The use of bed-dials to maintain recumbent positioning for critically ill mechanically ventilated patients (The RECUMBENT study): Multicentre before and after observational study

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Abstract

Background

Observational studies continue to report poor compliance with positioning recommendations for prevention of ventilator-associated pneumonia. Inability to accurately measure backrest elevation may contribute to this poor compliance.

Objective

To determine if provision of an accurate, simple to use angle measurement device with an accompanying education program improved compliance with semirecumbency at 45° over time.

Design

Using a prospective pre- and post-design we implemented angle measurement devices and an associated education intervention in three Australian ICUs. Backrest elevation, contraindications to semirecumbency at 45°, mean arterial pressure (MAP), inotrope use, enteral feeding and weaning status were recorded 3-times daily using a pre-determined randomization schedule for 7 consecutive days prior to implementation and again at 1, 3 and 6 months post-implementation. Illness severity and a clinical pulmonary infection score were recorded for each day of ventilation.

Results

Backrest elevation measurements (n = 1154) were recorded for 141 mechanically ventilated patients. Contraindications to semirecumbency at 45° were noted for 163/1154 (14.1%) measurements the proportion of measurements at 45° rose from baseline by 10.1% (P = 0.03) 1-month following implementation, however this change was not sustained over time. The proportion of measurements 30° increased by 43.8% at 1-month and remained above 70% 6-months after implementation (P < 0.001).

For measurements recorded in the absence of a contraindication to semirecumbency, and adjusted for covariates (MAP, inotropic support, sequential organ failure assessment maximum score, clinical pulmonary infection score maximum, and indication for ventilation), decreased backrest elevation was associated with higher severity of illness (0.3° [95% CI 0.1–0.5] for every 1-point increase in APACHE II score). Increased mean backrest elevation was noted for older patients (0.8° [95% CI 0.1–1.5] for each 10-year increment) and measurements recorded during weaning (2.7° [95% CI 1.2–4.1]).

Conclusions

Bedside implementation of an angle measurement device and associated educational intervention did not result in a sustained improvement to compliance with 45° semirecumbency, questioning the clinical feasibility of this nursing intervention. A sustained increased in semirecumbency at 30° or greater was achieved.

Introduction

Multiple practice guidelines are now available that recommend semirecumbent positioning with bed backrest elevation equivalent to or greater than 30° for prevention of ventilator-associated pneumonia (VAP) (American Association of Critical Care Nurses, 2005, American Thoracic Society, 2005, Dodek et al., 2004, Tablen et al., 2004). These guidelines are based on clinical studies demonstrating increased aspiration of gastric contents by patients in the supine position (Orozco-Levi et al., 1995, Torres et al., 1992), and reports including a single randomized controlled trial (Drakulovic et al., 1999) linking prolonged supine positioning, with little to no backrest elevation, to increased risk of VAP (Grap et al., 2005, Kollef, 1993).

Although there is strong evidence indicating failure to place patients in a semirecumbent position may worsen outcomes for mechanically ventilated patients, there is uncertainty as to the exact degree of backrest elevation required for prevention of VAP (Wip and Napolitano, 2009). This is partly due to a lack of studies comparing the effect of various degrees of backrest elevation and VAP incidence but also due to uncertain or poor compliance with targeted positioning in existing studies. The aforementioned randomized, controlled trial (Drakulovic et al., 1999) only assessed correctness of position (>45°) daily and did not report compliance. A subsequent randomized, controlled trial implemented continuous monitoring of backrest elevation via a transducer placed on the bed-frame and a dedicated research nurse to restore correct positioning three times a day for 7 days. In this study only 15% of patients achieved backrest elevation to 45° and there was no reduction in VAP incidence for the experimental group (van Nieuwenhoven et al., 2006).

To conduct further studies examining the effects of various degrees of semirecumbency and VAP prevention as well as the potential for pressure ulcer formation (Peterson et al., 2008), compliance with study targets must be assured. Improved compliance with positioning recommendations has been demonstrated using standardized orders and an associated education program in a single centre (Helman et al., 2003). Other reported educational and quality assurance interventions target multiple VAP prevention strategies resulting in limited reporting of positioning practices that may inform further research or guide clinical application (Babcock et al., 2004, Blamoun et al., 2009, Bloos et al., 2009, Zack et al., 2002).

Accurate measurement of semirecumbency is essential. Estimation studies report clinicians may overestimate the angle of semirecumbency resulting in inadequate elevation (McMullin et al., 2002, Peterlini et al., 2006) though results are not consistent (Dillon et al., 2002). Some beds designed for critically ill patients have angle measurement devices incorporated into their design (Hill-Rom, Bateville, IN), however availability of these beds is not standardized across intensive care units (ICUs). Nurses should not have to rely on estimation methods and require accurate, reliable and easy to use tools to guide semirecumbent positioning.

We hypothesized that implementation of an education program and provision of an accurate, simple to use angle measurement device available at every bed would improve compliance with semirecumbent positioning and compliance would be maintained over time. We conducted a prospective, multicentre study with repeated observations to evaluate this hypothesis.

Section snippets

Sample

During four observation periods over 7-days each during 2008 (January, March, June and November) all patients 16 years and over admitted to the 3 participating ICUs and receiving mechanical ventilation were eligible for the study. Patients receiving non-invasive ventilation were excluded. Patients became ineligible for further measurement of backrest elevation on extubation. Participating units were all mixed population ICUs in university-affiliated hospitals. The Institutional Review Boards of

Results

We recorded data on 141 patients during the 4 observation periods. Demographic characteristics of the 141 patients are shown in Table 1 according to each measurement period. Postoperative respiratory failure was the most frequent indication for mechanical ventilation.

VAP was diagnosed in 6/141 (4.2%) patients; 3/6 (50.0%) VAP diagnoses were confirmed microbiologically and 3/6 (50.0%) diagnoses were based only on clinical findings.

A total of 1154 backrest elevation measurements were recorded

Discussion

Our prospective, multicentre study evaluating the effect of a bedside angle measurement device and accompanying education program found compliance with semirecumbency at ≥45° was not achieved. A significant increase did occur in the proportion of patients positioned with the backrest elevation at ≥30°, an increase that was sustained over time. Our findings support those of a previous study suggesting semirecumbency at 45° may not be feasible (van Nieuwenhoven et al., 2006). Our study was not

Conclusions

In this multicentre prospective study we could not demonstrate compliance with semirecumbency at 45° suggesting that this degree of backrest elevation is not feasible for critically ill patients requiring mechanical ventilation. However we did demonstrate an improvement in the degree of backrest elevation to greater than 30°, and this was maintained over time. Reasons for the inability to achieve semirecumbency at ≥45° remain unclear and warrant further investigation. By using an objective

Acknowledgements

The authors would like to thank the study coordinators of the three Intensive Care Units for their assistance provided to this study. In addition, the authors thank Dr Alex Kiss for his statistical guidance.
Conflicts of interest

None declared.
Funding

Funding from the Connaught Start-up Award of the University of Toronto supported this study.
Ethical approval

Ethics approval was obtained from the University of Toronto Ref no. 21874 and the 3 participating sites.

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