Monitoring Elevation of Head to Reduce Ventilator-Acquired Pneumonia Being responsible for an intubated patient in the intensive care unit (ICU) can be an incredibly demanding job for the registered nurse. The fact that the patient is in need of an artificial airway via endotracheal tube into the lungs brings to the forefront the prospect of a ventilator associated infection, primarily pneumonia (VAP). VAP is also the leading cause of death from infections resulting from hospital acquired infections (Keeley, 2007). Over the past several years, reducing the risk of VAP has been at the forefront of nursing care and research. In the research article Reducing the Risk of Ventilator-Acquired Pneumonia through Head of Bed Elevation (Keeley, 2007), I will address the study’s background, method, ethical considerations, results and conclusion.
Creating an environment in ICU where an intubated patient’s chances of developing a VAP would be an ideal. The position the patient is placed has been suggested to minimize or contribute to a VAP (Keeley, 2007). The study considered the elevation of the head of bed 45 degrees to reduce the incidence of VAP. The method of study was quantitative using adult ventilated patients placed into two groups. Patients selected to participate were randomly placed into a control group; head of bed raised to 25 degrees (current practice within the ICU), and a treatment group, head of bed 45 degrees. An independent person made the selection of the patients, placed the needed information, (along with the treatment plan for that patient), into identical envelopes which were then shuffled and selected by a third person.
To address the ethical criteria, once selected for the study, the primary nurse obtained permission from the patient or family member of the patient within 24 hours of inclusion. Patients and families observed to be under stressful situations were not included in the study, and three patients or their relatives declined to be in the study for various reasons. Extubation of a patient, death, weaning of ventilator support were criteria for end of study. Withdrawal from the study protocol was done for; patient or family request, change in patient’s condition, transfer to another critical care unit, need for increased ventilator support, change of patient’s position for more than 6 hours in 24 hours (their randomized position for the study).
Once completed with the study, follow-up was done for 72 hours with final end-point documentation completed at the end of the 72 hours. The following items were evaluated for interpretation of the study. Chest X-ray if ordered by the physician possibly an indication of developing pneumonia. Clinical suspicions of pneumonia, new and persistent infiltrates, fever, change in WBC’s, and purulent tracheal secretions. Pneumonia confirmed by positive cultures of tracheobronchial aspirate and a suspicion of pneumonia. The study results were analyzed with the Minitab computer package and the assistance of a statistician.
Information was gathered over a 3-5 month period with a patient sample size of 54, down from the 71 assessed of eligibility. The treatment group consisted of 29 patients allocated to head of bed at 45 degrees and the control group consisted of 25 patients with head of bed at 25 degrees. In the treatment group five (29%) developed VAP, one suspected and four confirmed. In the control group seven (54%) developed VAP, two suspected and five confirmed.
Additional information includes hours ventilated and type of ventilation. Patients without VAP had an average number of hours 63 compared to 107 hours for those positive for VAP. In addition of the 12 patients who developed VAP, 11 had tracheostomies. Unfortunately the mortality of the VAP patients remained high with eight of the 12 patients dying as a result.
The discussion from this study makes a clear statement that there are several elements that may contribute to VAP. This study was however able to clinically document relevant differences in VAP rates in two groups. Unfortunately this difference was not statistically meaningful. The outcome of this study is noted to have a “type 2” error (failure to detect a difference where one exists), possibly due to the small sample size of patients. Patient care and satisfaction also impacted the study. A large amount of patients withdrew due to discomfort, the request to change to other positions and extubation within 24 hours of ventilation.
This study from a nursing stand point did not provide adequate evidence to support to change clinical practice. However ventilator care bundles for VAP suggests elevating the head of bed to a level of 30 degrees or higher as tolerated by the patient may reduce the risk for VAP (Collard, Matthay, & Saint, 2003). As stated and worth repeating VAP is the leading cause of death among hospital acquired infections. Patient care standards in the ICU should be elevated to a level where prevention of VAP can be implemented and achieved. Nursing care should include ventilator care bundles which follow evidenced based practice to prevent these VAPs.
In 2010 the Institute for Healthcare Improvement (IHI) examined the effectiveness of ventilator care bundles and found they were effective at reducing the rate of VAP (Sedwick, Lance-Smith, Reeder, & Nardi, 2012). These measures include head of bed elevation, prophylaxis to reduce DVT and PUD, daily sedation vacation with spontaneous breathing trials and providing oral care. In nursing care having the ability to be responsible for these cares to reduce and prevent VAP as indicated should be at the top of our daily cares.