp Epidemiol 2014;35(8):998-1005

Ventilator-associated pneumonia (VAP) is among the most
lethal of all healthcare–associated infections, with crude mor-
tality ranging from 15% to 70%.1 VAP is also associated with
increased length of stay and added costs.2 Numerous guide-
lines summarize effective interventions and provide recom-
mendations to prevent VAP.3,4 Studies suggest 55% of VAP
cases are preventable with current evidence-based recom-
mendations from guidelines.5 Nevertheless, there remains a
gap in delivering these recommendations to the bedside.6,7
One important contributing factor is the lack of practical
advice within many guidelines to assist readers with imple-
mentation of the recommendations.8-10
When guidelines are published, there is a period of ad-
aptation for clinicians. The emerging science of implemen-
tation can guide clinicians on how best to integrate new rec-
ommendations into routine practice. Implementation science
can help prepare and support stakeholders including hospital
leaders, project leaders, and clinicians to incorporate and ul-
timately sustain the new practices.
One successful model designed to improve adherence with
evidence-based care is the “four Es” model: engage, educate,
execute, and evaluate.11 This model addresses both technical
and adaptive (cultural) work and recognizes the importance
of change management, contextual factors, and staff engage-
ment in the implementation process. We conducted a sys-
tematic literature review to identify strategies to enhance
adoption of VAP prevention interventions using the “four Es”
implementation framework.
methods
Literature Search Strategy
We searched the biomedical literature using PubMed. Our
search strategy included both keyword searches and mapping

Affiliations: 1. Johns Hopkins Armstrong Institute for Patient Safety and Quality, Department of Anesthesiology and Critical Care Medicine, Johns
Hopkins University, Baltimore, Maryland; 2. Department of Medicine, Brigham and Women’s Hospital, and Department of Population Medicine, Harvard
Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts; 3. Department of Surgery, School of Medicine, and Department of
Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland.
Received September 11, 2013; accepted March 16, 2014; electronically published June 20, 2014.
䉷 2014 by The Society for Healthcare Epidemiology of America. All rights reserved. 0899-823X/2014/3508-0010$15.00. DOI: 10.1086/677152

figure 1. Selection of included studies. VAP, ventilator-associated pneumonia.
to the National Library of Medicine’s medical subject head-
ings. The search terms were “pneumonia, ventilator associ-
ated,” “implementation,” “health plan implementation,”
“quality improvement,” “intensive care units,” and “guideline
adherence.” Reference lists from eligible studies were reviewed
for additional potential relevant articles. Our search was lim-
ited to English-language articles published between January
2002 and August 2012 to reflect current clinical practice.
Selection Criteria
Eligible studies described effective strategies to increase the
reliable use of interventions to prevent VAP. We included
studies drawn from adult and pediatric intensive care units
(ICUs) in Western countries. We excluded studies that fo-
cused solely on determining the effectiveness of clinical in-
terventions to prevent VAP (eg, does the use of semirecum-
bant positioning reduce VAP?) or did not fully describe the
strategies used to implement the interventions.
Article Selection and Data Extraction
One reviewer (J.M.G.) screened and selected studies describ-
ing strategies to improve adherence to VAP prevention in-
terventions. A structured form was used to extract the fol-
lowing data: country, research design, setting, ICU type,
implementation strategies to prevent vap 999
outcomes, and information on costs and resources. The re-
sults were reviewed by a second researcher (S.M.B.).
