Body Positioning Of Intensive Care Patients: Clinical .

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Brief ReportBody positioning of intensive care patients: Clinical practice versusstandards*Sreenandh Krishnagopalan, MD; E. William Johnson, MPH; Lewis L. Low, MD, FACP;Larry J. Kaufman, MD, FCCPObjective: The routine turning of immobilized critically ill patients at a minimum of every 2 hrs has become the acceptedstandard of care. There has never been an objective assessmentof whether this standard is achieved routinely. To determine ifimmobilized patients in the intensive care unit (ICU) receive theprevailing standard of change in body position every 2 hrs. Todetermine prevailing attitudes about patient positioning amongICU physicians.Design: Prospective longitudinal observational study. E-mailsurvey of ICU physicians.Setting and Participants: Convenience sample of mixed medical/surgical ICU patients at three tertiary care hospitals in twodifferent cities in the United States. Random sampling of ICUprofessionals from a directory.Main Outcome Measures: Changes in body position recorded at15-min intervals.By the very nature of their condition, critically ill patients inthe intensive care unit (ICU)are usually relegated to strictbedrest, if not complete immobilizationby pharmaceutical or mechanical means.The complications of immobilizationhave been well documented in the medical literature and include decubitus ulcer(1–3), venous thromboembolism, andpulmonary dysfunction such as atelectasis, retained secretions, pneumonia, dysoxia, and aspiration (4 –7). In an effort toprevent these known and quite commoncomplications, one of the nursing strategies in the care of critically ill patientshas been to turn them from the supine*See also p. 2607.From the John A. Burns School of Medicine (EWJ)and the Departments of Medicine and Surgery (LLL,LJK), University of Hawaii, Honolulu, HI; and the St.Francis Medical Center, Honolulu, HI (SK, LLL, LJK).Address requests for reprints to: Larry J. Kaufman,MD, FCCP, University of Hawaii, 2230 Liliha Street,Honolulu, HI 96817. E-mail: Larryk@sfhs-hi.orgCopyright 2002 by Lippincott Williams & WilkinsDOI: 10.1097/01.CCM.0000034455.71412.8C2588Results: Seventy-four patients were observed for a total of 566total patient hours of observation, with a mean observation timeper patient of 7.7 hrs (range, 5–12). On average, 49.3% of theobserved time, patients remained without a change in body position for 2 hrs. Only two of 74 patients (2.7%) had a demonstrable change in body position every 2 hrs. A total of 80 –90% ofrespondents to the survey agreed that turning every 2 hrs was theaccepted standard and that it prevented complications, but only57% believed it was being achieved in their ICUs.Conclusions: The majority of critically ill patients may not bereceiving the prevailing standard of changes in body positionevery 2 hrs. This warrants a reappraisal of our care of critically illpatients. (Crit Care Med 2002; 30:2588 –2592)KEY WORDS: critically ill patients; postoperative care; body positioning; nursing strategiesposition every 2 hrs. The medical literature has since shown some convincingdata demonstrating the beneficial effectsof body position changes in postoperativecare (8), and the routine turning of patients every 2 hrs has become the nursingstandard of care for all immobilized andcritically ill patients (2, 9). However, nostudies to date have tested whether patients actually receive this accepted standard. The purpose of this study was toassess prevailing attitudes about turningin the critical care setting and to determine whether critically ill, immobilizedpatients are in fact turned every 2 hrs.MATERIALS AND METHODSTo assess professional opinion regardingpatient turning, we conducted an electronicmail survey. Intensive care specialists from aninternational directory were sent a questionnaire with three questions, requiring only single-letter responses (Yes or No). The questionnaire contained the following questions. 1) Doyou agree that the standard of care is to turnimmobile ICU patients approximately every 2hrs? 2) Do you agree that turning immobileICU patients every 2 hrs may reduce the riskfor complications (deep vein thrombosis, pressure sores, atelectasis, etc.)? 3) Do you believethat patients in your ICU are receiving thisturning care 50% of the time? Survey recipients were asked to send a reply e-mail withthree letters to indicate their responses (e.g.,YYY, YNN). Nonresponders were sent a reminder.In addition, we performed a prospectivelongitudinal observational study of the turning of patients in the ICUs of three majorhospitals. Hospital A was a 450-bed countyfacility in Phoenix, AZ, with an 11-bed multidisciplinary ICU. Hospital B was a 536-bedfacility, also with 11 multidisciplinary ICUbeds. Finally, hospital C was a 344-bed institution with 14 multidisciplinary critical carebeds. Hospitals B and C are located in Honolulu, HI. Each hospital had a similar nurse/patient ratio of 1:1–2. All three hospitals areaccredited by the Joint Commission on Accreditation of Healthcare Organizations andare university-affiliated tertiary care facilitieswith formalized critical care services and assigned medical directors. Directors of eachICU provided approval for the study to beconducted.Only ICU patients who had an expectedlength of stay of 18 hrs and who were unableCrit Care Med 2002 Vol. 30, No. 11

