eMETHODS
Details of Knowledge Translation Intervention
The implementation strategy, consisting of an educational strategy, reminder systems and local
implementation teams led by local opinion leaders (eTable 2), was based on the awareness, agreement,
adoption and adherence model [1-3] and a framework developed for guideline implementation in the
ICU [4]. The framework in these models emphasizes the specific roles of the knowledge translation
interventions and considers the perspectives of both providers (i.e. ICU clinician) and healthcare systems
(i.e., ICU). Within these models, education raises clinician awareness, local opinion leaders are the
enablers, and reminders can reinforce adherence.
The 14 guideline recommendations were divided into sections targeting the most appropriate
clinician group (e.g., airway management targeted to respiratory therapists, antibiotic recommendations
targeted to physicians). Each group was provided a full document and an executive bedside reference
guide.
The educational strategy was developed by the central study team, which consisted of a multidisciplinary team of 2 physicians (JM, TS), an ICU nurse educator, and a respiratory therapist. A
standardized 30-minute slide presentation was developed in 3 formats: (1) electronic version for groupbased teaching, (2) paper-based handout for one-on-one teaching, and (3) a web-based version for
individual learning. A document itemizing frequently asked questions (FAQs) was available along with
selected key VAP publications, and the published VAP guidelines [5,6]. A web-based self-assessment
quiz was developed for all multidisciplinary ICU clinicians to assess their knowledge about VAP and the
guideline recommendations.
The reminder systems consisted of a bedside patient rounds checklist (incorporating the
recommendations) integrated into daily morning bedside patient rounds, and monthly newsletters (each
focusing on a specific recommendation) prepared by the central study team, distributed to each ICU.
Page 1 of 12
Local opinion leaders assembled a local guideline implementation team consisting of an ICU
physician, nurse or nurse educator, respiratory therapist, and a pharmacist. The implementation team
was responsible for the educational strategy and reminders.
Before study initiation, a one-day workshop was held for all opinion leaders, during which
educational materials were distributed, change concepts introduced, and guideline use discussed. The
initial implementation strategy was standardized in all ICUs. After baseline data collection, at each site,
the local implementation teams presented educational materials (e.g., group or one-on-one presentations
to ICU staff, ICU housestaff seminars, email distribution of materials and/or group presentation to ICU
attending physicians), distributed educational materials at the bedside (e.g., summary of guidelines,
illustrations, FAQs, etc) and introduced the reminder systems.
Details of VAP Adjudication Process
Patients were screened daily, in consultation with the attending physician, by research
coordinators for the development of clinically suspected VAP according to predefined criteria. A
clinically suspected VAP was defined as new or persistent infiltrates on a chest x-ray plus 2 of abnormal
white blood cell count, presence of fever or hypothermia, purulent sputum, and deterioration in gas
exchange [7]. If the attending physician agreed that a clinical suspicion of VAP was present, this was
entered into the case report form. Once the patient was discharged from the ICU, the site principle
investigator reviewed the case report form to ascertain that the patient’s clinical course, culture results
and response to antibiotics was compatible with VAP. Thereafter, once the patient was discharged from
the hospital, all cases of suspected VAP were reviewed by the central adjudicators (TS, JGM) again to
ascertain that criteria were met for a clinical suspicion of VAP and that the patient’s clinical course,
results of any cultures and response to antibiotics were compatible with VAP. For each suspicion of
VAP, the appropriateness of empiric therapy and whether empiric therapy was initiated with
monotherapy or combination therapy was abstracted. For patients who were adjudicated for as having
Page 2 of 12
VAP the duration of antibiotic therapy was determined. For patients who were not adjudicated to not
have VAP, appropriate discontinuation of antibiotic therapy was determined.
Page 3 of 12
eReferences
1. Abraham C, Sheeran P, Johnston M. From health beliefs to self-regulation: the theoretical advances
in the psychology of action control. Psychol Health 1999;13(4): 569-593.
2. Pathman D, Konrad T, Freed G, Freeman V, Koch G.. The awareness-to-adherence model of the
steps to clinical guideline compliance: the case of pediatric vaccine recommendations. Med Care
1996; 34 (9): 873-89.
3. Kreuter M, Holt C. How do people process health information? Applications in an age of
individualized communication. Current Directions in Psychological Science 2001;10(6): 206-209.
4. Sinuff T, Cook D, Giacomini M, Heyland D, Dodek P. Facilitating guideline adherence in the
intensive care unit: A Multicentre Study. Crit Care Med 2007; 35(9): 2083-2089.