Summarizing Data in Implementation Framework
We organized the adherence strategies identified through the
literature review into the “four Es” framework as a guide to
translate evidence-based interventions into practice. This
framework was developed as a practical application of theories
related to diffusion of innovation and behavior change.11
Each “E” strategy of the framework targets the following key
stakeholders in the implementation process: senior hospital
leaders, improvement team leaders, and frontline staff. This
framework was used in over 100 ICUs across Michigan and
was associated with significant and sustained reductions in
central line–associated bloodstream infections (CLABSIs)
and VAP rates.12,13 This framework is also being used in na-
tional programs focused on eliminating CLABSI and
catheter-associated urinary tract infections (http://www
.onthecuspstophai.org).14
results
Our literature search found 618 citations (Figure 1). After
screening titles and abstracts, 37 candidate articles were re-
table 1. Study Characteristics
Study Research design Setting Outcomes
Aragon and Sole 2006 Review USA Overview of the latest evidence and clinical guide-
lines to prevent infection in the ICU; describes
comprehensive team effort approaches to infec-
tion reduction
Bassi et al 2010 Review Spain Summarizes effects of implementation of current
and past guidelines for management and treat-
ment of VAP
Berenholtz et al 2011 Observational Multicenter, diverse ICUs, USA Enhanced adoption of VAP prevention interventions
and reduced VAP rates
Bigham et al 2009 Observational Single center, pediatric ICU, Enhanced adoption of VAP prevention interventions
USA and reduced VAP rates
Bloos et al 2009 Observational Single center, surgical ICU, Enhanced adoption of VAP prevention interven-
Germany tions, reduced days of mechanical ventilation,
and reduced ICU length of stay
Bouadma et al 2010 Observational Single center, mixed ICU, Enhanced adoption of VAP prevention interventions
France and reduced VAP rates
Brierley et al 2012 Observational Single center, pediatric ICU, Enhanced adoption of VAP prevention interventions
United Kingdom and reduced VAP rates
Burns et al 2003 Observational Single center, diverse ICUs, Reduced days of mechanical ventilation; reduced
USA ICU and hospital length of stay, mortality, and
costs
Craven 2006 Review USA Highlights from recent guidelines and publications
discussing VAP prevention strategies and exam-
ines barriers to their implementation.
Hatler et al 2006 Observational Single center, mixed ICU, USA Enhanced adoption of VAP prevention interven-
tions; reduced VAP rates, ICU length of stay, and
costs
Hawe et al 2009 Observational Single center, mixed ICU, Enhanced adoption of VAP prevention interventions
United Kingdom and reduced VAP rates
Heimes et al 2011 Observational Single center, trauma ICU, Reduced VAP rates
USA
Johnson et al 2009 Observational Single center, trauma ICU, Reduced VAP rates
USA
Krimsky et al 2009 Observational Single center, mixed ICU, USA Enhanced adoption of VAP prevention interventions
Lyerla et al 2010 Observational Single center, mixed ICU, USA Enhanced adoption of VAP prevention intervention
Mangino et al 2011 Observational Multicenter, diverse ICUs, USA Enhanced adoption of VAP prevention interventions
and reduced VAP rates
Omrane et al 2007 Observational Single center, mixed ICU, Reduced crude VAP rates; reduction was not signifi-
Canada cant after adjusting for covariates in the regres-
sion model
Pinto et al 2011 Qualitative case study Multicenter, diverse ICUs, Perceived factors relating to the reliable application
United Kingdom of 4 clinical care practices targeting VAP
Pogorzelska et al 2011 Observational Multicenter, diverse ICUs, USA Reduced VAP rates associated with enhanced adop-
tion of VAP prevention interventions
Rello et al 2012 Observational Multicenter, diverse ICUs, Enhanced adoption of VAP prevention interven-
Spain tions; reduced VAP rates, days of mechanical
ventilation, and ICU length of stay
Salahuddin et al 2004 Observational Single center, mixed ICU, Reduced VAP rates
Pakistan
Scales et al 2011 Cluster randomized trial Multicenter, diverse ICUs, Enhanced adoption of VAP prevention interventions
Canada
Sinuff et al 2008 Review Canada Overview of guidelines and guideline implementa-
tion strategies; overview of behavior change and
clinician adherence to guidelines; current knowl-
edge about VAP guideline implementation; and a
framework for implementation of a VAP guide-
line in the ICU

table 1 (Continued)
Study Research design Setting
Weireter et al 2009 Observational Single center, burn and neuro-
surgical ICUs, USA
Westwell 2008 Observational Single center, mixed ICU, UK
Youngquist et al 2007 Observational Single center, mixed ICUs,
USA
Zaydfudim et al 2009 Observational Single center, surgical ICU,
USA
note. ICU, intensive care unit; UK, United Kingdom; VAP, ventilator-associated pneumonia.
