Aim: The primary objective of the study is to evaluate the Ventilator-associated pneumonia (VAP) bundle knowledge of critical care staff, comprising nurses and physicians, and to assess their compliance with the procedure. The second objective is to determine the incidence rate and risk factors of VAP in two hospitals.
Study design: A cross-sectional study was conducted at two hospital settings, namely adult ICUs at ACH and KAUH. The study population included 80 health practitioners (ICU physicians & nurses) comprising 40 practitioners from each hospital.
Results: Significant differences were observed between staff at ACH and KAUH in terms of knowledge (P = 0.001) and practices (P = 0.001) åfor prevention of VAP. A strong positive correlation was seen between knowledge and practices (r = 0.852, P < 0.001*). Conclusion: Staff knowledge regarding certain elements of VAP bundle was found inadequate, and the guidelines mentioned by CDC were incompletely implemented. There is a need to enhance co-operation between Department of Education and the Department of Infection Control to set up an intensive prevention programs to raise awareness among staff about transmission, prevention, and treatment of VAP. Key Words: Critical care staff, knowledge, compliance, ventilator associated pneumonia bundle INTRODUCTION Ventilator-associated pneumonia (VAP) is the second most common hospital acquired infection (HAI), which occurs in patients primarily due to invasive mechanical ventilation via tracheostomy or endotracheal tube intubation. VAP is prevalent in nearly 20% of the patients admitted in the Intensive Care Unit (ICU) and can result in increased ICU period, time spent on ventilator, and hospital stay. The in-hospital mortality could be as high as 46% as compared with patients without VAP at 32%. Depending on the stage of development, VAP can be classified as either early onset VAP (<5 days of mechanical ventilation) or late onset VAP (>5days).  
Following multiple recommended measures can curb VAP-causing infection, such as alcohol-based disinfection of hands, timely examination and removal of infected devices, and programs to limit the antibiotic prescribing practices. However, any single method is not sufficient for complete removal of the infection, therefore, requiring multiple approaches. Of these, the most widely used set of strategies is the VAP-bundle approach, which is based on 5-element practices. These include: a) elevating the head of bed between 30° and 45°; b) peptic ulcer prophylaxis; c) chlorhexidine based oral care; d) deep venous thrombosis prevention; e) daily assessment of sedation and spontaneous breathing trials. 
The technique has been proven effective in significantly reducing VAP rate; however, its implementation requires assessment of coordination and good administrative practices at both pre- and post-intervention levels. The role of critical care staff is vital to prevent VAP infection by decreasing the risk factors, identifiying initial symptoms, and supporting in the diagnosis. Thus, the success of VAP prevention and control relies majorly on educating the ICU staff and increasing their awareness toward the strategies to be followed. 
In the present study, our primary objective was to assess the knowledge and compliance of ctitical care staff at Asser Central Hospital and King Abdul-Aziz University Hospital, comprising physicians and nurses, and to determine the rate of VAP incidence, as well as risk factors, in these hospitals. 

Study design
The present cross-sectional study was conducted between …. and …. in two tertiary hospitals: Asser Central Hospital (ACH), which is a 750-bed hospital in the southern province of the Kingdom of Saudi Arabia and the teaching hospital of the King Khalid University medical faculty; and King Abdul-Aziz University Hospital (KAUH), which is an 890-bed hospital in the western province of the Kingdom of Saudi Arabia.
Study participants
The study included 80 health practitioners (ICU physicians and nurses) from the adult ICUs at ACH (27 beds) and KAUH (26 beds). The participants were randomly recruited according to the inclusion and exclusion criteria mentioned below. Healthcare staff, which provided direct care to mechanically ventilated patients were included in the study, whereas healthcare staff with less than 6 months experience were excluded. .
First part of the questionnaire included socio-demographic and background information of the participants such as age, sex, years of experience, and level of education. 
The second part comprised a 20-item knowledge questionnaire based on the guidelines by Centers for Disease Control and Prevention (CDC). This included 15 multiple choice questions and 5 true/false questions covering pathophysiology (4 items), risk factors (3 items), and preventive bundle practices (13 items) for ventilator-associated pneumonia. The scoring system for the questionnaire was as follows: each correct answer was given the score of “ONE”, whereas each wrong answer was scored “ZERO.” Based upon this scoring system, the knowledge level was categorized as Weak (<50%), Average (50%–75%), or Good (>75%). 
