Ventilator-associated pneumonia (VAP) is an infection which often develops as a result of poor handling of mechanical ventilation. Such as, poor nursing practice in caring for patients with difficulty in breathing can lead to microorganisms entering patient’s body through a tube inserted especially via mouth and nose of the patient. When these microorganisms get into the respiratory system they cause lung infection which is referred to as ventilator-associated pneumonia (VAP). In preventing this infection, it is important that nurses adopt best practices to reduce the incidence of VAP and provide quality care that is aimed at improving the wellness of the patient, reduce hospital stay and other health care cost associated with VAP. There are several practices which can be used to prevent VAP including intubation route, feeding method, using antibiotics, the positioning of the patient’s body and addressing deep venous thrombosis. However, this research will concentrate on the effectiveness of head elevation in comparison to standard practices in preventing microbiology confirmed ventilated associated pneumonia concentrating on the findings from six peer reviewed articles and make a conclusion on which nursing intervention is useful in achieving optimal desired outcomes in preventing VAP.
VAP is an infection that has the potential of increasing patient’s stay at the medical facility, mortality rate, and escalates medical cost both on the patient and the health care facility (Chad et al., 2010). Notably, the majority of pneumonia cases are as a result of patients being mechanically ventilated. A good number of these patients have ended up developing ventilator-associated pneumonia which occurs 48 hours (Institute for Healthcare Improvement, 2015). This condition is usually brought about by the lung parenchyma and the lower respiratory tract being invaded by microorganisms. This realization creates a way through which oral and gastric secretions enter into the lower airways. Therefore, it is important to take the necessary steps to address the problems brought about by this condition. In managing this condition the factors that need to be considered include the route of placing the tubes, the feeding program of the patient, positioning of the patient’s body, addressing deep venous thrombosis (Health Protection Surveillance Centre, 2011). Maintaining head of bed at high elevation has been singled out to directly affect patients’ outcomes. To establish whether this method is more effective in achieving desirable outcomes in VAP patients, it is vital that a comparison is made between the standard practice of addressing the problem and maintaining the HOB at high elevation
The question addressed in this literature review is among patients with mechanical ventilation, how does maintaining the head of the bed at high elevation compared to a standard practice affect the rates of microbiology-confirmed ventilated associated pneumonia?an analysis of six peer-reviewed articles on the topic was conducted with the intentions of fully addressing the problem.
Gocze et al (2013), sought to establish whether elevating patients with VAP an angle of 45° resulted in hemodynamic instability. In addition to addressing the problem of elevation to hemodynamic status, the study also investigated the contributing factors to mean arterial pressure and the saturation of central nervous oxygen when patients were elevated at 0°, 30° and 45°. The methodology employed was randomized whereby the sample was selected from multiple surgical care intensive care units (Gocze et al., 2013). A sample size comprising of 200 patients presented their written consent (Gocze et al., 2013). The sample was made up of mechanically ventilated patients who were over the age of 18 years and hemodynamically stable. It was approved by the EthikkommisionUniversität Regensburg, no 10-101-0280 Review Board (Gocze et al., 2013). Measurements were taken at all the three positions in a randomized manner. The randomizations were done in blocks to ensure that the results were uniformly distributed. Age, gender, weight, height, duration of the mechanical ventilation and the positioning degree were used as the parameters in the study. Blood pressure levels were evaluated using arterial catheters which were placed either in the femoral or radial arteries. The values of the central venous oxygen saturation were transferred from the blood analyzer automatically through a network cable to the records of the patient. Data analysis methods employed were mean, mode and median in addition to standard deviation. Mixed linear models were used in measuring the impact of head elevation and arterial blood pressure. Single and multivariate statistical analyses were also used in identifying the probable hypotension risk factors. The results from the study indicated that elevating the HOB to 45° resulted in reductions in mean arterial pressure (MAP) and central venous oxygen saturation (ScvO2). The significant factor responsible for hypotension was established to be pressure-controlled ventilation at 45° elevation. This study, therefore, proves that raising the HOB plays a significant role in decreasing the levels of MAP and ScvO2 which are possible microbiological causes of VAP. According to Gocze et al, (2013) elevating the HOB is more effective method of addressing the problem of VAP as compared to the standardized practices. A potential limitation of this study is that elevating the patient at this position is a possible contributor to intra-abdominal pressure. Also, the sample size was small which reduces reliability for all patients in most acute care units. Future studies need to address these two factors.
