Helman Donald L, Sherner John H, Fitzpatrick Thomas M, Callender Marcia E, Shorr Andrew F
Pulmonary and Critical Care Medicine Service, Walter Reed Army Medical Center, Washington, DC, USA.
Crit Care Med. 2003 Sep;31(9):2285-90. doi: 10.1097/01.CCM.0000079609.81180.15.
Semirecumbent head-of-bed positioning in mechanically ventilated patients decreases the risk of developing ventilator-associated pneumonia (VAP). The purpose of this study was to determine whether the addition of a standardized order followed by the initiation of a provider education program would increase the frequency with which our patients were maintained in the semirecumbent position.
Prospective, pre-, and postintervention observational study.
A tertiary care, U.S. Army teaching hospital.
Mechanically ventilated medical and surgical intensive care unit patients.
The first intervention involved the addition of an order for semirecumbent head-of-bed positioning to our intensive care unit order sets. This was followed 2 months later with a second intervention, which was a nurse and physician education program emphasizing semirecumbent positioning.
Data regarding head-of-bed positioning were collected on 100 patient observations at baseline and at 1 and 2 months after each of our interventions. The mean angle of head of bed increased from 24 +/- 9 degrees at baseline to 35 +/- 9 degrees (p <.05) 2 months after the addition of the standard order. The percentage of observations with head of bed >45 degrees increased from 3% to 16% 2 months after the standardized order (p <.05). Two months after our provider education program, the mean angle of the head of bed was 34 +/- 11 degrees and the percentage of patients with head of bed >45 degrees was 29% (p = NS compared with values after the first intervention). Data collected 6 months after completion of our education programs showed that these improvements were maintained.
Standardizing the process of care via the addition of an order specifying head-of-bed position significantly increased the number of patients who were placed in the semirecumbent position. In an era of cost-conscious medicine, interventions that utilize protocols and education programs should be emphasized.
对机械通气患者采用床头半卧位可降低发生呼吸机相关性肺炎（VAP）的风险。本研究旨在确定增加一项标准化医嘱并启动一项医护人员教育计划是否会提高患者保持半卧位的频率。
前瞻性、干预前及干预后观察性研究。
一家美国陆军三级护理教学医院。
机械通气的内科及外科重症监护病房患者。
第一项干预措施是在我们的重症监护病房医嘱集中增加一项床头半卧位的医嘱。2个月后进行第二项干预，即开展一项强调半卧位的护士和医生教育计划。
在基线时以及每次干预后1个月和2个月，对100例患者的床头位置数据进行了收集。在增加标准医嘱2个月后，床头平均角度从基线时的24±9度增加到35±9度（p<0.05）。在标准化医嘱下达2个月后，床头角度>45度的观察次数百分比从3%增加到16%（p<0.05）。在我们的医护人员教育计划实施2个月后，床头平均角度为34±11度，床头角度>45度的患者百分比为29%（与第一次干预后的数值相比，p=无显著差异）。在我们的教育计划完成6个月后收集的数据显示，这些改善得以维持。
通过增加一项指定床头位置的医嘱来规范护理流程，显著增加了采用半卧位的患者数量。在注重成本效益的医疗时代，应强调利用方案和教育计划的干预措施。