VAP bundle compliance tool
The checklist to assess VAP bundle compliance covered eight key areas: infection control measures (5 items), positioning strategies (1 item), endotracheal suctioning care (10 items), ventilator circuit care (5 items), oral care (2 items), testing of enteral feeding & peptic ulcer prophylaxis (3 items), weaning trials and extubation (2 items), and DVT prophylaxis (1 item). Each area included sub-items. The responses were scored “ONE”, if the answer was “comply” and “ZERO” if the answer was “not comply”. Based on this scoring system, the performance level was categorized as Weak (<50%), Average (50%–75%), or Good (>75%).
Data Collection 
The study protocol was approved by the ethics research committee in each hospital. Data collection was initiated by the researchers and every participant was explained the purpose and nature of the study. Participation in the study was entirely voluntary, the anonymity and confidentiality of the responses were assured. The participant were allotted 45–60 min to complete the sociodemographic and knowledge questionnaire sheet. The time for collecting data through this questionnaire lasted 2 weeks, after which the VAP bundle compliance tool was employed to assess individual practitioner who was caring for mechanically ventilated patient throughout shift (morning and night in KAUH) and (morning, evening, and night in ACH) for three consecutive times.

Data analysis
Categorical variables were analyzed with the ?2 test using Yates’s correction. Student’s t-test or Mann–Whitney U test was used to test the differences in distributions between two continuous variables. Data was entered and analyzed by using IBM SPSS Statistics version 22 (SPSS Inc., Chicago, IL, USA) and P values <0.05 were considered significant.  RESULTS Table 1 summarizes the sociodemographic information of study participants. Overall, the study included 80 participants, of which 69 were male and 11 were female. There was no significant difference between participants from ACH and KAUH in terms of gender/sex. However, a significant difference in participants' age, education and experience was seen between the hospitals (P < 0.001). While majority of the participants in ACH belonged to the 25–30 y age group, in KAUH, the participants were mainly >30 y old. Also, majority participants in ACH had Baccalaureate nursing (60%), whereas in KAUH, majority had technical diploma (73%). Interestingly, more than half the participants in KAUH (55%) had experience of >20 y, as compared with ACH (20%). Furthermore, we compared the incidence rate of VAP and the risk factors in the two hospitals and found that VAP rate (2013–2014) at KAUH was 1.7/1000 ventilator days, whereas that at ACH was 2.56/1000 ventilator days. Next, we tried to determine the types of risk factors, which could increase the rate of infection in each hospital. A significant difference in co-morbidity was seen in COPD patients (KAUH, 7.50%, ACH, 0%), DM patients (KAUH, 40%; ACH, 15%), Chronic renal disease (KAUH, 11.25%; ACH, 5%), and HF (KAUH, 8.75%; ACH, 2.5. In the Comparison between ACH and KAUH with reference to the type of admission, most of the cases that were admitted in ICU of KAUH (72.5%) were Medical, whereas in ACH, most of the cases admitted in ICU (72.5)% were Trauma cases. Additionally, 10% of infected patients died in ACH, as compared with 42.50% in KAUH, highlighting high rate of non-modifiable risk factors for VAP.
Moreover, no significant difference was seen between the hospitals in terms of knowledge of the route of endotracheal intubation (P = 0.20), type of airway humidifier (P = 0.022), open vs. closed suction systems (P = 0.165), frequency of change in suction systems (P = 0.11), and patient positioning (P = 0.619). However, the knowledge of frequency of ventilator circuit change (P = 0.001), frequency of humidifier changes (P = 0.002), and kinetic vs. standard beds (P < 0.001) significantly differed between the groups (Table 2).  In terms of following recommended care practices, no significant differences were seen in most of the practices. However, there was a significant difference in critical procedures such as certain infection control measures including washing hands before/after (P < 0.001) or between patients (P < 0.001), and changing gloves between patients (P = 0.03); patient positioning (P = 0.03); ventilator care measures such as periodically draining discards (P = 0.03) changing soiled heat moisture exchanger (P = 0.01); endotracheal suction care practices such as wearing sterile gloves with an open suction system, using sterile , using saline/distilled water, replacing the solution used for suction, and continuous aspiration of sub glottis secretions if the patient is on ventilator for >48 h.  The knowledge of participants also significantly differed in terms of peptic ulcer prophylaxis, such as checking gastric residual volume every 4 to 6 and administering intermittent feeding and 
following DVT prophylaxis. Moreover, no significant difference was seen in all practices relating to extubation and weaning trials (Table 3). 