trieved for full-text review. Of the 37 potential articles, 10
were excluded because implementation strategies were not
described. The remaining 27 articles in our review represented
observational studies, reviews, qualitative case studies, and a
randomized controlled trial (Table 1). Two studies provided
data on program infrastructure costs, and 1 study estimated
reductions in total costs for patients requiring long-term
mechanical ventilation and reductions in direct cost per
case.15,16
Strategies to Improve Adherence
The study characteristics and outcomes for each included
study are described in Table 1. Multiple strategies to imple-
ment VAP guidelines were used in 72% of the studies.
“Four Es” Framework for Implementing VAP
The following sections describe the attributes of engagement,
education, execution, and evaluation, illustrating where the
implementation strategies identified in our review fit in the
framework and offering a guide for translating evidence into
practice. Table 2 describes key features of the implementation
strategies in the framework.
Engagement
When implementing evidence-based interventions into prac-
tice, it is essential to engage staff. Success is often contingent
on the extent to which staff believe the proposed interventions
are important and will improve care.8,17 The first step is to
assemble a multidisciplinary team of providers that care for
patients receiving mechanical ventilation to do the work and
recruit a local champion, often a physician or nurse, to lead
the team.13,15,16,18-20 The multidisciplinary team is charged with
identifying available local resources and evaluating current
guidelines. They are then tasked with establishing standards,
shaping strategies, and defining routine procedures to im-
plement the proposed interventions to prevent VAP on the
basis of local resources. The team is also responsible for de-
fining benchmarks and outcomes to provide feedback.21 A
motivated and well-coordinated multidisciplinary team can
enhance adoption of evidence-based practices and encourage
staff participation.22 Moreover, programs developed through
implementation strategies to prevent vap 1001
Outcomes
Enhanced adoption of VAP prevention interven-
tions; reduced VAP rates and days of mechanical
ventilation
Enhanced adoption of VAP prevention interventions
Enhanced adoption of VAP prevention interven-
tions, reduced VAP rates, and reduced ICU
length of stay in 1 of 2 ICUs
Enhanced adoption of VAP prevention interventions
and reduced VAP rates
local team consensus tend to be more effective than programs
implemented from the top down.17,21,23
Local champions are important because they engage rel-
evant stakeholders, educate peers regarding the need to
change practice, maintain project momentum, and empower
staff to own the work.6,11 The presence of a local champion
also increases buy-in and ownership from staff and hospital
administration.6,13,15,17,21 Local champions should understand
the hospital’s interests and needs and know how to shape
strategies to fit their unit’s culture, monitor progress, and
evolve the implementation process to maintain progress.24
Early and continued communication from the champion en-
folds staff in the work, encourages them to ask questions,
helps resolve concerns, prepares staff for action, and sustains
improvements.
During engagement, establish peer networks horizontally
across units to share learning and vertically to capture support
from departmental or hospital leaders.13,25,26 Peer networks
create mutual opportunity and accountability for imple-
menting best practices and establish collaboration and com-
mitment to specific goals. Simultaneous measurement across
several ICUs allows units to examine local practices and com-
pare results, prompting continuous improvement of care
processes.27
Education
Education is a critical component to understanding and ac-
cepting proposed changes in practice. Healthcare providers
and senior leaders are often unfamiliar with some of the
evidence supporting VAP interventions. Education efforts ex-
plain why providers should change their practices and how
the interventions can eliminate VAP.28,29 Education was the
most commonly (59%) described implementation strategy
among the citations we identified.
