The Science Journal of the American Association for Respiratory Care

2008 OPEN FORUM Abstracts


Marie Duggan1, Carol Spada1, Paul F. Nuccio1, Barrett T. Kitch2

Background: Ventilator-associated pneumonia (VAP) is the second most common nosocomial infection in the U.S., occurring in 9 to 25% of ICU patients. VAP is associated with increased ICU and hospital LOS by as much as 22 to 25 days respectively. Mortality attributable to VAP may be as high as 27%, and associated costs of VAP can be greater than $40,000 per case. Elevation of the head of bed (HOB) to greater than 30 degrees has been shown to play a significant role in reducing VAP. Beginning in July 2008, Massachusetts will begin mandating the reporting of HOB elevation compliance. Given the significance of this practice, a quality improvement team focused on the monitoring of HOB elevation on all mechanically ventilated patients.

Methods: The charge given to the QI team was to assure accuracy of data recording and standardize measurements. An MS Access database has been used to track elements of ventilatory care and was modified to include tracking of ventilator bundle items. The QI process involved the identification of types of beds in the ICUs and a comparison of each bed's method of HOB measurements. Protractors were used to verify/compare HOB readings with precise measurements. RTs were consulted regarding current practices in measurement and recording HOB angle.

Results: Findings revealed 6 different bed types with various degrees of HOB angle accuracy. Although 66% of the beds were within +/-2 degrees, 33% were found to be +/-10 degrees. Important variation was found with measuring practices, with the most difficulty found when beds were in reverse trendelenburg. Some RTs were adjusting measurement to reflect reverse trendelenburg while others were not. Other RTs recorded the "found" angle, while others reported "corrected" angle following measurement and adjustment.

Conclusion: Inconsistencies were found in measurement techniques among RT staff which led to a plan of action that included the development of a protocol for standardizing HOB measurement, and the development of an education program for both respiratory therapists and nursing to inform them of the importance of the 30 degree HOB angle. Also included was the development of a quality improvement monitor to assure documentation and compliance with HOB elevation. Further investigation will be performed to correlate the HOB elevation with a decreased incidence of VAP.