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Background: Ventilator associated pneumonia is the most common hospital-acquired infection among patients receiving mechanical ventilation in pediatric intensive care unit. Using an evidence based guidelines for the prevention of ventilator associated pneumonia (VAP) are recommended. Objectives: to investigate nurses' knowledge and practice toward evidence-based guidelines for the prevention of ventilator associated pneumonia in pediatric intensive care units Methods: A quasiexperimental pre-post intervention study was done on 51 nurses of different categories working in medical, neurology and surgical ICU at Mansoura University children's Hospital, Egypt. Three tools were used; An interview questionnaire sheet was developed by the researcher in Arabic language. Nurses' knowledge of evidence-based guidelines for the prevention of VAP, multiple choice questionnaire and observational checklist for nurses' performance to ventilator bundles for VAP prevention. Results: mean score level of nurses general knowledge about VAP, Knowledge of Evidence-based guidelines for VAP prevention and nurses performance to ventilator bundled for VAP prevention where the mean score were 8.6078±1.9908, 2.4706±1.3469, 2.1400±1.4287 respectively before program implementation compared to 12.1569± 1.0464, 7.2941± 1.7005, 5.5800±1.5265 respectively after program. There is a highly significant difference between nurses knowledge and practices to Evidence-based guidelines for prevention of VAP before and after the program (t= -11.059, -22.106, -13.796 and p = .000, 0.000, 0.000 respectively). Conclusion: Adequate improvement in nurses' knowledge and practice after applied evidence based guidelines for prevention of ventilator associated pneumonia in pediatric intensive care unit. Keyword: Evidence based guidelines; nurses knowledge and practice; pediatric intensive care; ventilator associated pneumonia. INTRODUCTION Ventilator-associated pneumonia is pneumonia in mechanically–ventilated patients in intensive care units that develops later than or at 48 hours after the patient has been placed on mechanical ventilation.(1-3) VAP is the second most 172 Bull High Inst Public Health Vol.40 No.1 [2010] common hospital-acquired infection among pediatric intensive care unit (PICU) patients.(4) Empirical therapy for VAP accounts approximately 50% of antibiotic use in ICUs, surveillance studies of nosocomial infections in ICU patients indicate that pneumonia comprises 6.8 to 32.3% of nosocomial infections in this setting.(5,6) The incidence of VAP attributed mortality is difficult to quantify due to the possible confounding effect of associated conditions, but VAP is thought to increase the mortality of the underlying disease by about 30%. VAP is also associated with considerable morbidity, including prolonged ICU length of stay, prolonged mechanical ventilation, and increased costs of hospitalization.(7,8) Ventilator associated pneumonia is typically categorized as either earlyonset occurring in the first 3-4 days of mechanical ventilation or late –onset, this distinction is important microbiologically.(9) Early onset VAP is commonly caused by antibiotic –sensitive community acquired organisms, while lateonset VAP is commonly caused by antibiotic–resistant nosocomial organisms.(10) According to Centers of Disease Control and Prevention, the risk factors of VAP are thought to develop from the aspiration of oropharyngeal secretions containing potentially pathogenic organisms, aspiration of gastric secretions, supine position, and prolonged use of ventilatory support or potential exposure to contamination of ventilatory accessories, such as ventilator tubing, as well as poor infection control techniques by health care staff, and poor oral hygiene.(11, 12) The guidelines are designed to reduce the incidence of nosocomial pneumonia and is indented for use by personnel who are responsible for surveillance and control of infection in pediatric intensive care unit. When clinicians follow the care bundle guidelines for every patient it has been Abusaad &Tantawey 173 proven that this can reduce or eliminate VAP.(7) A care bundle is a cohesive set of evidence-based, well-established clinical practices that, when implemented together, achieve better patient outcomes than when implemented individually.(6) There is evidence in pediatrics that implementing a VAP prevention bundle, especially with a coordinated, multidisciplinary approach, can result in significant, sustained reduction in VAP rates, hospital length of stay, and costs.(13) Most of the children in the intensive care units are intubated and on ventilatory support. Intubated children are at increased risk of acquiring VAP because mechanical ventilation is the primary risk.(13) Nurses lack of knowledge may be a barrier to the adherence to evidence-based guidelines for preventing ventilator associated pneumonia.