One method of education is through sessions, which can
distill evidence down to manageable information, provide
expectations for the elimination of VAP, and explain changes
in care processes.7,24 Such sessions could be workshops,
hands-on training of the new care practices, conferences,
computer-based slide presentations, and interactive discus-
sions.6,28-30 Both the local champion and topic experts (eg,
1002 infection control and hospital epidemiology august 2014, vol. 35, no. 8

table 2. Implementation Framework for Ventilator-Associated Pneumonia (VAP) Prevention Using the “Four Es” Model
Model attribute, implementation strategy
Engagement
Develop a multidisciplinary team
Involve local champions
Encourage peer networking
Education
Hold educational sessions
Provide educational materials
Execution
Standardize care processes
Create redundancy
Evaluation
Measurement of performance
Feedback on outcome to staff
Key features
Team includes representatives from every discipline that cares for a patient re-
ceiving mechanical ventilation, including, at a minimum, unit directors, phy-
sicians, nurses, and respiratory therapists; other disciplines that could
strengthen the team are infection preventionists, pharmacists, nutritionists,
physical therapists, and occupational therapists; the multidisciplinary team
sets the VAP improvement program goals, defines each step to implement the
program, and monitors progress towards reaching the goals
Identify a local champion (either formally or informally, who is often a physi-
cian or nurse with dedicated time, to lead the team; local champions engage
stakeholders, educate peers about best practices, maintain momentum, and
establish buy-in and ownership among staff and administrators; local cham-
pion should know their hospital’s interests and needs, know how to shape
strategies to match local unit culture, monitor progress, and evolve interven-
tions to maintain progress; establish early and continued communication be-
tween local champion and frontline staff
Horizontal networking of peers across units or hospitals promotes and increases
compliance with evidence-based practices; encourages collaboration, analysis
of performance, accountability, commitment to specific goals, brainstorming
solution to common problems, and understanding local strengths and
weaknesses
Summarize evidence, explain new processes, and set performance expectations;
methods for education include workshops, training, conferences, slide presen-
tations, and interactive discussions; local champions and topic experts should
lead educational sessions; multidisciplinary educational programs as well as
specific educational session to ensure that the information is relevant for the
learner
Educational materials summarize evidence, support self-study, and remind staff
about new practices; examples include pocket cards, brochures, posters, fact
sheets, daily guides, summaries of guidelines, flow sheets, and 1-page bulletins
Standardization helps to establish new care processes; examples include imple-
mentation of guidelines, bundles, protocols, or pathways; daily multidisciplin-
ary rounds with structured format
Reminds staff about the new practices and serves as another check to help en-
sure the practices are appropriately completed; examples include posters, bul-
letins, pens, stamps, pocket cards, 1-page signs, daily goals sheets in patient
rooms, checklists, preprinted order sets, text messaging, and screensavers on
clinical computers
Measurement of performance highlights awareness, establishes expectations, cre-
ates urgency and rewards changes in behavior; performance can be measured
using formal and informal audits
Feedback on outcomes allows staff to correlate improvements in performance
with a decrease in VAP rates or number of VAPs, which reminds staff about
the new processes and motivates them to improve

infection preventionists) can lead these sessions.17,25 This ed-
ucation must be informative and relevant for the learner.
Thus, there should be multidisciplinary programs to cross-
educate disciplines and specific sessions for each involved
specialty.11,21,31 During sessions, questions can be answered,
concerns resolved, and input incorporated in the new care
process to fit the local context.32
Another educational method is to supply staff with ma-
terials to familiarize them with and remind them of the new
care process, support self-study, and summarize the evidence.
Examples of educational materials described in the literature
are cards, brochures, posters, fact sheets, daily guides, guide-
line summaries, flow sheets, and 1-page bulletins.13,17,27,28,33,34
Maintaining high compliance levels is difficult, strengthening

the need for continuous education of healthcare staff.27,30,34
Finally, there should be a process in place to train new staff
and to use multidisciplinary training, combining physicians,
nurses, and other staff in these efforts.11,27
Execution
Execution is based on the principle of safe system design,
which aims to simplify the system and create redundancy.35
Systems can be simplified by standardizing care processes with
guideline-based bundles, protocols, or pathways. Standardi-
zation increases the consistency of care and establishes new
care processes as normal behavior.24 Standardization does,
however, often require changes in workflow.24 Care bundles
or other standardized tools are often used in critical care to
manage multifaceted interventions for a single outcome (such
as VAP) or to guide treatment of multiple conditions.6,13,17,19,
21-24,27,32,34,36-38
A common barrier to implementing guideline
recommendations is ease of access to needed supplies.17,21
Walking the proposed care processes with clinicians can help
to identify potential barriers to adherence as well as potential
solutions. Daily multidisciplinary rounds are widely advo-
cated to solicit multiple perspectives, improve communica-
tion, and increase adoption of evidence-based practices.