to turn themselves in bed were included. Common reasons for immobility were decreasedlevel of consciousness, use of sedatives or paralytics, and chemical or physical restraints.Patients were excluded if they were able toturn spontaneously or were on specialty bedsproviding continuous lateral rotation (automated turns). Staff nurses and other ICU personnel were unaware of the nature of thestudy to prevent any change of nursing carethat may have resulted from their knowledgeof the observation.Various members of a team consisting of avolunteer nurse, a medical resident, a medicalstudent, and two paid research coordinatorsperformed the observations. Each member ofthe research team used identical methods ofobservation and data recording. Patients wereobserved at 15-min intervals for a minimum of5 hrs. Patients who were observed for 5 hrswere discarded from the database. An equalamount of day and night shifts were sampledat each institution. The periods of observationwere continuous. Furthermore, if a patientwas temporarily transferred out of the ICU fora procedure (e.g., radiograph, computed tomography scan) or was undergoing a procedure in the unit, these times were not included. Blinding of the nature of the study wasmaintained by encrypting data collection, and,if asked, ICU personnel were told that observers were “evaluating monitor function.” Datawere recorded utilizing a code consisting oftwo numbers corresponding to a clock representative of the plane of the patients shouldersas viewed cephalad; for example, flat was as-signed 9 –3 and a 30-degree rightward elevation with the same degree of leftward declination was assigned 10 – 4. Only positionchanges along an axis in the coronal planewere considered and recorded. Data werestored and analyzed using Microsoft Excel (Seattle, WA) and SPSS (SPSS, Chicago, IL).RESULTSIn the survey of ICU specialists, 392surveys were sent by electronic mail, andreplies were obtained from 72 people, aresponse rate of 18.4%. A total of 60 ofthose replying (83%) agreed that thestandard of ICU care was turning the patient every 2 hrs (Table 1). To the question of whether this standard may prevent complications, 65 (90%) againagreed. As to whether this standard isbeing achieved the majority of the time intheir ICUs, the respondents were divided.Only 41 (57%) felt that the standard ofturning every 2 hrs was achieved; theremaining 30 (42%) felt that this standard was not practiced in their ICU.There was one person who answered affirmative to the first question but did notrespond to the latter two questions.Eighty-four percent of all returned surveys were from practitioners in theUnited States, and the international sample was too small to show any statisticaldifference in responses.Table 1. Critical care survey results (72 respondents)QuestionDo you agree that the standard of careis to turn immobile ICU patientsapproximately every 2 hrs?Do you agree that turning immobileICU patients every 2 hrs may reducethe risk for complications (DVT,pressure sores, atelectasis)?Do you believe that patients in your ICUare receiving this turning care 50%of the time?Yes,% (n)No,% (n)83 (60)17 (12)90 (65)8 (6)1 (1)57 (41)42 (30)1 (1)A total of 74 patients were observed inthree separate ICUs. Table 2 shows thetotal observation times by site and perpatient. Patients were observed for an average of 7.7 hrs each (SD, 1.6 hrs), with amedian of 8 hrs, and 77% of patients wereobserved for 7 hrs. A total of 566 patient hours of observation were includedin the analysis.To assess changes in body positioning,we analyzed data based on the time perpatient for which there was no change inbody position. To be sure our results werenot skewed by what time we began recording patient body position, we assumed that a change in body position hadoccurred immediately before the beginning of the observation period for all patients. If patients were out of the room orhad procedures performed, a similarmethod of initial 2-hr satisfactory periodwas employed. Thus, no turns were expected during the first 2 hrs of observation, and therefore, our results are themost conservative estimates of time without position change.If patients received no change in bodyposition after remaining in one positionfor 2 hrs, the time after the 2-hr markwas considered time left in a position inwhich a change should have occurred. Ifa patient remained in one position for 2hrs, this was considered to be within thelimits of the standard of care. A summaryof these data are shown in Figure 1. Ninety-seven percent of patients did not receive the minimum standard of body re-No Response,% (n)0ICU, intensive care unit; DVT, deep vein thrombosis.Table 2. Observation hoursIndividual Patient Observation HoursSite ASite BSite CTotalTotal Crit Care Med 2002 Vol. 30, No. 11Figure 1. Hours without change in body position(n 74). The insert indicates the number ofpatients with no turns during observation.2589

positioning every 2 hrs. Fortunately, 23%of patients only missed required turns by1 or 2 hrs. However, about half of observed patients were supine for 4 – 8 hrs.Finally, another 23% of patients were notrepositioned by staff for 8 hrs, and100% of these 17 patients were supinethe entire study observation period. Combining this finding with data from othergroups shows a total of 28% of all patients were similarly supine throughoutall observation periods.DISCUSSIONPatients in ICUs are often immobilizeddue to a number of factors related to thenature of their illness. The many shortand long-term complications of immobilization have been clearly delineated andstudied, and they include significantly increased risks for decubitus ulcer (1–3),venous thromboembolism, and pulmonary dysfunction (4 –7). For the criticallyill, these complications carry significantcomorbidities that increase the physiologic burden to an already severely challenged patient population. To preventthese complications, it would be logicalsimply to turn immobilized patients.Conceptually, this has served to establishstandards of care. From nursing texts (9),published guidelines (2), and from theresults of our physician survey, it seemsthat the standard of turning every 2 hrs isthe accepted standard