A simple device to increase rates of compliance in maintaining 30-degree head-of-bed elevation in ventilated patients

1
A simple device to increase rates of compliance
in maintaining 30-degree head-of-bed elevation
in ventilated patients
Zev Williams, MD, PhD Rodney Chan, MD Edward
Kelly, MD
From Brigham and Womens Hospital Boston, MA(ZW,
RC, EK) and Massachusetts General
Hospital, Boston, MA (ZW)

• Presenter R2 ???
• Supervisor Dr ???

Crit Care Med 2008 3611551157
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2

• Objective To determine whether a highly visible
  device that clearly indicates whether the
  head-of-bed is adequately elevated would increase
  rates of compliance with head-of-bed elevation
  guidelines
• Design A prospective, single-center, multi-unit,
  two-phase study
• Setting Surgical, thoracic, trauma, and medical
  intensive care units.
• Patients Cohort of intubated patients.

3
VAP is the most common hospital-acquired
infection in ICU

• It occurs in 9 to 40 of all ICU patients and
  has an incidence of 5 to 35 cases per 1000
  ventilator days
• 3x increased duration of mechanical ventilation,
  a 2-6x increase in ICU stay, a 2- to 3-day
  increase in hospital stay
• Each case of VAP increases hospital costs by
  40,000 to 50,000 and results in a 15 to 45
  increase in attributable mortality

4
Elevation of the head-of-bed (HOB) of intubated
patients is an effective method for reducing
rates of aspiration pneumonia
Semirecumbent position decreased rates of
aspiration of gastric contents four-fold
Torres A, Serra-Batlles J, Jos E, et al
Pulmonary aspiration of gastric contents in
patients receiving mechanical ventilation The
effect of body position. Ann Intern Med 1992
116540543
Head position 30 degrees in the first 24 hrs of
intubation was an independent risk factor for
developing VAP.
Kollef MH Ventilator-associated pneumonia A
multivariate analysis. JAMA 1993 27019651970
5
Drakulovic MB, Torres A, Bauer TT, et al Supine
body position as a risk factor for nosocomial
pneumonia in mechanically ventilated patients A
randomised trial. Lancet 1999 35418511858
Those patients in the supine position and
receiving enteral nutrition had the highest
frequency of VAP (50).
MVgt7 days GCSlt9
The only modifiable risk factor for the
development of VAP was elevation of HOB.
6
Tablan OC, Anderson LJ, Besser R, et
al Guidelines for preventing health-care
associated pneumonia, 2003 Recommendations of
CDC and the Healthcare Infection Control
Practices Advisory Committee. MMWR Recomm Rep
2004 53136
Elevating the HOB of a patient at high risk for
aspiration at an angle of 3045 degrees unless
this is contraindicated
Elevation of HOB as a means of preventing
aspiration pneumonia, and its intrinsic
cost-effectiveness, rates of adequate HOB
elevation remain low
HOB elevation as a method to reduce aspiration
pneumonia
Curtis JR, Cook DJ, Wall RJ, et al Intensive
care unit quality improvement A how-toguide
for the interdisciplinary team. Crit Care Med
2006 34211218
7
Grap MJ, Munro CL, Bryant S, et al Predictors of
backrest elevation in critical care. Intensive
Crit Care Nurs 2003 196874

• In one observational study, mean HOB elevations
  were only 1623 degrees with the vast majority
  (70 to 86) of patients being supine
• The purpose of this study was to determine
  whether a simple, easy-to-view, and
  easy-to-interpret device that displayed whether
  the HOB was adequately elevated could increase
  rates of compliance with HOB elevation
  guidelines.
• Additionally, we sought to determine whether the
  device was acceptable to nursing staff.

8
All HOB and calibration measurements were taken
using the Johnson Level 700 Magnetic Angle
Locator placed onto the side rail
Material cost 42
Silk suture
Steel nut
lt30 degree
gt30 degree
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Interventions

• A 4-wk trial was performed.
• At the onset of the trial, nurses were reminded
  to maintain head-of-bed elevation gt30 degrees.
• Over the subsequent 2 wks, head-of-bed elevations
  of intubated patient beds were measured.
• An Angle Indicator, designed to clearly display
  whether the head-of-bed was adequately elevated,
  was then placed on side rails of beds of
  ventilated patients, and head-of-bed elevation
  measurements were taken for an additional 2 wks.
• A survey was then handed out to nursing staff to
  assess satisfaction with the device.

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RESULTS
(p lt.005)
32 nurses completed the anonymous surveya 100
response rate. 72 the device to be an
improvement over existing methods, 88 helpful
in monitoring HOB elevation, 84 wanted the
device to be permanently used. 94 previously
aware of the HOB elevation guidelines in the
ICU 66 the device increased awareness of the
importance of ensuring the correct
elevation.
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DISCUSSION

• Compliance with HOB elevation guidelines can be
  improved using a simple device that clearly
  indicates whether adequate HOB elevation is
  achieved

Overestimate the angle of HOB elevation
Low rates of compliance
McMullin JP, Cook DJ, Meade MO, et al Clinical
estimation of trunk position among mechanically
ventilated patients. Intensive Care Med 2002
28304309
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The angle indicators are small and are located
under the bed, making them difficult to read and
easily forgotten.
Patient beds are often kept in a slight
Trendelenburg position to prevent patients from
sliding off the beds, and this makes some of the
existing bed angle indicators inaccurate as they
assume a level bed axis.
Nursing education was not one of the contributing
factors, since 94 of respondents said they were
aware of the guidelines and the importance of
maintaining adequate elevation.
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Placing the bed-angle indicator on the side of
beds increased the average HOB elevation from
21.9 to 30.9 degrees, and beds with the device
were almost four times more likely to be
compliant with the hospital, CDC, and Institute
for Healthcare Improvement guidelines.
Hawthorne effect or observer influence
Control phase of our study by measuring beds
without the device for the first 2 wks
Compliance rates with the device could decrease
once the novelty of using a new device wore off
To have the device visible only when needed.
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The control and test periods were not run
concurrently as there was concern that the
presence of this device in the ICU would improve
awareness of HOB elevation guidelines and thus
falsely improve the rates of adequate HOB
elevation in those beds without the device.
Intermittent Measurements in both the control and
intervention phases of the study were made at
roughly the same times of day. In addition, all
measurements were made 18 hrs apart to prevent
oversampling a single bed and to give time for
nursing changes.
Bed measurements were not made if a patient was
to have a procedure, test, cleaning, or feeding
or if for any other reason was not at his or her
baseline position.
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? Attention
This bed-angle indicator may be a simple and
cost-effective method for improving compliance
with HOB guidelines and decreasing rates of VAP.