Rounds should include a discussion about the patients’ goals
for the day, what resources are necessary to achieve the goals,
potential barriers in reaching the goals, and any safety
issues.13,20,22,31
Creating redundancy is important to help staff members
comply with the new processes. Redundancy can be created
through reminders, such as posters, bulletins, pens, stamps,
pocket cards, text messaging, and computer screensavers, and
through independent checks, such as daily goals in patient
rooms, and checklists.8,24,25,29,33,34,36,37,39 The combination of re-
minders and education can substantially improve the reli-
ability of care.7,29
Evaluation
Evaluation serves to measure whether the intervention im-
proved the targeted outcome and to provide feedback on
performance to staff and leaders. Among the citations we
identified, measurement and feedback was the second most
common implementation strategy (52%). When measure-
ment and feedback are integrated in the ICU, staff see the
correlation between increased compliance and decreased VAP
rates, establishing expectations and rewarding and reinforcing
adherence to new care processes.11,17,22,24,38,40
Measurement of performance increases awareness, estab-
lishes expectations, creates a sense of urgency, and rewards
changes in behavior.24,40 Studies suggest an inverse association
between compliance and VAP. One study found no significant
associations between VAP rates and having a policy, moni-
toring compliance, or low compliance with bundle elements.
When an ICU had a policy, monitored compliance, and had
95% or greater compliance, however, VAP rates were signif-
implementation strategies to prevent vap 1003
icantly lower.38 Another study found holding staff accountable
for completion of the ventilator bundle resulted in a signif-
icant decrease in VAP.15 Frequent audits can rapidly identify
and rectify poor compliance.40 Implementation of an elec-
tronic dashboard for ongoing, real-time feedback of com-
pliance rates improved compliance with ventilator bundle
measures and reduced VAP rates.37
Compliance rates and outcomes can be routinely reported
to staff through wall displays and staff meetings.17,24,28,32,34 The
frequency of feedback will depend on the type of data and
local staff preferences. Daily, weekly, and monthly models
have all been described.24,25,31,36,37,40 Feedback of outcome data
is also important for future efforts, because it serves to pin-
point areas for improvement and mark successful transitions
to new standards of care.24 Reporting of outcome data is
perceived by hospital staff as a potentially effective strategy
to boost adherence to clinical guidelines in ICUs.22
discussion
In this study, we systematically reviewed the literature for
strategies to enhance adoption of evidence-based interven-
tions to prevent VAP in the ICU. We found wide variation
in strategies described in the literature. We used the “four
Es” implementation framework to summarize the strategies
and describe where and how the strategies may be most useful
in influencing change and increasing guideline compliance.
