Evaluation of prevention and control measures for ventilator-associated pneumonia

This study aimed to evaluate the quality of health care delivered in an Intensive Care Unit, concerning the use of pneumonia prevention and control measures in high-risk patients on mechanical ventilation. In this descriptive and exploratory research, 839 observations of patients under invasive ventilation care were carried out, between November 2009 and January 2010, using the Indicator of Evaluation of Adherence to Prevention and Control Measures in High-risk Patients (IRPR). Some isolated measures that compose the mentioned indicator reached rates close to 100%, but the general compliance rate with all prevention and control measures of ventilator-associated pneumonia was 26.94%. It is concluded that, although the evaluated practices are accomplished at the unit, systematic evaluations of the interventions is needed so as to permit the discussion and practice of other educational strategies by the health team.


Introduction
Health institutions have adopted different strategies in recent years to assess services, with a view to obtaining a certification level according to the service quality they offer.According to one study (1) , available activities to guarantee the accomplishment of this process can be divided in internal and external, Thus, clinical indicators have been increasingly used as essential tools, defined as a continuous or periodical quantitative measure of a given process or system's Silva LTR, Laus AM, Canini SRMS, Hayashida M.
variables, characteristics or attributes, which permits recognizing wanted or unwanted results that can guide the establishment of the best health practices (2) .
Indicators can incorporate health quality assessment dimensions (3) , i.e. structure, process and outcome, which are mutually complementary to obtain a better quality and contribute to improve the results.The advantage of using one assessment type will depend on the event one intends to measure (2) .
Hospital infections (HI) raise morbidity and mortality rates, extend the duration of patients' hospital stay and, consequently, increase costs for health services.Various measures strongly based on scientific evidence exist for their prevention and control, but health professionals' use of these measures is still a great challenge (2) .
Regarding cost, three times higher costs have been reported for patients with infection when compared with uninfected patients.Despite the legislation in force in Brazil, HI rates remain high at 15.5%, corresponding to 1.18 infection episodes per patient hospitalized in Brazilian hospitals (4) .
Among the main nosocomial infections, pneumonia stands out, which figures among the five most frequent nosocomial infections in people older than 65 years in the USA and is still considered the main cause of death in developing countries (5) .
Pneumonia is the second main nosocomial infection and, at Intensive Care Units (ICU), when associated with mechanical ventilation, it is the infection that most affects hospitalized patients, with incidence rates ranging between 9% and 68%, depending on the diagnostic method used and the study population (6) .
This information is in line with the findings of a study (7) that determined HI incidence at a Brazilian adult ICU, in which pneumonias added up to 25.6%.
Therefore, accomplishing surveillance for mechanical ventilation-associated pneumonia (MVAP), using standardized ICU definitions, calculating MVAP rates and, mainly, associating these rates with pertinent prevention measures are strongly recommended actions.
These indicators can turn into an important ally for care quality assessment (8) .
In view of the above, it was considered pertinent to accomplish this study, aimed at assessing the health care quality delivered at an ICU regarding the use of pneumonia prevention and control measures in patients under mechanical ventilation care, limited consciousness and/or nutrition through digestive tubes, and at calculating the adherence rate through a clinical indicator.

Methods
A descriptive and exploratory study with a quantitative approach was accomplished at two founded, so that adherence rates can be calculated after the assessment (9) .
With a view to checking the inclination angle of the headrest, a goniometer fixed to the headrests was used, available at the units.
It is highlighted that, due to the practices and responsibility for the type of activities assessed, only the nursing and physiotherapy teams' activities were observed.
To calculate the general adherence rate, according to the IRPR indicator's formula, the total number of Total number of patients under ventilatory care and with limited consciousness and/or nutrition through digestive tubes in which all hospital pneumonia control components are correctly applied X 100 Total number of patients assessed under the conditions described in the numerator observations was considered in which all measures were conforming for the same patient.Thus, it was enough for one of the four measures not to be correctly applied for adherence not to be obtained in that patient.
To calculate the adherence rates for the practices included in the indicator that was applied, the formula recommended in the operational construct was used, as described below, assessing the IRPR's general adherence, as well as adherence for each indicator component.
The researcher collected the data together with three nurses experienced in intensive care, who had been properly trained for assessment and data collection.