Wright and Flynn carried review of the study using the prone position for ventilated patients with respiratory failure to establish the validity of the study if there is any existence of evidence that relates to clinical outcomes and prone positioning in ventilated patients who have been diagnosed with respiratory failure (Wright & Flynn, 2011). The study was necessitated by the fact that mortality rates among adult respiratory distress (ARDS) and acute lung injury (ALI) patients under ventilation was high (Wright & Flynn, 2011). Moreover, the study was critical to bridging the existing gaps in ventilated patients nursing position since there were no clear nursing practice guidelines on how nurses should position those patients under ventilation. The aim of the study was to enable nurses who offer care to ventilated patients to have knowledge on how best they can utilize available evidence to enhance their medical decisions (Wright & Flynn, 2014).The methodology for this study involved using data from secondary sources. Library databases such as Medline, Cinahl, Scopus, and Cochrane were employed. The studies for review were chosen on the basis of their titles and abstracts relevance to the review. The evaluation of the retrieved studies was done using Critical Appraisal and Skills framework which is a guideline for critical appraisal (Wright & Flynn, 2014). This evaluation tool provided a reliable and systematic assessment of every research paper that was reviewed. The analysis showed there was a growing interest on how ventilated patients suffering from ARDS or ALI should to be nursed. The results indicated that only 14 study reports were appropriate for addition in this study since they were considered relevant based on Cochrane database. It was established that patient care for those in prone position had varying mortality rates. Thus, it can be concluded that the prone position is beneficial to ALI and ARDS patients (Wright & Flynn, 2014). Further research needs to be carried out to determine the tangible benefits of prone nursing position in the care of seriously ill patients.
A multicenter observational study was conducted by Rose, Baldwin, Crawford, and Parke (2010) to identify probable risk factors associated with VAP. . As such, the study sought to the application of semirecumbency in critical care units in Australia and New Zealand. The methodology used in this study included; the application of mailed flyers sent to the level I, II and II critical care units in the two countries (Rose et al., 2010). A total of 2112 study participants aged 16 and above were selected. The authors received written consents from the participants of the study in addition to an approval from the Multiregion Ethics Committee of New Zealand, and RMIT University (Rose et al., 2010). The researchers worked with RNs in these ICU who played the role of site coordinators. Measurements of the elevation of the backrest were taken three times daily for seven consecutive days. Additionally, measurements of the use of inotropic agents, mean arterial pressure, weaning status and enteral were feeding were taken three times daily for the 7 day study period. As such, there were a total of 21 observations from all the studies. These measurements were helpful in examining the variables that were associated with semi-recumbent and hemodynamic status (Rose et al., 2010). The Sepsis-related Organ Failure Assessment (SOFA) measurements in addition to clinical pulmonary infection score were also recorded during the course of the study. Statistical analysis focused on inter-quartile ranges and standard deviation at 95% confidence level. Differences in measurements were examined by the use of Student t measurements. The tolerant statistic was used to establish whether the variables included in the study had co-relation in them. .
Rose, et al. (2010) provided two sets of result. The first, set of results recorded for 112 participants of 2112 indicated that the measurements were between 4.3 and 6.3 for 45° backstreet elevation. The second set of results indicated that results when the elevation rates were between 30° and 45° for 472 participants indicated that the measurements were between 20.6 and 24.1. These measurements were all taken at 95% confidence level. Additionally, the study established that with decreasing backstreet elevation, there was reduced the level of mean arterial pressure, inotropic support, and organ failure. The weaning status of the patient was directly related with semirecumbent inpatient weaning status. As such, this study has confirmed that indeed, elevating the head of the bed is beneficial in addressing microbiology-related causes (Rose et al., 2010). A limitation of this study is that monitoring of the elevations was only done thrice daily which is not in line with the methodologies of randomization. As such, the study may not be conclusive in linking these two factors. Secondly, only a fifth of all critical care units in Australia was checked which cannot reflect the situation worldwide.