The “four Es” framework manages change at every level of
a healthcare organization. Statewide and nationwide pro-
grams that have realized sustained decreases in CLABSI and
VAP rates successfully used the “four Es” framework.13,35,41-43
We also found several other strategies that lead to successful
implementation of VAP interventions. One was small-scale
pilot testing of new interventions for a short period (several
weeks), with the impact on outcomes measured to quickly
discern what worked.17,24 This strategy engaged frontline cli-
nicians in testing the bundle intervention, adapting the im-
plementation to fit the workflow on the unit, and taking
ownership of the program. Short-cycle pilots can help re-
searchers quickly identify unknown factors in different clin-
ical settings and adjust their study methods.17,24
Another strategy let the local unit tailor the implementation
of VAP interventions to fit their needs. Frontline clinicians
are more accepting of projects when they can fit the new
practices into their workflow.23,34 A final strategy was contin-
uous flexibility of implementation methods. Projects are more
successful when local champions and multidisciplinary teams
can evolve strategies to resolve problems and match the unit’s
culture.24,34
Clinical guidelines summarize the strongest evidence to
improve care, but they are useless if clinicians fail to use them
at the bedside. A recent review assessed interventions at-
tempting to improve adherence to guidelines for the preven-
tion of device-related infections.44 Although the evidence of
selected studies was deemed to be of low quality, the authors
1004 infection control and hospital epidemiology august 2014, vol. 35, no. 8
concluded that repeated multimethod educational interven-
tions and involvement of providers trained in aspects of care
were worth further study. The “four Es” framework includes
common attributes among successful implementation strat-
egies; engagement, education, execution, and evaluation. Our
synthesis and organization of strategies complements current
clinical practice guidelines and fills an important gap by of-
fering recommendations to enhance adoption of VAP pre-
vention interventions.
We recognize several limitations. First, we only searched
the PubMed database and may have missed studies in other
databases. Nevertheless, PubMed accesses the National Li-
brary of Medicine database, which has a very comprehensive
repository of biomedical literature. Second, the articles in this
study had different research designs and used different in-
terventions to eliminate VAP. Therefore, we could not define
an optimal strategy or determine success of any individual
strategy. Despite these limitations, we achieved our goal and
summarized practical strategies to enhance adoption of VAP
prevention interventions.
Guidelines summarize evidence-based practices to prevent
VAP, yet few guidelines offer strategies to implement these
recommendations. We summarized and organized practical
implementation strategies into a framework to enhance adop-
tion of these practices. This approach fills an important void
in most clinical practice guidelines, and broad use of these
strategies may expedite VAP reduction efforts in diverse ICUs.
acknowledgments
Potential conflicts of interest. All authors report no conflicts of interest rel-
evant to this article. All authors submitted the ICMJE Form for Disclosure
of Potential Conflicts of Interest, and the conflicts that the editors consider
relevant to this article are disclosed here.
Address correspondence to Sean M. Berenholtz, MD, MHS, Armstrong
Institute for Patent Safety and Quality, Johns Hopkins University, 750 East
Pratt Street, 15th Floor, Baltimore, MD 21202 (sberenho@jhmi.edu).
references
1. Klevens RM, Edwards JR, Richards CL Jr, et al. Estimating health
care–associated infections and deaths in U.S. hospitals, 2002.
Public Health Rep 2007;122(2):160–166.
2. Safdar N, Dezfulian C, Collard HR, Saint S. Clinical and eco-
nomic consequences of ventilator-associated pneumonia: a sys-
tematic review. Crit Care Med 2005;33(10):2184–2193.
3. Coffin S, Klompas M, Classen D, et al. Strategies to prevent
ventilator-associated pneumonia in acute care hospitals. Infect
Control Hosp Epidemiol 2008;29(S1):S31–S40.
4. Tablan OC, Anderson LJ, Besser R, Bridges C, Hajjeh R. Guide-
lines for preventing healthcare-associated pneumonia, 2003: rec-
ommendations of CDC and the healthcare infection control
practices advisory committee. MMWR Recomm Rep 2004;53:1–
36.
5. Umscheid CA, Mitchell MD, Doshi JA, Agarwal R, Williams K,
Brennan PJ. Estimating the proportion of healthcare-associated
infections that are reasonably preventable and the related mor-
tality and costs. Infect Control Hosp Epidemiol 2011;2(32):101–
114.
6. Craven DE. Preventing ventilator-associated pneumonia in
adults: sowing seeds of change. Chest 2006;130(1):251–260.
7. Grimshaw JM, Thomas RE, MacLennan G, et al. Effectiveness
and efficiency of guideline dissemination and implementation
strategies. Health Technol Assess 2004;8(6):iii-iv, 1–72.
