Nurses’ Accuracy in Estimating Backrest Elevation

Related factors to semi-recumbent position compliance and pressure ulcers in patients with invasive mechanical ventilation: An observational study (CAPCRI study)

BACKGROUND

Semi-recumbent position is recommended to prevent ventilator-associated pneumonia. Its implementation, however, is below optimal.

OBJECTIVES

We aimed to assess real semi-recumbent position compliance and the degree of head-of-bed elevation in Spanish intensive care units, along with factors determining compliance and head-of-bed elevation and their relationship with the development of pressure ulcers. Finally, we investigated the impact that might have the diagnosis of pressure ulcers in the attitude toward head-of-bed elevation.

METHODS

We performed a prospective, multicenter, observational study in 6 intensive care units. Inclusion criteria were patients ≥18 years old and expected to remain under mechanical ventilator for ≥48h. Exclusion criteria were patients with contraindications for semi-recumbent position from admission, mechanical ventilation during the previous 7 days and prehospital intubation. Head-of-bed elevation was measured 3 times/day for a maximum of 28 days using the BOSCH GLM80(®) device. The variables collected related to patient admission, risk of pressure ulcers and the measurements themselves. Bivariate and multivariate analyses were carried out using multiple binary logistic regression and linear regression as appropriate. Statistical significance was set at p<0.05. All analyses were performed with IBM SPSS for Windows Version 20.0.

RESULTS

276 patients were included (6894 measurements). 45.9% of the measurements were <30.0°. The mean head-of-bed elevation was 30.1 (SD 6.7)° and mean patient compliance was 53.6 (SD 26.1)%. The main reasons for non-compliance according to the staff nurses were those related to the patient's care followed by clinical reasons. The factors independently related to semi-recumbent position compliance were intensive care unit, ventilation mode, nurse belonging to the research team, intracranial pressure catheter, beds with head-of-bed elevation device, type of pathology, lateral position, renal replacement therapy, nursing shift, open abdomen, abdominal vacuum therapy and agitation. Twenty-five patients (9.1%) developed a total of 34 pressure ulcers. The diagnosis of pressure ulcers did not affect the head-of-bed elevation. In the multivariate analysis, head-of-bed elevation was not identified as an independent risk factor for pressure ulcers.

CONCLUSIONS

Semi-recumbent position compliance is below optimal despite the fact that it seems achievable most of the time. Factors that affect semi-recumbent position include the particular intensive care unit, abdominal conditions, renal replacement therapy, agitation and bed type. Head-of-bed elevation was not related to the risk of pressure ulcers. Efforts should be made to clarify semi-recumbent position contraindications and further analysis of its safety profile should be carried out.

S2e guideline: positioning and early mobilisation in prophylaxis or therapy of pulmonary disorders : Revision 2015: S2e guideline of the German Society of Anaesthesiology and Intensive Care Medicine (DGAI)

The German Society of Anesthesiology and Intensive Care Medicine (DGAI) commissioneda revision of the S2 guidelines on "positioning therapy for prophylaxis or therapy of pulmonary function disorders" from 2008. Because of the increasing clinical and scientificrelevance the guidelines were extended to include the issue of "early mobilization"and the following main topics are therefore included: use of positioning therapy and earlymobilization for prophylaxis and therapy of pulmonary function disorders, undesired effects and complications of positioning therapy and early mobilization as well as practical aspects of the use of positioning therapy and early mobilization. These guidelines are the result of a systematic literature search and the subsequent critical evaluation of the evidence with scientific methods. The methodological approach for the process of development of the guidelines followed the requirements of evidence-based medicine, as defined as the standard by the Association of the Scientific Medical Societies in Germany. Recently published articles after 2005 were examined with respect to positioning therapy and the recently accepted aspect of early mobilization incorporates all literature published up to June 2014.

