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(Chest. 2002;122:656-661.)
© 2002 American College of Chest Physicians

Why Do Physicians Not Follow Evidence-Based Guidelines for Preventing Ventilator-Associated Pneumonia?*

A Survey Based on the Opinions of an International Panel of Intensivists

Jordi Rello, MD, PhD; Carmen Lorente, MD; Maria Bodí, MD; Emili Diaz, MD; Maite Ricart, RN and Marin H. Kollef, MD, FCCP

* From the Critical Care Department (Drs. Rello, Lorente, Bodí, and Diaz, and Ms. Ricart), University Hospital Joan XXIII, University Rovira and Virgili, Tarragona, Spain; and the Pulmonary and Critical Care Division (Dr. Kollef), Washington University School of Medicine, St. Louis, MO.

Correspondence to: Jordi Rello, MD, PhD, Critical Care Department, University Hospital Joan XXIII, Dr Mallafre Guasch, 4, E43007 Tarragona, Spain; e-mail: jrc{at}hjxxiii.scs.es

Objective: Adherence to clinical practice guidelines is highly variable. Our objective was to review barriers to physicians’ adherence to evidence-based guidelines (EBGs) for preventing ventilator-associated pneumonia (VAP).

Methods: A questionnaire was administered to 110 opinion leaders on VAP from 22 countries to indicate whether 33 pharmacologic and nonpharmacologic practices that had been listed in a recent publication had been implemented in their ICUs. If these prevention strategies were not used, the respondents were asked to indicate one of seven reasons for nonadherence, with the objective of identifying barriers to adherence to EBGs.

Results: The overall nonadherence rate was 37.0%. The nonadherence rate was 25.2% for strategies recommended for clinical use, compared with 45.6% for strategies with less effectiveness (odds ratio [OR], 1.80). Pharmacologic strategies had a higher degree of nonadherence than nonpharmacologic strategies (OR, 2.92). Nonadherence to recommendations graded A, B, C, D, and U based on an objective assessment of the consistency of the supporting evidence was 41.3%, 35.7%, 16.0%, 45.7%, and 20.8%, respectively. The most common reasons for nonadherence were the following: disagreement with interpretation of clinical trials (35%); unavailability of resources (31.3%); and costs (16.9%).

Conclusion: We conclude that nonadherence to EBGs for preventing VAP was common and largely uninfluenced by the degree of evidence. A rational approach toward improving VAP guideline adherence should take into account the heterogeneous factors that influence physician adherence to them.

Key Words: evidence-based guidelines • ICU • nonadherence • prevention • ventilator-associated pneumonia




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