VENTILATOR-ASSOCIATED PNEUMONIA (VAP) has been well-documented as one of the most common infectious complications among patients admitted to an ICU.1 Hospitals are now in complex financial situations, with many insurance carriers no longer reimbursing for healthcare-associated infections that could have been prevented. In addition, the Centers for Medicare & Medicaid Services will no longer reimburse for certain preventable complications, including VAP.
The CDC, along with other organizations, have established guidelines to prevent VAP, which include many recommendations for nursing care.2 Among them is head-of-bed (HOB) elevation of 30 to 45 degrees for ventilated patients—a simple but effective measure that nurses can control. This article discusses how nurses at one hospital improved patient care by researching reasons HOB isn't always maintained at 30 degrees for patients on mechanical ventilation. It also reveals steps nurses can take to improve adherence to this standard of care.
In early 2008, the CCU at Morristown Memorial Hospital in Morristown, N.J., began its journey for the Beacon Award from the American Association of Critical-Care Nurses (AACN). The Beacon Award recognizes critical care units that achieve high-quality outcomes. A portion of the application tool involves an analysis of patient outcomes, including the unit-based rate of VAP per 1,000 ventilator days.
During our Beacon journey, we were pleased to discover that our VAP rate in the CCU was far below national averages. At the same time, we realized that some components of our VAP prevention strategy needed improvement.
Our patient outcome analysis made us take a step back and reassess everything we were doing, including the degree of HOB elevation for endotracheally intubated patients on mechanical ventilation. The more we looked at this intervention, the more we realized that what many nurses perceived as a 30-degree angle for ventilated patients wasn't actually 30 degrees. Thirty degrees is much higher than what the staff thought, and many patients on ventilators weren't being maintained at that level.
Due to this discovery, from June to October of 2008, we randomly selected 50 patients on mechanical ventilation in the CCU to evaluate for HOB elevation angle using the AACN Data Collection Tool for HOB elevation.3 Our results showed that 70% of the angles for these patients were between 5 and 25 degrees; only 30% had an angle of 30 degrees or higher. (The HOB angle was measured with an angle measurement mechanism built into the bed. Measurements between 25 and 30 degrees were rounded up or down.)
The AACN lists contraindications to HOB elevation greater than 30 degrees, including hypotension, physiologic instability, low cardiac index, a medical order for no HOB elevation, a medical or nursing procedure in progress where HOB elevation is inappropriate, and prone positioning. According to the AACN tool, if a contraindication is present, then the HOB evaluation is to be omitted.3 Revising our analysis accordingly, we found that 66% of HOB angles were from 5 to 25 degrees, and 33% were 30 degrees or greater.
When the HOB degree angle was found to be less than 30 degrees, nurses were questioned about why they believed raising the HOB to 30 degrees was contraindicated for that patient. The CCU nurses mentioned the AACN contraindications but added two more of their own: femoral vascular access and the risk of skin breakdown.
In the CCU, many patients have femoral vascular access, particularly arterial sheaths, central venous catheters, dialysis catheters, pulmonary artery catheters, and intra-aortic balloon catheters. Many nurses felt that when ventilated patients have a femoral vascular access, they shouldn't be positioned at 30 degrees due to flexion at the insertion site.
The second contraindication CCU nurses mentioned involved skin care. Many nurses felt that certain patients, such as shorter, obese patients and those with diminished level of consciousness, were prone to continually sliding down in the bed if positioned at a 30-degree angle. They believed that these shearing forces would contribute to pressure ulcer development, especially in the sacral area. They felt this was unacceptable, especially if for patients at high risk for skin breakdown.
Let the investigation begin
To investigate nurses' concerns about femoral vascular access, we contacted four companies that provide Morristown Memorial Hospital with various types of femoral catheters. Three of the four companies wouldn't give a recommendation for HOB elevation when their product was inserted into a femoral vessel. Instead, they recommended following hospital policy and healthcare provider order. The fourth company, which manufactured the intra-aortic balloon catheter, was the only one that officially approved of the 30-degree HOB elevation.
We then performed a literature review to find the most recent evidence on HOB elevation and post-percutaneous coronary intervention (PCI). Unfortunately, this investigation revealed little recent literature on this topic, but the following information was relevant.
