title: Management of ventilator-associated pneumonia in intensive care units: a mixed methods study assessing barriers and facilitators to guideline adherence.
abstract: Guidelines from the Infectious Diseases Society of America/The American Thoracic Society (IDSA/ATS) provide recommendations for diagnosis and treatment of ventilator-associated pneumonia (VAP). However, the mere presence of guidelines is rarely sufficient to promote widespread adoption and uptake. Using the Systems Engineering Initiative for Patient Safety (SEIPS) model framework, we undertook a study to understand barriers and facilitators to the adoption of the IDSA/ATS guidelines.
  
  
  
  We conducted surveys and focus group discussions of different health care providers involved in the management of VAP. The setting was medical-surgical ICUs at a tertiary academic hospital and a large multispecialty rural hospital in Wisconsin, USA.
  
  
  
  Overall, we found that 55 % of participants indicated that they were aware of the IDSA/ATS guideline. The top ranked barriers to VAP management included: 1) having multiple physician groups managing VAP, 2) variation in VAP management by differing ICU services, 3) physicians and level of training, and 4) renal failure complicating doses of antibiotics. Facilitators to VAP management included presence of multidisciplinary rounds that include nurses, pharmacist and respiratory therapists, and awareness of the IDSA/ATS guideline. This awareness was associated with receiving effective training on management of VAP, keeping up to date on nosocomial infection literature, and belief that performing a bronchoscopy to diagnose VAP would help with expeditious diagnosis of VAP.
  
  
  
  Findings from our study complement existing studies by identifying perceptions of the many different types of healthcare workers in ICU settings. These findings have implications for antibiotic stewardship teams, clinicians, and organizational leaders.
authors.affiliation: William S. Middleton Memorial Veterans Hospital, Madison, WI, USA. ns2@medicine.wisc.edu.|Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA. ns2@medicine.wisc.edu.|Department of Infectious Disease, University of Wisconsin Hospital and Clinics, Madison, WI, USA. ns2@medicine.wisc.edu.
authors.forename: Nasia
authors.initials: N
authors.lastname: Safdar
authors.affiliation: Institute for Clinical and Translational Research, University of Wisconsin, Madison, WI, USA.
authors.forename: Jackson S
authors.initials: JS
authors.lastname: Musuuza
authors.affiliation: Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
authors.forename: Anping
authors.initials: A
authors.lastname: Xie
authors.affiliation: Center for Quality and Productivity Improvement, University of Wisconsin-Madison, Madison, WI, USA.
authors.forename: Ann Schoofs
authors.initials: AS
authors.lastname: Hundt
authors.affiliation: Department of Infectious Medicine, Marshfield Clinic, Marshfield, WI, USA.
authors.forename: Matthew
authors.initials: M
authors.lastname: Hall
authors.affiliation: R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA.
authors.forename: Kenneth
authors.initials: K
authors.lastname: Wood
authors.affiliation: Center for Quality and Productivity Improvement, University of Wisconsin-Madison, Madison, WI, USA.
authors.forename: Pascale
authors.initials: P
authors.lastname: Carayon
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001291:Attitude of Health Personnel; D005260:Female; D017144:Focus Groups; D019983:Guideline Adherence / Q000706:statistics & numerical data*; D019538:Health Care Surveys; D006801:Humans; D007362:Intensive Care Units / Q000592:standards* / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D053717:Pneumonia, Ventilator-Associated / Q000175:diagnosis* / Q000628:therapy*; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D014922:Wisconsin
keywords: Barriers and facilitators; Guidelines; Systems Engineering Initiative for Patient Safety; VAP; Ventilator-associated pneumonia