8. Sinuff T, Muscedere J, Cook D, Dodek P, Heyland D; Canadian
Critical Care Trials Group. Ventilator-associated pneumonia:
improving outcomes through guideline implementation. J Crit
Care 2008;23(1):118–125.
9. Weinert CR, Mann HJ. The science of implementation: changing
the practice of clinical care. Current Opinion in Crit Care 2008;
4(14):460–465.
10. Gagliardi AR, Brouwers MC, Palda VA, Lemieux-Charles L,
Grimshaw JM. How can we improve guideline use? a conceptual
framework of implementability. Implement Sci 2011;6–26.
11. Pronovost PJ, Berenholtz SM, Needham DM. Translating evi-
dence into practice: a model for large scale knowledge trans-
lation. BMJ 2008;337:a1714.
12. Pronovost P, Needham D, Berenholtz S, et al. An intervention
to decrease catheter-related blood stream infections in the ICU.
N Engl J Med 2006;(355):2725–2732.
13. Berenholtz SM, Pham JC, Thompson DA, et al. Collaborative
cohort study of an intervention to reduce ventilator-associated
pneumonia in the intensive care unit. Infect Control Hosp Epi-
demiol 2011;32(4):305–314.
14. Berenholtz SM, Lubomski LH, Weeks K, et al. Eliminating cen-
tral-line associated bloodstream infections: a national patient
safety imperative. Infect Control Hosp Epidemiol 2014;1(35):56–
62.
15. Heimes J, Braxton C, Nazir N, et al. Implementation and en-
forcement of ventilator-associated pneumonia prevention strat-
egies in trauma patients. Surg Infect (Larchmt) 2011;12(2):1–6.
16. Burns SM, Earven S, Fisher C, et al. Implementation of an
institutional program to improve clinical and financial outcomes
of mechanically ventilated patients: one-year outcomes and les-
sons learned. Crit Care Med 2003;31(12):2752–2763.
17. Bigham MT, Amato R, Bondurrant P, et al. Ventilator-associated
pneumonia in the pediatric intensive care unit: characterizing
the problem and implementing a sustainable solution. J Pediatr
2009;154(4):582–587.e2.
18. Weireter LJ Jr, Collins JN, Britt RC, Reed SF, Novosel TJ, Britt
LD. Impact of a monitored program of care on incidence of
ventilator-associated pneumonia: results of a longterm perfor-
mance-improvement project. J Am Coll Surg 2009;208(5):700–
705.
19. Bloos F, Muller S, Harz A, et al. Effects of staff training on the
care of mechanically ventilated patients: a prospective cohort
study. Br J Anaesth 2009;103(2):232–237.
20. Johnson V, Mangram A, Mitchell C, Lorenzo M, Howard D,
Dunn E. Is there a benefit to multidisciplinary rounds in an
open trauma intensive care unit regarding ventilator-associated
pneumonia? Am Surg 2009;75(12):1171–1174.
21. Aragon D, Sole ML. Implementing best practice strategies to
prevent infection in the ICU. Crit Care Nurs Clin North Am
2006;18(4):441–452.
22. Pinto A, Burnett S, Benn J, Brett S, Parand A, Iskander S, Vincent
C. Improving reliability of clinical care practices for ventilated

patients in the context of a patient safety improvement initiative.
J Eval Clin Pract 2011;1(17):180–187.
23. Brierley J, Highe L, Hines S, Dixon G. Reducing VAP by insti-
tuting a care bundle using improvement methodology in a UK
paediatric intensive care unit. Eur J Pediatr 2012;171(2):323–
330.
24. Hatler CW, Mast D, Corderella J, et al. Using evidence and
process improvement strategies to enhance healthcare outcomes
for the critically ill: a pilot project. Am J Crit Care 2006;6(15):
549–555.
25. Scales DC, Dainty K, Hales B, et al. A multifaceted intervention
for quality in a network of intensive care units: a cluster ran-
domized trial. JAMA 2011;4(305):363–372.
26. Mangino JE, Peyrani P, Ford KD, et al. Development and im-
plementation of a performance improvement project in adult
intensive care units: overview of the improving medicine
through pathway assessment of critical therapy in hospital-
acquired pneumonia (IMPACT-HAP) study. Crit Care 2011;
15(1):R38.