- In one study, researchers found no increase in complications among 120 patients after coronary angiography when the HOB was gradually elevated from 15 to 60 degrees over 5.5 hours after femoral artery sheath removal.4
- In another study, researchers found no increase in vascular access site bleeding in 54 patients who were allowed to control their own HOB position following PCI with femoral artery sheath in place.5
- No occurrence of a complication was related to any patient or practice-related characteristic per the records of 306 inpatients postdiagnostic coronary angiography whose HOB angles were allowed at 30 degrees after femoral artery sheath removal.6
- The Wound, Ostomy and Continence Nurses Society recommends maintaining the HOB at 30-degree elevation for supine positions and 30 degrees or less for side-lying positions for skin protection.7
- The CDC recommends HOB elevation of 30 to 45 degrees to prevent aspiration and VAP for patients who are mechanically ventilated and for those with enteral tube placement.2
We concluded that HOB elevation is a nursing judgment and nurses need to weigh the risks and benefits to the patient. In general, HOB should be 30 degrees or higher for mechanically ventilated patients at all times unless specific contraindications are present. This includes patients with femoral vascular access unless associated with a complication, such as active bleeding or hematoma, and patients who've had PCI if the femoral access site is stable, per the PCI order set. The rationale is that HOB elevation of 30 degrees or higher helps prevent aspiration and VAP.2
Contraindications to HOB elevation of 30 degrees or more include those listed in the AACN Practice Alert: Audit of HOB Elevation in Intubated Patients,3 as well as an unstable femoral vascular access site, a high skin breakdown risk (based on daily assessment using the Braden Scale), and mobilization precautions/trauma.
Staff education on the job
The unit educator believes in bringing education directly to the staff and doing everything in her power to enhance their education. She makes learning easy and convenient by providing a 10- to 15-minute presentation to educate the staff while they're working. She approaches nurses right before, during, or after their shift with her laptop and asks them for 10 minutes of their time. Our staff has become very receptive to this style of education.
The HOB elevation project was introduced in this manner, and the entire staff participated over a 2-week period.
The overall CCU action plan included one-on-one staff education, removable and laminated HOB elevation signs placed over the beds of all mechanically ventilated patients, and hands-on education on how to use the HOB elevation alarms on the beds, if activated. (The educator didn't mandate activating the alarm system because it required nurses to shut if off and reset it whenever the bed was lowered, which can be a burdensome use of time.) The educator conducted a reevaluation with the AACN Data Collection Tool for HOB elevation after the entire staff was educated.
The HOB education was completed by the end of April 2009. The reevaluation of our HOB elevation rates using the AACN Data Collection Tool began in May 2009 and was completed in July 2009. Of the 50 ventilated patients reevaluated, adherence to the 30-degree HOB elevation was 79%, an astonishing accomplishment when compared with the 33% rate in 2008.
Our VAP rate reflects the value of this initiative. At the first evaluation in 2008, our VAP rate was 1.07 per 1,000 ventilator days. At the reevaluation conducted between May and July 2009, the VAP rate was 0.
The unit educator believes that the success of this project came from listening to our nurses first before developing an action plan specific to a practice improvement project for CCU patients. This patient-safety initiative brings us one step closer to maintaining a VAP rate of 0 in the CCU—the only acceptable goal. As nurses, we must do all we can to continue patient-safety initiatives like this to ensure that we're giving our patients the best chance at a full hospital recovery without avoidable complications.
1. Luna CM, Blanzaco D, Niederman MS, et al. Resolution of ventilator-associated pneumonia: prospective evaluation of the clinical pulmonary infection score as an early clinical predictor of outcome. Crit Care Med
2. Tablan OC, Anderson LJ, Besser R, Bridges C, Hajjeh R. Guidelines for preventing health-care-associated pneumonia, 2003: recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee. MMWR Recomm Rep
3. American Association of Critical Care Nurses (AACN). AACN Practice Alert: Ventilator Associated Pneumonia Audit Tool [revised 1/2008]; Directions for Conducting Audit of HOB Elevation [revised 1/2008], Data Collection Tool for HOB Elevation [revised 1/2008]
4. Coyne C, Baier W, Perra B, Sherer BK. Controlled trial of backrest elevation after coronary angiography. Am J Crit Care.
5. Sulzbach LM, Munro BH, Hirshfeld JW Jr. A randomized clinical trial of the effect of bed position after PTCA. Am J Crit Care.
6. McCabe PJ, McPherson LA, Lohse CM, Weaver AL. Evaluation of nursing care after diagnostic coronary angiography. Am J Crit Care
7. Ratliff CR, Bryant DE. Guideline for prevention and management of pressure ulcers. In: WOCN Clinical Practice Guideline no. 2
. Glenview, IL: Wound, Ostomy, and Continence Nurses Society (WOCN); 2003.