Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada.
Int J Nurs Stud. 2010 Nov;47(11):1425-31. doi: 10.1016/j.ijnurstu.2010.04.002. Epub 2010 May 14.
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.
To determine if provision of an accurate, simple to use angle measurement device with an accompanying education program improved compliance with semirecumbency at 45 degrees over time.
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 degrees , 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.
Backrest elevation measurements (n=1154) were recorded for 141 mechanically ventilated patients. Contraindications to semirecumbency at 45 degrees were noted for 163/1154 (14.1%) measurements the proportion of measurements at 45 degrees 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 degrees 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 degrees [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 degrees [95% CI 0.1-1.5] for each 10-year increment) and measurements recorded during weaning (2.7 degrees [95% CI 1.2-4.1]).
Bedside implementation of an angle measurement device and associated educational intervention did not result in a sustained improvement to compliance with 45 degrees semirecumbency, questioning the clinical feasibility of this nursing intervention. A sustained increased in semirecumbency at 30 degrees or greater was achieved.
观察性研究继续报告预防呼吸机相关性肺炎的体位建议的依从性很差。无法准确测量床头抬高角度可能是导致这种低依从性的原因之一。
确定提供准确、易于使用的角度测量设备并伴随教育计划是否会随着时间的推移提高半卧位 45 度的依从性。
采用前瞻性预前后设计，我们在澳大利亚的 3 个 ICU 实施了角度测量设备和相关的教育干预措施。使用预定的随机时间表，在实施前连续 7 天每天 3 次记录床头抬高、45 度半卧位的禁忌症、平均动脉压（MAP）、儿茶酚胺使用、肠内喂养和撤机状态。在机械通气的每一天都记录疾病严重程度和临床肺部感染评分。
记录了 141 例机械通气患者的 1154 次床头抬高测量值。在 1154 次测量中，有 163 次（14.1%）存在 45 度半卧位的禁忌症。在实施后 1 个月，45 度的测量比例增加了 10.1%（P=0.03），但随着时间的推移，这种变化并未持续。30 度的测量比例在 1 个月时增加了 43.8%，并且在实施后 6 个月仍保持在 70%以上（P<0.001）。对于在没有半卧位禁忌症的情况下记录的测量值，并调整了协变量（MAP、儿茶酚胺支持、序贯器官衰竭评估最高评分、临床肺部感染评分最高和通气指征），床头抬高降低与疾病严重程度增加相关（APACHE II 评分每增加 1 分，角度降低 0.3 度[95%CI 0.1-0.5]）。随着年龄的增加，平均床头抬高增加（每增加 10 岁，角度增加 0.8 度[95%CI 0.1-1.5]），并且在撤机期间记录的测量值也增加（2.7 度[95%CI 1.2-4.1]）。
床边实施角度测量设备和相关教育干预措施并未导致 45 度半卧位依从性的持续改善，这质疑了这种护理干预的临床可行性。半卧位 30 度或更大角度的持续增加得到了实现。