Backrest position in prevention of pressure ulcers and ventilator-associated pneumonia: conflicting recommendations

Pressure ulcers and ventilator-associated pneumonia (VAP) are both common in acute and critical care settings and are considerable sources of morbidity, mortality, and health care costs. To prevent pressure ulcers, guidelines limit bed backrest elevation to less than 30 degrees, whereas recommendations to reduce VAP include use of backrest elevations of 30 degrees or more. Although a variety of risk factors beyond patient position have been identified for both pressure ulcers and VAP, this article will focus on summarizing the major evidence for each of these apparently conflicting positioning strategies and discuss implications for practice in managing mechanically ventilated patients with risk factors for both pressure ulcers and VAP.

[Evaluation of the compliance of semirecumbent position between 30-45° in intubated patients]

AIMS

To determine compliance of the standard "semirecumbent position between 30-45° in patients with artificial airway (AA)". To know the opinion of the professionals on this issue.

MATERIAL AND METHODS

An observational, prospective study was carried out in December 2009 in the ICU department of a tertiary hospital that excluded the limitation of therapeutic effort, prone position and antitrendelemburg.

DATA COLLECTED

headrest angle, professional experience of the nurse, shift, perception of the auditor, diagnostic, type of AA (tracheostomy or endotracheal tube), mechanical ventilation (MV) (yes/no) and enteral nutrition (EN). Nurses were surveyed to verify if they knew the standard, if they complied with it, the method used and their suggestions. We used the Student's t test and ANOVA for multivariable analysis, and Fisher's χ2; p<0.05=significant.

RESULTS

A total of 546 valid measurements were obtained from 53 patients, of which 40.9% had the correct semirecumbent position (30-45°). Professionals with <1 year of experience were those who raised the headrest the least, with only 26.4% of these measurements over 30°. The standard was met in only 34.8% of the neurocritical patients (NC) vs non NC (46.7%) (p<0.05). It was <30° in 29.2% of patients with tracheostomy vs 44% measurements performed on patients with TOT (p<0.05). There were no differences between shifts, the use of MV or EN. Diagnostic accuracy of the auditor: sensitivity: 91.6%; specificity: 72.5%; positive predictive value: 70.2%; negative predictive value (NPV): 92.4%. 97.9% of responders know the standard. Visual judgment was used in 97.2% of the cases.

CONCLUSIONS

Measured compliance was less than 50% although the standard is well known by the nursing team. Even though the subjective perception has a high NPV, it does not achieve the standard.

Clinicians' perception of head-of-bed elevation

BACKGROUND

Head-of-bed elevation of 30 degrees to 45 degrees is important in preventing ventilator-associated pneumonia, but clinicians' perception and determination of head-of-bed elevation are not widely reported.

OBJECTIVES

To (1) document the accuracy of clinicians' perception of head-of-bed elevation, (2) document methods clinicians use to determine the head-of-bed angle, and (3) assess knowledge of recommended head-of-bed elevation.

METHODS

Clinicians (n = 175) viewed a simulated patient with head of bed elevated 30 degrees and elevation gauge concealed. They answered 3 questions: What is the level of the head of the bed? What head-of-bed elevation is associated with decreased incidence of ventilator-associated pneumonia? When providing care, how do you routinely determine the head-of-bed elevation?

RESULTS

Fifty percent of 89 registered nurses and 53% of 39 physicians identified head-of-bed elevation correctly (+/-5 degrees ). Head-of-bed elevation was perceived accurately by 86% of 21 respiratory therapists, 63% of 16 medical assistants, and 50% of 10 physical/occupational therapists. Ninety-five percent of nurses and respiratory therapists, 79% of physicians, 90% of physical/occupational therapists, and 46% of medical assistants correctly identified the head-of-bed angle associated with decreases in occurrence of ventilator-associated pneumonia. Techniques for determining the angle varied; 58% of respondents reported using the gauge.

CONCLUSIONS

Head-of-bed angle was perceived correctly by 50% to 86% of clinicians. Nurses tended to underestimate the angle, whereas other clinicians tended to overestimate. Nurses, respiratory therapists, and physical/occupational therapists showed the best understanding of the correct angle for minimizing occurrence of ventilator-associated pneumonia. Elevation gauges were most often used to determine the angle.