27. Rello J, Afonso E, Lisboa T, et al. A care bundle approach for
prevention of ventilator-associated pneumonia. Clin Microbiol
Infect 2013;4(19):363–369.
28. Berenholtz SM, Pronovost PJ. Barriers to translating evidence
into practice. Curr Opin Crit Care 2003(9):321–325.
29. Salahuddin N, Zafar A, Sukhyani L, et al. Reducing ventilator-
associated pneumonia rates through a staff education pro-
gramme. J Hosp Infect 2004;57(3):223–227.
30. Bouadma L, Mourvillier B, Deiler V, et al. Changes in knowledge,
beliefs, and perceptions throughout a multifaceted behavioral
program aimed at preventing ventilator-associated pneumonia.
Intensive Care Med 2010;36(8):1341–1347.
31. Krimsky WS, Mroz IB, McIlwaine JK, et al. A model for in-
creasing patient safety in the intensive care unit: increasing the
implementation rates of proven safety measures. Qual Saf Health
Care 2009;18(1):74–80.
32. Bassi GL, Ferrer M, Saucedo LM, Torres A. Do guidelines change
outcomes in ventilator-associated pneumonia? Curr Opin Infect
Dis 2010;23(2):171–177.
33. Lyerla F, LeRouge C, Cooke DA, et al. A nursing clinical decision
implementation strategies to prevent vap 1005
support system and potential predictors of head-of-bed position
for patients receiving mechanical ventilation. Am J Crit Care
2010;1(19):39–47.
34. Hawe CS, Ellis KS, Cairns CJ, Longmate A. Reduction of ven-
tilator-associated pneumonia: active versus passive guideline im-
plementation. Intensive Care Med 2009;35(7):1180–1186.
35. DePalo VA, McNicoll L, Cornell M, Rocha JM, Adams L, Prono-
vost PJ. The rhode island ICU collaborative: a model for re-
ducing central line-associated bloodstream infection and ven-
tilator-associated pneumonia statewide. Qual Saf Health Care
2010;19(6):555–561.
36. Youngquist P, Carroll M, Farber M, et al. Implementing a ven-
tilator bundle in a community hospital. Jt Comm J Qual Patient
Saf 2007;33(4):219–225.
37. Zaydfudim V, Dossett LA, Starmer JM, et al. Implementation
of a real-time compliance dashboard to help reduce SICU ven-
tilator-associated pneumonia with the ventilator bundle. Arch
Surg 2009;144(7):656–662.
38. Pogorzelska M, Stone PW, Furuya EY, et al. Impact of the ven-
tilator bundle on ventilator-associated pneumonia in intensive
care unit. Int J Qual Health Care 2011;5(23):538–544.
39. Omrane R, Eid J, Perreault MM, et al. Impact of a protocol for
prevention of ventilator-associated pneumonia. Ann Pharma-
cother 2007;41(9):1390–1396.
40. Westwell S. Implementing a ventilator care bundle in an adult
intensive care unit. Nurs Crit Care 2008;13(4):203–207.
41. Pronovost PJ, Goeschel CA, Colantuoni E, et al. Sustaining re-
ductions in catheter related bloodstream infections in Michigan
intensive care units: observational study. BMJ 2010;340:c309.
42. Lin DM, Weeks K, Bauer L, et al. Eradicating central line-as-
sociated bloodstream infections statewide: the Hawaii experi-
ence. Am J Med Qual 2012;2(27):124–129.
43. Hong AL, Sawyer, Shore A, et al. Decreasing central-line asso-
ciated bloodstream infections in Connecticut intensive care
units. J Health Qual 2013;5(35):78–87.
44. Flodgren G, Conterno LO, Mayhew A, Omar O, Pereira CR,
Shepperd S. Interventions to improve professional adherence to
guidelines for prevention of device-related infections. Cochrane
Database Syst Rev 2013;3:CD006559.