Results
During the study period, 114 patients were hospitalized at the study hospital's ICU and 38 complied with the inclusion criteria.Male patients predominated (68.4%) and ages ranged from 19 to 82 years.As for origin, most patients came from the Surgical Unit, with 11 (28.95%)coming from the Recovery Room and five (13.16%) from the Operating Room, while eight   The general adherence rate, which considers the sum of the four correct measures at the same time, corresponded to 26.94%.This rate varied among the shifts.This result differs from the rates found in a study at an adult ICU of a public teaching hospital, in which three process units were applied to assess the MVAP prevention and control practices, including the IRPR indicator, with a general adherence rate of 68%, below the rate the author expected (80%) (9) .
The calculation of isolated measures revealed that "keeping the headrest at 30-45°" and "respiratory physiotherapy care" were the main factors responsible for not achieving general adherence, ranging from 46.26% to 52% and from 31.05% to 44.76%, respectively.The measures that exceeded this adherence rate were the use of sterile solution, with 100% during the afternoon shift, and respiratory therapy material change (adherence rates between 94.22% and 96.49%), demonstrating that these recommendations are well established in care delivery to patients under mechanical ventilation.
As for low adherence to the recommended headrests at 30-45º, it is highlighted that most beds have a goniometer (instrument used for this measurement), and that moments when patients were undergoing procedures that demanded changes in headrest height were not taken into account.Besides, the 424 cases on non-adherence to the raised headrest referred to lower degrees than recommended and occurred across all periods, with heights bordering on 20-25°.This data was found in another study (9) , which identified non-adherence rates of 75% (morning shift), 77.4% (afternoon) and 82.2% (night).These results show that many professionals are not accustomed to checking the headrest height with the goniometer, but merely restrict themselves to visual impression.
Critically ill patients frequently suffer from depressed consciousness levels and impaired vomiting reflex, so that contaminated secretion joins in the posterior part of the oropharynx (10) .Thus, keeping the headrest at 30-45° represents benefits to reduce the risk of gastric content reflux and aspiration in patients undergoing mechanical ventilation (11) .This measure is recommended in the guidelines of the Centers for Disease Control and Prevention (CDC), with evidence level II.Its application has been suggested in patients submitted to MV e/or enteral tube use since 2003 (12)(13) and, although it represents a simple and low-cost non-pharmacological measure, it still lacks further incorporation by health professionals involved in care practice (9,(14)(15) .
A study that analyzed nurses' adherence to clinical guideline recommendations for the prevention of MVAP presents that 96.8% of professionals informed using protective gloves and gowns in view of the risk of contamination with biological material, 88.5% applied respiratory physiotherapy to patients, 84.3% followed the institution's routine regarding mechanical ventilator circuit change, 76.4% placed the headrest at 30-45°, among other measures mentioned (16) .The semirecumbent position (30-45°) was also recommended in a systematic literature review (17) , because it showed a reduction in MVAP incidence and was a low costmeasure.
A study (18) that directly observed MVAP prevention and control measures in care practice analyzed the introduction of three new prevention measures into the should be changed once per week in the same patient.As for patients' headrest positioning at 30-45°, 90% of participants reported that they knew the recommendation (19) .
The implementation of clinical MVAP guidelines published by the CDC was assessed in a study (10) that involved 1200 nurses, who participated in two educational events in the United States.The results showed that 34% of the nurses affirmed that they kept the headrest raised at 30-45° during 75% of the day, and 52% the whole day.
An integrative literature review (20) on MVAP prevention measures showed that the semi-recumbent position seems to play a role in MVAP prevention, although the authors appoint the need for better designed studies to recommend this measure safely and effectively.
Besides keeping the headrest raised, another assessed measure that contributed to non-adherence was physiotherapy care.In controlled studies that assessed the importance of physiotherapy for pneumonia prevention, it was observed that thoracic physiotherapy was an independent factor associated with MVAP reduction, suggesting the benefit of this technique for MVAP prevention (21)(22) .Other authors (15) , however, appoint that there is no evidence on the efficacy of percussion and vibration techniques to prevent MVAP.
Research on adherence to physiotherapy care is scarce.In this study, the adherence rate of 57.64% remains below the rates found for the adoption and application of clinical guideline recommendations for MVAP prevention by nurses (16) , who appointed that respiratory physiotherapy was performed in 88.5% of cases.It should be highlighted that, in that study, the research population consisted of nurses and, among them, the authors found adherence to 19 nonpharmacological MVAP prevention measures.
Physiotherapy care was assessed based on patient file records, in line with IRPR orientations and, hence, procedures performed may not have been registered.
Therefore, although it demands more time, direct observation is the most adequate technique to assess this item (9) .
The results obtained in this research appointed low adherence rates, mainly because the institution is a teaching hospital.Higher adherence levels were expected for specific MVAP prevention and control measures, as