Jansson, Kääriäinen, &Kyngäs (2013), conducted a study entitled Effectiveness of educational programmes in preventing ventilator-associated pneumonia to try to uncover the effectiveness of educational programs in an aim of preventing ventilator-associated pneumonia through a systematic review of the published literature (Jansson, Kääriäinen, &Kyngäs, 2013). They noted that ventilator-associated pneumonia (VAP) is a frequently encountered device-associated and nosocomial infection in the critical care setting thus causing increase of morbidity, a double-fold increase in the mortality rate and unreasonable cost. This study observed that many strategies such as educational interventions and reminders have been put in place because the previous studies have shown low effectiveness to prevent VAP in critical-care knowledge to nurses as well as attitudes and adherence to guidelines was used without implementation of evidence-based guidelines (Jansson, Kääriäinen, &Kyngäs, 2013). This prompted this study to assess the existing body of literature that is concerned with the effectiveness of educational programs with an aim of learning and identifying clinical outcomes to discover ways to strengthen the current research. This study reviewed the past published studies between the year 2003 and 2012 which were contained in several multi-disciplinary databases as one of a method of study. The databases reviewed include Web of Science, Medic, Academic Search Premier, Cochrane library, Scopus, Medline Ovid, and Cumulative Index to Nursing and Allied Health Literature. This comprehensive literature research was conducted in an association with an information specialist. The study process was carried out by two researchers objectively and independently (Jansson, Kääriäinen, &Kyngäs, 2013). The findings incorporated eight original studies in the ultimate review. It was found out that by enhancing education in the intensive care unit personnel, there was a significant perfection in terms of the level of knowledge and adherence to guidelines as well as considerable improvement in clinical outcomes. Such clinical outcomes include decreased length of ICU and hospital stays, reduced mortality, and costs in addition to lower incidences of VAP. The study concluded that education has immense benefits for enhancing patient’s safety. This study recommends a further research to be carried out in order to design randomized, multi-centered and controlled follow-up activities (Jansson, Kääriäinen, & Kyngäs, 2013). Additionally, it recommends that a universal method of measuring the outcome be established so as to facilitate supplementary evaluation of the correlation between educational programs rendered out and clinical outcomes.
Metheny & Frantz (2013), carried a study in an effort to resolve the conflict between the guidelines for head-to-bed elevation to prevent aspiration and pressure ulcers. Some expert sources are calling for 450 HOD elevations while others are calling for an elevation of the angle between HODs of 300 to 450. The exception is that unless the patients are medically contraindicated. On the other hand, pressure ulcer guidelines are recommending an HOD elevation of not more than 300 in order to avoid too much pressure on the sacral region. As a result of these two conflicting guidelines, there is no known optimal HOB elevation to strike a balance between the risks for pressure ulcers and aspiration (Metheny and Frantz, 2013). This is more complicated by few types of research that have been done on the positioning of the head of the bed to assist in the prevention of pressure ulcers. The study showed that the recommendations were overlapping but a 450 elevation in most cases was favorable because it prevented aspiration in critically ill patients who were being tube fed and in addition to having mechanical ventilation. Additionally, aspiration was established to be a threat to oxygenation. As such, aspiration is of a greater importance and immediate concern than pressure ulcers. This research paper recommends that clinicians should play the role of maintaining an HOD elevation of 450 for critically ill patients unless it is medically contraindicated; for patients who are not receiving mechanical ventilation, and HOD of at least 300 should be adopted; they should use a pressure-relieving surface for all the patients who are critically ill in order to reduce skin-bed interface pressure that is associated with elevated HOD and lastly they should minimize the shear pressure that they use when lifting sheet to reposition a patient rather than sliding the patient in bed (Metheny and Frantz, 2013).