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VAP is a critical issue in patients admitted to the ICU, which results in high morbidity and mortality. One of the foremost approaches to prevent such complication is educating the critical care staff about the preventive measures. In the present study, we assessed the knowledge of critical care staff about VAP in AUH and KUAH, the staff’s compliance with VAP bundle practices, and the incidence rate of VAP in the two hospitals and the risk factors.
For this study, we designed a comprehensive questionnaire developed as per Evidence-based guidelines. It was observed that most of the staff from both the hospitals was aware that oral route should be preferred for end tracheal intubation than nasal route (ACH, 80%; KAUH, 90%). This could be attributable to the knowledge acquired from work experience as oral intubation reportedly reduces the incidence of VAP by preventing the aspiration of infected secretions Kollef 2004.  
In 2007, Labeau reported the guidelines for VAP bundle, which recommend using heat and moisture exchangers and weekly changing the humidifiers or when indicated clinically. In our study, we observed that only majority of the participants recommended heat and moisture exchangers (ACH, 87.5%; KAUH, 65%), and 45.5% participants from ACH and 77.5% from KAUH mentioned changing humidifiers every 72 h (or when clinically indicated). Similar results were reported by Heyland et al. (2002), Ricart et al. (2003), and Sierra et al. (2005) who reported that 80%, 84%, and 96% respondents used heat and moisture exchangers. Furhtermore, Sierra et al. (2005) indicated that 75% of the ventilator circuits in ICUs were changed after every 36–72 h, and Blot & Labeau (2007)
eported weekly change or later in 76% respondents. 
Overall, 65.5% participant from ACH and 40% from KAUH recognized closed systems as recommended, whereas 7.5% from ACH and 12.5% from KAUH recommended open suction systems. Previous study by Heyland (2002) and Sierra (2005) have reported the use of closed systems in 88% of the ICUs in Canada but open system in 96% ICUs in Spain and highlighted that closed systems are not ordinarily used, thus suggesting the unacquaintedness with the recommended system. More than half of the staff in the present study identified that frequent change in suction systems decreases the risk and occurrence of pneumonia, and 87% participants in ACH and 27.5% in KAUH recognized that the risk and occurrence of pneumonia reduces by the use of kinetic beds. Moreover, 92.5% participants in ACH and 87.5% in KAUH answered that semi-recumbent positioning is advised, and it decreases the risk and occurrence of pneumonia. Similarly, Heyland (2002) & Sierra (2005) also reported that, in a study, nearly half the nurses identified the benefits of kinetic beds, and semi-recumbent positioning was also the accepted method to prevent VAP. 
Staff compliance with VAP bundle practices
Measures to control VAP-causing infection play a vital role in limiting the disease. Hand hygiene is the foundation of all infection-controlling practices. CDC highly advises hand washing hands prior to and after direct patient care or handling potentially contaminated articles (Tablan et al. 2004 & CDC 2004). Augustyn (2007) reported a direct correlation between not washing hands or changing gloves between patients and increased incidence of VAP. In our study, we observed a significant difference between the staff’s compliance with hand hygiene. Interestingly, 100% participants in ACH and 92.5% in KAUH showed agreement to maintaining head of bed elevation. Similarly, 
Jimenez & Vega (2009) also reported that 14% of evaluated cases, in pre-education component, were in agreement with the 30° or more elevation of the bed, and 74% of the cases were compliant to HOB elevation with an increase in 60%.