(14) As VAP is preventable and many practices have been demonstrated to reduce the incidence of VAP and its associated burden of illness, so educating health care workers who care for children receiving mechanical ventilation about the causes, manifestation, patho-physiology, risk factors and evidence-based preventive measures of VAP would promote nurses awareness for efficient quality of care and consequently decrease morbidity of ventilator associated pneumonia in pediatric intensive care setting. Aim of the study The aim of this study is to investigate nurses' knowledge and practice toward evidence-based guidelines for the prevention of ventilator associated pneumonia in pediatric intensive care units Research Hypotheses 1. Nurses have better knowledge about ventilator associated pneumonia and its prevention after implementation of training program regarding evidence based guidelines. 2. Nurses' practice related to ventilator bundles improved after 174 Bull High Inst Public Health Vol.40 No.1 [2010] implementation of training program regarding evidence based guidelines. SUBJECTS AND METHODS Design A quasiexperimental pre-post design was used. Setting and target population: The study was conducted in Pediatric Intensive Care units (medical, neurology and surgical ICU) at Mansoura University Children's Hospital, Egypt. Official permission was obtained from the administrator of selected intensive care units to conduct the study. Sample Size: 1. The subjects of the study were all available nurses (n= 51) of different categories working at the previously mentioned setting and who were providing care to all mechanically ventilated children over a period of three months regardless of their age, qualification or years of experience. 2. Informed consent was obtained from each nurse for participation after explaining the aim of the study and confidentiality of data. 3. Acceptance was obtained from ethical committee from faculty of nursing at Mansoura University to carry out the research. METHODOLOGY: Data collection: The data were collected using the following (pre/ post format). First: An interview questionnaire sheet was developed by the researcher in Arabic language after reviewing the related literatures.(9,15,16) the interview questionnaire was tested for its content validity by five jury members of pediatric and critical care nursing staff. A pilot study was done on five nurses to test the clarity of the questions and any unclear question was modified. The questionnaire comprised the following two parts Part I: Sociodemographic data of the nursing staff such as age, years of Abusaad &Tantawey 175 experience, level of education, working hours, previous training program about VAP prevention. Part II: This part concerned nurses' knowledge regarding ventilator associated pneumonia such as knowledge about the definition, risk factors, causes, manifestations and diagnostic criteria. Second: Nurses' knowledge of evidence-based guidelines for the prevention of VAP Questionnaire: Validated multiple choice questionnaire adopted from Labeau et al. (2007) (17) that included questions about : Oral vs. nasal route for endotracheal intubation, frequency of ventilator circuits changes, types of airway humidifier, frequency of humidifier changes, open vs. closed suction system, frequency of change in suction system, endotracheal tubes with extra lumen for drainage of subglottic secretion, kinetic vs. standard beds and Patient positioning. The nurses were interviewed individually to assess their knowledge (pre-test). A scoring system was applied to knowledge questions. The maximum score for the knowledge questions was 25. A score 0 was given for each incorrect answer and a score 1 for each correct answer. Third: Observational checklist for nurses' performance to ventilator bundles for VAP prevention: Adopted from Arlene et al. (2007) (18) that measures the compliance of nursing staff to ventilator bundle that was recommended as evidence based guidelines for the prevention of VAP such as the following items: frequent hand washing by all care providers and careful infection control practice, elevating head of bed 3045 degrees, unless contraindicated, monitoring gastric residuals every 4 hours in enterally fed patients to prevent aspiration, performing oral care using oral swab and chloroxideine every 2 hours, using separate suction catheter for tubing 176 Bull High Inst Public Health Vol.40 No.1 [2010] catheter and for oral suctioning, suction hypopharynx before endotracheal(ET), repositioning patient or repositioning ET tube and deflating cuff, using in – line ET tube suction system, keeping end of ventilator circuit, suction devices, manual ventilation bag and mask off the bed, draining ventilator condensate frequently without opening the circuit. Each nurse was observed by the researcher while performing the procedure of enteral feeding, suctioning, oral care, hand washing, bed positioning, and change of ventilator circuit from initiation of the procedure till termination to assess implementation of ventilator bu

Nurses Knowledge and Practice to Evidence-based Guidelines for the Prevention of Ventilator Associated Pneumonia in Pediatric Intensive Care Units