It is believed that standard practices are preferred to HOB elevation due to poor perception and lack of knowledge health practitioners have on HOB elevation. Chad et al. (2010), tried to confirm these claims by conducting a research to evaluate perceptions among health practitioners on the usage of HOB elevation. This study included a sample of 175 health practitioners was carried out at the Harborview Medical Center, a level I trauma center in Seattle, Washington and got approval from University of Washington internal review boards (Chad et al., 2010). The study used questionnaires with three questions to get caregivers views on HOB elevation and the correct angle concerning the positioning of the head. The results of the survey showed a significant number of the nurses had considerable knowledge about HOP elevation including the correct angle compared to physicians. The purpose of the study was to find out the knowledge of health practitioners on HOB elevation including their perception regarding the practice. The study concluded that there was the need to educate caregivers on the role of HOB elevation in preventing VAP since a majority of practitioners had no knowledge in regards to this intervention. Thus, according to this study, it is safe to say a majority of caregivers prefer standard practice to HOB elevation since they have no expertise on it. The limitations of this study include using three questions in the questionnaires, small sample size and not utilizing scientific methods to analyze the data.
Consistencies and Contradictions
According to the studies above in managing VAP, Head-of-bed (HOB) elevation has emerged as one of the leading strategies in preventing the occurrences of this illness (Chad et al., 2010). It recommended that the angle of elevation of the HOB need to be in the position of 0°, 30° to 45°. This recommendation is from the CDC and Institute for Healthcare Improvement has received support from the Joint Commission as a measure of preventing, manage and improve the well-being of patients who are critically ill due to VAP. However, despite the numerous evidence bases, recommendations from several health professional bodies and availability of numerous guidelines of how HOB elevation can be utilized in hospitals to minimize the prevalence of VAP, many health care practitioners are still not convinced on this measure and their compliance in including this practice into a normal routine in giving care to intubated patients has been poor. Nevertheless, nurses have an immense responsibility in ensuring that positioning of the patient is implemented together with adherence to its guidelines. Nurses should be adequately trained and educated on this measure so that they can use it in giving care to patients on the ventilator on a daily basis.
Gocze, I., Strenge, F., Zeman, F., Creutzenberg, M., Graf, B. M., Schlitt, H. J., &Bein, T. (2013). The effects of the semirecumbent position on hemodynamic status in patients on invasive mechanical ventilation: prospective randomized multivariable analysis. Crit Care, 17(2), R80.
Health Protection Surveillance Centre. (2011). Guidelines for the prevention of ventilator-associated pneumonia in adults in Ireland. Retrieved from https://www.hpsc.ie/A-Z/MicrobiologyAntimicrobialResistance/InfectionControlandHAI/Guidelines/File,12530,en.pdf
Hiner, C., Kasuya, T., Cottingham, C., & Whitney, J. (2010).Clinicians’ perception of head-of-bed elevation. American Journal of Critical Care, 19(2), 164-167. Retrieved from http://www.iqg.com.br/pbsp/img_up/01330689810.pdf
Jansson, M., Kääriäinen, M., &Kyngäs, H. (2013). Effectiveness of educational programmes in preventing ventilator-associated pneumonia: a systematic review. Journal of Hospital Infection, 84(3), 206-214.
Metheny, N. A., & Frantz, R. A. (2013). Head-of-bed elevation in critically ill patients: a review. Critical care nurse, 33(3), 53-67.Retrieved from http://www.aacn.org/wd/Cetests/media/C1332.pdf
Rose, L., Baldwin, I., Crawford, T., & Parke, R. (2010).Semirecumbent positioning in ventilator-dependent patients: a multicenter, observational study.American Journal of Critical Care, 19(6), e100-e108.
Wright, A. D., & Flynn, M. (2011).Using the prone position for ventilated patients with respiratory failure: a review. Nursing in critical care, 16(1), 19-27