Effect of a Nursing Practice Promotion Program in Prevention of Ventilator-Associated Pneumonia in Intensive Care Units of a Tertiary Care Hospital in a Middle-Income Country

Background: Ventilator-associated pneumonia (VAP) poses a significant healthcare challenge in intensive care units, particularly within the cardiovascular-thoracic surgical ICU (ICU-CVT), which experiences elevated rates compared to overall hospital averages. Objective: This quasi-experimental study aimed to assess the effectiveness of a nursing practice promotion program grounded in Herzberg's Motivation Theory to enhance VAP prevention practices and reduce incidence rates in the ICU-CVT of a tertiary care hospital. Methods: A one-group pretest-posttest design was implemented involving 15 registered nurses and mechanically ventilated patients (48 pre-intervention, 32 post-intervention) from November 2023 and February 2024. The intervention focused on motivating factors (group discussions, feedback, recognition, training, and role modeling) and hygiene factors (clear guidelines, adequate equipment, supportive supervision, and effective communication). Data were collected via a knowledge assessment, a practice observation form based on the WHAPOS protocol (Weaning, Hand hygiene, Aspiration precautions, Prevention of contamination, Oral care, and Suction), and VAP surveillance. Statistical analysis included descriptive statistics, chi-square tests, and VAP rates per 1,000 ventilator-days. Results: Following the intervention, compliance with VAP prevention guidelines among nurses significantly increased from 40% to 90% (p<0.04). Notable improvements were recorded in patient assessments using weaning protocols (10.70% to 100%, p=0.002), hand hygiene practices (64.50% to 100%, p=0.003), and oral care (29% to 100%, p<0.001). However, VAP incidence rates did not show a significant difference between pre- and post-intervention periods (5.18 vs. 5.78 per 1,000 ventilator-days). It is important to note that post-intervention patients had significantly higher APACHE II scores (16.71 vs. 28.22, p<0.0001), indicating greater illness severity. Conclusion: The nursing practice promotion program effectively increased adherence to VAP prevention guidelines, yet did not lead to a reduction in VAP incidence rates. This outcome may be attributed to patient-specific risk factors, including higher illness severity in the post-intervention group. These findings highlight the necessity for comprehensive VAP prevention strategies that not only enhance nursing practices but also address individual patient risk, particularly in high-risk populations with complex medical conditions 1. Haque M, Sartelli M, McKimm J, Bakar MA. Health care-associated infections–an overview. Infect Drug Resist. 2018;11:2321-2333. doi:10.2147/IDR.S177247 2. Kollef MH, Hamilton CW, Ernst FR. Economic impact of ventilatorassociated pneumonia in a large matched cohort. Infect Control Hosp Epidemiol. 2012;33(3):250-256. doi:10.1086/664049 3. Duangmanee D, Sawawiboon C, Klaewkasikij P, Chantanalage R, Suebklay S. Incidence of ventilator-associated pneumonia in intensive care unit, Faculty of Medicine, Vajira Hospital. Vajira Med J. 2016;60(3):201-209. doi:10.14456/vmj.2016.21 4. Lertloykulchai T. The incidence and etiology of hospitalacquired pneumonia and ventilator-associated pneumonia in Somdetphraphutthaloetla Hospital. Chonburi Hosp J. 2021;46(2):121- 121. 5. Kalyan G, Bibi R, Kaur R, Bhatti R, Kumari R, Rana R, et al. Knowledge and practices of intensive care unit nurses related to prevention of ventilator-associated pneumonia. Iran J Nurs Midwifery Res. 2020;25(5):369-375. 6. Herzberg F, Mausner B, Snyderman BB. The motivation to work. 2nd ed. John Wiley 1959. 7. Bandura A. Social foundations of thought and action: A social cognitive theory. Prentice-Hall; 1986. 8. Jansson M, Ala-Kokko T, Ylipalosaari P, Syrjälä H, Kyngäs H. Effect of an education intervention on nurses' knowledge and practice related to ventilator-associated pneumonia. Nurs Crit Care. 2013;18(4):191-197. 9. Khan RM, Hassan R, Bilal S, Sultana P, Ali Z. Effectiveness of an educational program on knowledge and practices of nurses regarding ventilator associated pneumonia in intensive care unit. Pak Armed Forces Med J. 2021;71(2):547-552. 10. Tantrakul T, Kachana S, Multongsong S. Development of practice guidelines for ventilator-associated pneumonia prevention in intensive care units. J Health Sci. 2019;28(2):103-112. 11. Knowles MS. Andragogy in action: Applying modern principles of adult learning. Jossey-Bass; 1984. 12. Álvarez-Lerma F, Palomar M, Olaechea P, Otal JJ, Insausti J, Cerdá E. Prevention of ventilator-associated pneumonia: The multimodal approach of the Spanish ICU "Pneumonia Zero" program. Crit Care Med. 2018;46(2):181-188. 13. Sharma H, Singh D, Pooni P, Mohan U. Impact of nursing education on prevention of ventilator-associated pneumonia in neonate. Nurs Midwifery Res J. 2016;12(4):177-185. 14. Rosenthal VD, Jin Z, Memish ZA, Rodrigues C, Myatra SN, Kharbanda M, et al. Multinational prospective cohort study of rates and risk factors for ventilator-associated pneumonia. Antimicrob Steward Healthc Epidemiol. 2023;3(1):e6.Chen GJ, Chen SH, Tien KL, Pan SC, Chen YC. Epidemiology and disease burden among hospital-acquired pneumonia/ventilator-associated pneumonia patients in a tertiary care hospital. J Microbiol Immunol Infect. 2022;55(5):892-898 16. Reason J. Human error. Cambridge University Press; 1990. 17. Jain PK, Gupta S, Kumar R, Raghuwanshi S. Impact of nurseled implementation of a ventilator bundle on the incidence of ventilator-associated pneumonia in intensive care unit. Nurs J India. 2016;107(1):21-26. 18. Plsek PE, Greenhalgh T. Complexity science: The challenge of complexity in health care. BMJ. 2001;323(7313):625-628.