5. Muscedere J, Dodek P., Keenan S, et al. for the VAP Guidelines Committee and the Canadian
Critical Care Trials Group. Comprehensive Evidence-Based Clinical Practice Guidelines for
Ventilator Associated Pneumonia: Prevention. J Crit Care, 2008; 23(1): 126-137.
6. Muscedere J, Dodek P, Keenan S, et al. for the VAP Guidelines Committee and the Canadian
Critical Care Trials Group. Comprehensive Evidence-Based Clinical Practice Guidelines for
Ventilator Associated Pneumonia: Diagnosis and Treatment. J Crit Care, 2008; 23(1): 138-147.
7. Horan T, Andrus M, Dudeck M. CDC/NHSN surveillance definition of health care-associated
infection and criteria for specific types of infections in the acute care setting. Am J Infect Control
2008; 36(5): 309-332.
Page 4 of 12
eFigure 1: Variability in the Incidence of Ventilator Associated Pneumonia Across Sites
Legend for eFigure 1: Variability of the incidence of ventilator associated pneumonia across the 11 sites
over a 24-month duration. VAP = Ventilator Associated Pneumonia
Page 5 of 12
eTable 1: VAP Guideline Prevention, Diagnosis, and Treatment Recommendations
Prevention Recommendations
Exclusions
Route of Intubation
We recommend that the orotracheal route of intubation
should be used when intubation is necessary.
 Maxillofacial trauma
 Head and neck surgery
 Difficult intubation
 No exclusions
Frequency of Ventilator Circuit Changes
We recommend new circuits for each patient, and changes
if the circuits become soiled or damaged, but no scheduled
ventilator circuit changes.
 HMEa soiled
 Excessive moisture on
We recommend changes of heat and moisture exchangers
HME
for each new patient every 5-7 days, and as clinically
indicated.
Frequency of Change Of Airway Humidification
 No exclusions
Type of Endotracheal Suctioning System
We recommend the use of closed endotracheal suctioning
system.
Frequency of Change of Endotracheal Suctioning
System
 Soiled or tear in outer
sleeve
 Malfunction of system
We recommend that closed endotracheal suctioning
systems be changed for each new patient and as clinically
indicated.
 Nasally intubated,
 Tracheostomy tube
We recommend the use of subglottic secretion drainage in  Difficult endotracheal
patients expected to be mechanically ventilated for > 72
intubation
hrs.
Subglottic Secretion Drainage
Page 6 of 12
 Patient on vasopressors
or undergoing
We recommend that the head of the bed be elevated to 45
resuscitation
degrees. Where this is not possible, attempts to raise the
 Spine unstable or not
head of the bed as near to 45 degrees as possible should be cleared
considered.
 Pelvic instability or
fractures
 Prone position
 Intra aortic balloon
pump in femoral
vessels
 Obesity
 Procedures (includes
bathing)
Semi-Recumbent Positioning
Oral Antiseptic: Chlorohexidine
The use of the oral antiseptic chlorohexidine should be
considered.
a
 Allergy
 Lack of access to
patient’s oral cavity
HME = Heat and Moisture Exchangers
Diagnosis Recommendation
Exclusions
 Patients known to be
colonized or previously
We recommend that, if empiric antibiotic therapy is being
infected with
initiated at the time VAP is suspected that endotracheal
Pseudomonas sp. or
aspirates with nonquantitative cultures be used as the
MDRa organisms,
initial diagnostic strategy.
 Immunocompromised
patients
Invasive vs. Non-Invasive Techniques
a
MDR = Multi-drug Resistant
Treatment Recommendations
Exclusions
Empiric vs. Delayed Culture Directed Therapy
We recommend empiric therapy when there is a clinical
suspicion of VAPa.
Page 7 of 12
 No exclusions
Mono therapy vs. Combined Empiric Antibiotic
Therapy
We recommend appropriate spectrum effective
monotherapy for empiric therapy of VAP.
Choice of Antibiotics (e.g., Antibiotic “A” vs. “B”)
 Patients known to be
colonized or previously
infected with
Pseudomonas sp. or
MDRb organisms,
 Immunocompromised
patients
 No exclusions
We recommend that the antibiotic treatment of VAP be
based on local resistance patterns and patient factors.
Antibiotic Discontinuation Strategy Based on Clinical
Criteria
 No exclusions
We recommend that an antibiotic discontinuation strategy
be utilized for the empiric treatment of suspected VAP.