Ventilator-associated pneumonia and pressure ulcer prevention as targets for quality improvement in the ICU

The health care culture must change. Florence Nightingale wrote [8] "deep-rooted and universal is the conviction that to give a medicine is to be doing something, or rather everything and to give air, warmth, cleanliness etc. is to do nothing." Hygiene care practices and mobility activities are fundamental and independent care components in the nursing profession. When implemented using available evidence, they can significantly improve patient outcomes. It is time to claim and demonstrate the importance of consistent delivery of the fundamentals of basic nursing care. Interventional patient hygiene is an effective framework to ensure the the basics of nursing care are consistently applied to improve patient outcomes.

Subjective assessment of backrest elevation: magnitude of error

BACKGROUND

Backrest elevation, defined as the angle of the backrest height above the horizontal position, is a common nursing intervention that is often used by subjective visual estimation in critically ill patients.

OBJECTIVES

The aim of the study was to describe the magnitude of error during the subjective assessment of backrest elevation.

METHODS

This prospective study was conducted in a sample of 160 subjects: 97 registered nurses, 48 undergraduate nursing students, and 15 nursing assistants. Data were collected by recording the degrees of backrest elevation identified by the subjects through an individual random presentation of the selected study angles of 20 degrees, 30 degrees, 35 degrees, 40 degrees, and 45 degrees. A measurement instrument was developed for determination of the angles.

RESULTS

Of the 800 investigated angles, 14.9% were estimated accurately, 61.6% were overestimated, and 23.5% were underestimated, with an error average of 8 degrees (+/-13.5 degrees). It was determined that the larger the angle estimated, the greater the average error. A statically significant difference (P <or= .001) was found between the actual degree of backrest elevation and the estimated backrest elevation for 20 degrees, 40 degrees, and 45 degrees with the exception of 30 degrees and 35 degrees, which had similar averages of error. Years of critical care experience did not significantly influence the magnitude of error.

CONCLUSION

The results indicate that the subjective assessment of backrest angle may result in errors that may potentially compromise the patient's condition and supports the need for a more objective method for determining backrest angle.

Enteral nutrition in intensive care

The aims of this descriptive study were to examine (1) nurses' perceptions of responsibility, knowledge and documentation focusing on enteral nutrition and (2) nursing practice regarding enteral feeding in the intensive care unit. Forty-four nurses in three intensive care units responded to a questionnaire (response rate 70%) and 40 bedside observations were performed. The nurses' primary source of knowledge was consultation with colleagues. Regarding responsibility, knowledge and documentation, the focus was more on planning, implementation and prevention than on the assessing phase of the nursing process. Gastric residual volumes were almost never checked, and none of the tubes were labelled. Seven out of 40 bedside observations revealed a backrest elevation of 30 degrees or more. Mean backrest elevation was 20.7 degrees. Comparisons between nurses in the three hospitals revealed significant differences. This study indicates that enteral nutritional nursing care within intensive care has its strength in planning, implementation and prevention of complications. Regarding nutritional assessment, the registered nurses (RNs) scored low. There are gaps between recommended nursing care and nursing practice regarding enteral nutrition. Knowledge and awareness of responsibilities in combination with a systematic documentation could increase the optimal nutritional care of the intensive care patient.

Quality improvement in backrest elevation: improving outcomes in critical care

The positioning of critically ill patients is an independent nursing decision, often has multiple rationales, and may significantly affect morbidity and mortality. Recent evidence suggests that backrest elevation in critically ill patients may reduce ventilator-associated pneumonia. However, use of recommended levels of backrest elevation is infrequent in the critical care environment. In addition, published guidelines for backrest elevation to reduce pneumonia conflict with those for protecting skin integrity. This article reviews the benefits and complications of backrest elevation, data related to current positioning practices, and recommendations for backrest elevation. A quality improvement process to guide evidence-based care related to backrest positioning is also described.

Effect of Backrest Elevation on the Development of Ventilator-Associated Pneumonia

• Background Ventilator-associated pneumonia is a common complication of mechanical ventilation. Backrest position and time spent supine are critical risk factors for aspiration, increasing the risk for pneumonia. Empirical evidence of the effect of backrest positions on the incidence of ventilator-associated pneumonia, especially during mechanical ventilation over time, is limited.