Conclusions
The adherence rate in this study corresponded to 26.94%, although some isolated measures from the IRPR indicator reached rates bordering on 100%.Keeping the headrest at 30-45° showed the lowest adherence across all shifts assessed.Although this is a simple recommendation that demands little time, professionals' low adherence to this measure is evidenced.
Some measures analyzed are routine nursing activities inside the unit, appointing the need for systematic assessment.Besides the educative process, this involves issues related to supervision and care management at the unit, as standards, although established, have not always been incorporated into clinical practice.Thus, the health team at these units should discuss and put in practice other educative strategies.
The use of indicators can be incorporated as a useful measure to assess the quality of the services delivered, due to their easy application and reproduction.
Internal Quality Assessment, Nursing Audit, Hospital Infection Prevention and Control, Research Ethics, Risk Management, Internal Accident Prevention Commissions and Permanent Education, Client and Hospital Accreditation Services.
Approval for the research was obtained from the Institutional Review Board at the study institution (HCRP Process No 11193/2008).

( 21 .
05%) came from the Care room for patients with multiple traumas.ICU time ranged between one and seven days in 44.74% of patients.In total, 839 observations of MVAP prevention and control measures were accomplished according to the IRPR indicator, 277 during the morning and afternoon shifts and 285 at night.This difference was due to the hospitalization and discharge times after the established time for data collection, thus increasing observation opportunities during the night shift.
the HICC's activities at the research institution, and even more at the ICU under study, have been intense, mainly regarding professionals' training on adherence to infection prevention measures.It is highlighted that, months before the start of data collection, the HICC organized a recycling course for the nursing team on the main health service-associated infection and their prevention measures, evidencing the magnitude of the research findings.One limitation in this study was the fact that no other important measures were assessed, such as adherence to hand washing, oral hygiene, assessment of the presence of condensate in the respirator circuit and humidifying filter change, which can affect a reduction in infection density rates and MVAP.

Table 1 -
Distribution of patient observations in absolute figures and respective general adherence percentages, per work shift, for specific MVAP prevention and control measures, Ribeirão Preto, SP, Brazil, 2009-2010

Table 3
presents the situations found that determined non-adherence to MVAP prevention and control measures in each work shift.www.eerp.usp.br/rlaeSilva LTR, Laus AM, Canini SRMS, Hayashida M.

Table 2 -
Total number of observations and adherence and non-adherence rates for each specific MVAP prevention and control measure, per work shift, Ribeirão Preto, SP, Brazil, 2009-2010 *No physiotherapy during the night period

Table 3 -
Non-adherence rates to each specific MVAP prevention and control measure, according to work shift, DiscussionHI represent a significant risk for users' health.According to the Manual of Hospital InfectionControl Practice Quality Assessment Indicators(2), an assessment and qualification system for the control and prevention of infections caught in health services (ICHS) needs to be constantly updated, incorporating new practices and approaches that are able to handle www.eerp.usp.br/rlaeRev.Latino-Am.Enfermagem 2011 Nov.-Dec.;19(6):1329-36.
incidence reduction protocol at five ICU's in the same hospital, involving medical and nursing teams.