Duration of Antibiotic Use for Confirmed VAP
We recommend a maximum of 8 days of antibiotic
therapy for the treatment of VAP, in patients who receive
adequate initial antibiotic therapy.
a
VAP = Ventilator Associated Pneumonia
b
MDR = Multi-drug Resistant
Page 8 of 12
 Immunocompromised
patients
eTable 2: Multifaceted Behavior Change Intervention
Intervention
Description
Education
Educational Package Consisting of:
 Summary of guideline recommendations targeted for each ICUa
clinician group
 Bibliography of evidence based literature to support each
recommendation
 Bedside illustrations and algorithms (included all recommendations)
 Frequently asked questions and answers
 Power-point presentation for multi-disciplinary rounds or seminar
presentation
 Electronic version of power-point presentation
 Educational material for one-on-one teaching
 Web-based self assessment quiz with answers
Bedside daily morning rounds checklist for the following
recommendations:
 Semirecumbent position (head of bed elevation >45 degrees)
 Use of chlorhexidine for oral care
 Daily assessment of suspicion of VAPb
 Daily assessment for discontinuation of antibiotics for VAP treatment
Monthly electronic distribution of newsletter highlighting a specific VAP
guideline recommendation.
Incorporation of guideline recommendations into pre-printed orders.
3-4 local team consisting of a local opinion leader (usually a physician)
plus an ICU nurse, ICU nurse educator, ICU respiratory therapist, and/or
ICU pharmacist.
Guideline implementation team was responsible for provision of
education to all ICU clinician groups at baseline and throughout the study.
Reminders
Local Opinion Leader
and Guideline
Implementation Team
aICU
b
= Intensive Care Unit
VAP = Ventilator Associated Pneumonia
Page 9 of 12
eFigure 2: Example of Concordance Rate Calculation for VAP Guideline for a Patient Admitted
to the ICU
Concordance Rate is
Patient days for patients who are eligible for semirecumbency and are semirecumbent PLUS patients who
_______________are ineligible for semirecumbency and are not semirecumbent____________________
Total Number of Patient Days
For the example depicted in the table below, guideline oncordance rate for semirecumbency is 83%, where
eligibility for semi-recumbency recommendation:
1.
2.
3.
4.
5.
Patient has been intubated greater than 48 hours
Patient is not hypotensive (Mean > 65 mmHg)
Patient is not undergoing a procedure at time of assessment
Patient is not receiving nursing care at time of assessment
Patient has a specific contra-indication for semirecumbency (e.g., Spine
fracture)
Page 10 of 12
eTable 3: Example of Concordance for VAP Guideline for a Patient Admitted to the ICU
Guideline
Recommendation
Prevention
Semirecumbency
Day 1
Day 2
Day 3
Day 4
Day 5
Day 6
Observation
Eligible for
Guideline
recommendation
(Y/N)
Received Guideline
recommendation
(Y/N)
Guideline
Concordance
(Y/N)
Patient
semirecumbent
Hypotension at
time of guideline
assessment
Y
Y
Y
N
N
Y
Central line
insertion at time
of guideline
assessment
Patient prone due
to ARDS
management
Patient being
bathed
Patient supine
and no reason
found
N
N
Y
N
N
Y
N
N
Y
Y
N
N
Does not have
tube, ICU ran out
of tubes
Y
N
N
Endotracheal
Aspirate
Y
Y
Y
Ceftriaxone
Ceftazidime and
Ciprofloxacin
Y
Y
Y
N
Y
N
Use of Subglottic
Secretion Drainage
Diagnosis
Endotracheal
Aspirate for
Suspected VAP
Treatment
Single BroadSpectrum Antibiotic
for initial Treatment
of VAP
Episode 1
Episode 2
Page 11 of 12
eTable 4: Clinical Outcomes for Each Study Period
Clinical
Outcome
Baseline
(n = 330)
6 Month
(n = 330)
15 Month
(n = 330)
24 Month
(n = 330)
Duration of
Mechanical
Ventilation
(days)
median [IQR a]
8.9
[4.6, 45.2]
9.6
[4.7, 28.8]
8.5
[4.7,23.8]
8.1
[4.5, 28.3]
0.43
ICUb LOSc
(days)
median [IQR]
13.7
[7.4,undefined]
14.1
[7.0,undefined]
13.2
[7.7,69.5]
12.6
[7.4,undefined]
0.20
Hospital LOS
(days)
median days
[IQR]
62.0
[21.2,undefined]
57.1
[21.8,undefined]
48.7
[20.7,undefined]
43.5
[18.6,undefined]
0.02
ICU Mortality
No. (%)
94 (28.5)
85 (25.8)
72 (21.8)
84 (25.4)
0.26
Hospital
Mortality
No. (%)
126 (38.2)
119 (36.1)
98 (29.7)
100 (30.3)
0.03
a
IQR = Interquartile Range
ICU = Intensive Care Unit
c
LOS = Length of Stay
b
Page 12 of 12
P-value