Effect of standardized orders and provider education on head-of-bed positioning in mechanically ventilated patients

A closed-book, multiple-choice examination following this article tests your under standing of the following objectives:1. Describe the risks and benefits of head-of-bed elevation. 2. Identify the findings at 30° and 45° head-ofbed elevation. 3. Discuss the early outcomes regarding head-ofbed elevation. Background Guidelines recommending head of bed (HOB) elevation greater than 30º to prevent ventilator-associated pneumonia conflict with guidelines to prevent pressure ulcers, which recommend HOB elevation less than 30º. Objectives To examine the feasibility of 45º HOB elevation and describe and compare the occurrence of reflux, aspiration, and pressure ulcer development at 30º and 45º HOB elevation. Methods A randomized 2-day crossover trial was conducted. HOB angle was measured every 30 seconds. Oral and tracheal secretions were analyzed for pepsin presence. Skin was assessed for pressure ulcers. Wilcoxon signed rank tests and

Section: Discussionmentioning

confidence: 73%

Section: Discussionmentioning

confidence: 95%

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Head-of-Bed Elevation and Early Outcomes of Gastric Reflux, Aspiration and Pressure Ulcers: A Feasibility Study

Schallom¹,

Dykeman²,

Metheny³

et al. 2014

“…The presence of a unit policy recommending semirecumbency did not affect backrest elevation. Various studies [33][34][35] have shown that implementation of unit protocols and objective measurement devices can result in improved compliance with semirecumbency. We did not directly assess nurses' awareness of unit protocols or use of measurement devices available to them in our study.…”

Section: Discussionmentioning

confidence: 99%

Semirecumbent Positioning in Ventilator-Dependent Patients: A Multicenter, Observational Study

Rose¹,

Baldwin²,

Crawford³

et al. 2010

Background Positioning of patients is a modifiable risk factor for ventilator-associated pneumonia. Current guidelines for prevention of ventilator-associated pneumonia recommend semirecumbency at 30º, with 45º preferable unless contraindicated. Objective To assess the use of semirecumbency for ventilator patients in Australian and New Zealand intensive care units. Methods In a multicenter, observational study, backrest elevation, mean arterial pressure, use of inotropic agents, enteral feeding, and weaning status were recorded 3 times per day by using a predetermined randomization schedule for 7 consecutive days (maximum 21 observation episodes). Severity of illness was recorded daily by using the Sepsis-Related Organ Failure Assessment (SOFA) score. Results Measurements (n = 2112) were recorded for 371 ventilator patients in 32 intensive care units. Backrest elevation at ≥45º was noted for 112 of 2112 (5.3%; 95% confidence interval [CI], 4.3-6.3) measurements; elevation ≥30º but <45º for 472 of 2112 (22.3%; 95% CI, 20.6-24.1). Contraindications to semirecumbency were noted during 447 measurements. Increased backrest elevation occurred during enteral feeding (2.2º, P < .001) and weaning (3.1º, P < .001). Decreased backrest elevation was associated with inotropic support (2.8º, P < .001), decreased mean arterial pressure (0.7º/10 mm Hg, P < .001), and organ failure (0.5º/1-point increment in SOFA max score, P < .001). For measurements recorded with no contraindication to semirecumbency, weaning status (P = .003) and SOFA max score (P = .008) remained associated with the degree of backrest elevation. Conclusions The findings of this multicenter, observational study suggest that backrest elevation was less than recommended and was influenced by clinical practices and patient condition.

“…Helman et al 32 suggests that nurses may be inclined to place patients in lower HOB positions at night to facilitate sleep. However, our findings do not support time of day as a predictor of HOB elevation.…”

Section: Time Of Daymentioning

confidence: 99%

A Nursing Clinical Decision Support System and Potential Predictors of Head-of-Bed Position for Patients Receiving Mechanical Ventilation

Lyerla

LeRouge

Cooke

et al. 2010

Background Patients receiving mechanical ventilation are at high risk for pneumonia due to aspiration. Published guidelines recommend elevating the head of the bed 30º to 45º, if not contraindicated, to reduce risk, but this intervention is underused. Objectives To facilitate incorporating evidence-based practice by improving positioning of patients receiving mechanical ventilation and to identify patient and nurse characteristics that predict use of the guideline. Methods A modified interrupted time-series design was used. Data were collected on 43 patients and 33 nurses 3 separate times in a 12-bed intensive care unit at a medium-sized hospital. A total of 105 observations were recorded for analysis each time. Results Mean elevations of the head of the bed increased significantly from phase 1 (27.7º) to phase 2 (31.7º) and from phase 1 to phase 3 (31.1º). Elevations were higher for tube-fed patients than for patients not given enteral tube feedings. Elevations were higher for patients with a pulmonary-related diagnosis and lower for patients with a gastrointestinal diagnosis than for patients with other diagnoses. Elevations were lower for patients with a body mass index between 25.0 and 29.9 (overweight) than for patients with other body mass index values. Nurse characteristics were not significant predictors of elevation. Conclusion A nursing clinical decision support system integrated into a patient's electronic flow sheet can increase nurses' adherence to guidelines. Pulmonary and gastrointestinal diagnoses, body mass index, and tube feeding are predictors of elevation of the head of the bed.