Moreover, 100% participants in ACH and 95% in KAUH agreed to maintain sufficient pressure in ETT cuff; however, only 87.5% participants in ACH and 20% in KAUH answered in favor of constant aspiration of the subglottic secretions, suggesting insufficient knowledge of this strategy. Comparable results were reported by Goncalves & Brasil (2012) who reported that the staff was inappropriately performing the calibration of intra cuff pressure of ETT, thus highlighting its low frequency (18.1%), and suggested measuring this pressure at least three times in a day. Furthermore, the lack of asepsis during suctioning care predominated among the staff, which could be due to the absence of training surveillance on infection control measures. The staff of ACH showed higher adherence to measures to control infection when employing tracheal suctioning or when working with suction equipment, as compared with KAUH, suggesting the need training programs for staff of KAUH to control infection.
Oral care is another factor which has a possible impact on the risk of developing VAP (Pruitt & Jacobs, 2006), as infected oral secretions can potentially flow to the subglottis and get aspirated subsequently, thus resulting in VAP. Therefore, adequate suctioning is advised to avoid pooling of secretions, hence reducing oropharyngeal colonization (Schleder, 2004). We observed that 97.5% participants in ACH and 90% in KAUH had knowledge of the advantage of providing timely oral care and its association with the incidence of VAP. Monitoring GRV every 4–6 h is strongly recommended for VAP prophylaxis, and administering intermittent enteral feeding is preferred over rather continuous feeding along with regular acidification of gastric feeding. We observed a significant difference between ACH and KAUH in terms of compliance with the abovementioned strategies; 95% particpants in ACH checked the GRV every 4–6 h and they have protocol to follow in these units even with patient receiving continuous enteral feeding, whereas only 37.5% participants in KAUH agreed, and the remaining staff in KAUH did not follow the recommended guidelines. This could be due to lack of knowledge and as the protocol in the unit mentions that checking GRV in asymptotic patient receiving tube feeding is not required and should be measured if the patient displays a clinical change.
Evaluating the patient’s willingness to extubated and using daily “sedation vacations” are important strategies followed in ventilator bundle, and previous studies have been associated these with a decrease in the rate of VAP (Kunis & Puntillo, 2003). These measures are related with shorter period of mechanical ventilation and prevention of VAP (Wood et al. 2007). In this study, these vital steps were performed by the staff with cooperation between the nurses and physician by following sedation vacation protocol and using weaning trials and interrupting sedation utilizing sedation scale.
The correlation between DVT prophylaxis and reducing rates of VAP is unclear. In our experience, applying DVT prophylaxis as a part of a package of interventions for ventilator care results in decreasing rate of pneumonia. The intervention is widely followed in general care of ventilated patients. However, we observed that 100% participants in ACH and 87.5% in KAUH complied with the guidelines of applying sequential compression or anti-embolic stockings. 
Furhtermore, the comparative study also showed a significant relation between knowledge and age where the practices increase in 20-25 years (f = 7.317, P-value < 0.001*). However, no significant association was seen with Gender (t = 0.085, P-value = 0.932), thus highlighting that knowledge and demographic data are not significantly related. Also, a significant strong positive correlation was seen between Knowledge and Practices (r = 0.852, P-value < 0.001*). Therefore, in conclusion, Staff knowledge pertaining to VAP bundle was found inadequate in some cases, and not all the CDC-recommended guidelines were implemented.  Our study had a few limitations. First, the sample size was small; hence the results did not completely reflect the knowledge and awareness of the two hospitals. Also, since the study focused on only two centers, these results cannot be generally applied to all the hospitals in the area. Nevertheless, these results lay the foundation for developing education programs for the critical care staff in both the hospitals, which focuses on improving the knowledge of key areas which are probably overlooked presently in these places.  Recommendations: Based on our results, we present the following recommendations for preventing VAP: - Encourage in-service education of the staff and incorporate evidence-based guidelines.  - Based on the present evidence-based guidelines, protolocls for VAP prevention should be developed and revised to ensure these are regularly followed in the ICUs.  - Every element of bundle evidence-based practices should be implemented as, cumulatively these display better outcomes than when followed separately.  - Co-operation between the Department of Education and the Department of Infection Control but be enhances to set up an intensive prevention programs to raise awareness among staff about modes of transmission and methods of prevention and treatment.


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