• Objective To describe the relationship between backrest elevation and development of ventilator-associated pneumonia.

• Methods A nonexperimental, longitudinal, descriptive design was used. The Clinical Pulmonary Infection Score was used to determine ventilator-associated pneumonia. Backrest elevation was measured continuously with a transducer system. Data were obtained from laboratory results and medical records from the start of mechanical ventilation up to 7 days.

• Results Sixty-six subjects were monitored (276 patient days). Mean backrest elevation for the entire study period was 21.7°. Backrest elevations were less than 30° 72% of the time and less than 10° 39% of the time. The mean Clinical Pulmonary Infection Score increased but not significantly, and backrest elevation had no direct effect on mean scores. A model for predicting the Clinical Pulmonary Infection Score at day 4 included baseline score, percentage of time spent at less than 30° on study day 1, and score on the Acute Physiology and Chronic Health Evaluation II, explaining 81% of the variability (F=7.31, P=.003).

• Conclusions Subjects spent the majority of the time at backrest elevations less than 30°. Only the combination of early, low backrest elevation and severity of illness affected the incidence of ventilator-associated pneumonia.

[Repercussion on the hemodynamic measurements across a Swan-Ganz catheter with the postural changes]

AIM

Usually hemodynamic measures are done with the patient in dorsal decubitus and the bedside at 0 degrees. Our aim has been to evaluate the influence that postural changes has in the hemodynamic measures which were carried out with a pulmonary artery catheter, so as called Swan-Ganz.

MATERIAL AND METHOD

It's a prospective study. The same patient is control group and study group. There were done tree consecutive measures in each patient. Firstly in dorsal decubitus, then right lateral decubitus and finally in left lateral decubitus. Before doing the measures after change of posture a thirty minutes period was left in order to stabilise the hemodynamical flow. The items of study were, a part of demographic ones, cardiac index, pulmonary artery systolic pressure, pulmonary artery diastolic pressure, pulmonary artery mean pressure, pulmonary artery occlusion pressure, right atrial pressure, systolic arterial pressure, diastolic arterial pressure, mean arterial pressure and heart rate. 28 patients were included in the study.

RESULTS

The age average was 62.5 years (27.05-67.05); a 78.6% were male. Who had a NEMS average of 42.4 (39.9-44.9). No difference was found between hemodynamic measures in the different postures.

CONCLUSIONS

Postural changes in stable patients have no influence in pressures and other hemodynamic variables measures.

Preventing ventilator-associated pneumonia: evidence-based care

Ventilator-associated pneumonia is a common complication of mechanical ventilation with significant morbidity and mortality. This article summarizes the data related to specific risk factors associated with ventilator associated pneumonia (patient position, oral health, airway management, and gastrointestinal factors) and provides recommendations for practice based on the present evidence.

Predictors of backrest elevation in critical care

Low backrest and supine positions are associated with increased mortality and ventilator associated pneumonia (VAP). Data are not available across ICU settings about the level of backrest position used and its relationship to enteral feeding and hemodynamic status. The purpose of this descriptive study was to document the level of backrest elevation and position and identify factors associated with and predict positioning in a medical, surgical and neuroscience intensive care unit. Data were collected randomly in each unit over a 6-week period, resulting in 506 observations for170 patients. Backrest elevation was determined by electronic bed read-out or bed frame elevation gauge. BP, HR and enteral feeding status were retrieved from the medical record. Results showed that mean backrest elevation was 19.2 degrees and 70% of subjects were supine. No difference in backrest elevation among units was found. Significant correlations between backrest elevation and systolic BP (r=0.15, P=0.006); and backrest and diastolic BP (r=0.13, P=0.02) were found. There was no difference in backrest elevation between patients being fed and not being fed. Differences in backrest elevation for intubated versus nonintubated patients approached significance (P=0.07) with intubated patients at lower backrest elevations. In summary, use of higher backrest elevations (>30 degrees ) is minimal, is not related to feeding and minimally related to hemodynamic status. Strategies to meet published recommendations for backrest elevation (30-45 degrees ) must include repeated feedback about nurse's use of backrest elevation and estimates of elevation.