and expected goal.The results of our study demonstratethat this nursing standard is not met inthe majority of cases. In fact, in 566patient hours of observation, only twopatients had a change in body positionevery 2 hrs. We have demonstrated inthree representative sites that the highestrisk, critically ill patients are infrequentlyturned. From the data in our survey, atleast half of all ICU physicians suspectthat the turning standard is not achievedin their institutions as well. It impliesthat most critically ill patients may not bereceiving the standard of care and, assuch, are at an increased risk for themany complications of immobilization.At a minimum, these complications mayincrease length of stay and hospital costs.At worst, these complications may contribute to increased mortality.Implication for Previous SpecialtyBed Studies. The results of our study areparticularly compelling when consideredin the light of numerous studies thathave assessed the efficacy and benefits ofspecialty rotational beds in preventing2590the complications of immobilization.These studies have demonstrated thatthere are significant positive outcomes inrelation to mortality, length of stay, nosocomial pneumonia, and skin breakdown(10 –16) when patients are randomized tospecialty beds. However, the controlgroups used in these studies are worthexamining.In their methodology, the publishedprotocols call for the patients to be randomized to a “conventional hospital bed”(10), manual turning every 2 hrs (11–14,16), or specialty beds. Yet, there is noindication that the performance of thecontrol, manual turning, was monitoredor assessed. In three particular case studies, we have been informed that the control groups were in fact not monitored forcompliance (personal communication).These studies have shown compellingand convincing evidence that automatedbed technology is clearly superior to conventional treatment. As it is not readilyapparent from these studies that themanual turning of patients was strictlymonitored or enforced, we believe ourstudy at least calls into question the definition of conventional or routine care.Our data suggest that perhaps the conventional treatment in most ICUs is indeed prolonged immobilization, andtherefore, the specialty bed–study resultsare not surprising. The general assumption in these studies was that the controlgroup was receiving the nursing standardof turning every 2 hrs. Extrapolatingfrom our results, the specialty-bed studies may have in fact been comparingthese specialty beds with a control groupthat was not turned adequately. The specialty beds merely assured that the standard of care was being met (or exceeded).As a result, positive study conclusionsmay actually represent the difference between being turned or not, rather thanspecialty-bed turning vs. manual turning.We present this data not as an indictmentof these clearly important studies, butrather to point out what may be an overlooked and systematic lapse in the current care of critically ill patients.Interestingly, of all the studies we reviewed utilizing specialty beds, only onedid not show any significant benefit ofspecialty beds. Traver et al. (17) studied103 ICU patients randomly assigned tostandard turning or turning by an oscillating bed. He included turning every 2hrs as part of the protocol and documented the degree to which this was being done. The control group was manu-In this age of shrinkingnurse/patient ratios, inwhich scarce personnelresources are stretched to thelimit, and the failure of behavioral educational programs,the institution of automatedbed technology may be themost economic and reliableway to guarantee that critically ill patients achieve asimple but clearly beneficialintervention.ally turned every 1–2 hrs 67% of thetime, and when compared with the specialty beds, there was no significant difference for length of stay, duration ofventilation, or prevalence of pneumonia.This suggests that when stress is placedon repositioning patients to the standardof care, and it is achieved in at least themajority of patients, specialty beds mayoffer no significant benefit. Whether ornot the beds themselves confer any intrinsic or additional benefit beyond simply achieving the standard of care wouldhave to be decided by more rigorous studies with valid control groups.Study Limitations. The response rateto our survey was admittedly quite low.We utilized an e-mail survey to improvethe ease of response for recipients andthereby the response rate. Nonresponderswere sent reminders. Despite our efforts,the response rate remained low. We believe, however, that there is no selectionbias of this smaller sample that wouldpreclude drawing conclusions from thedata for trends.Other limitations of our study stemprimarily from its observational nature.Despite our attempts to blind caregiversto the nature of our study, it is possiblethat our intention was known and thedata do not accurately reflect the realityof care rendered. Any unblinding, however, would be expected to actually increase adherence to prevailing standardsof care, and this did not seem to be theCrit Care Med 2002 Vol. 30, No. 11

case. To reduce sampling error, we havemade particular effort to include a varietyof observational settings: day and nightshift, medical and surgical specialty, anddifferent types of hospitals with variedgeographic locations. We have no reasonto believe that this represents an isolatedphenomenon exclusive to shifts, specialties, or these three institutions. Finally, itis possible that the patients we observedwere indeed turned adequately before orafter our observation period. Therefore,all observations for less than five consecutive hours were discarded because wefelt that this would eliminate the possibility that our data were due to an inadequate sampling of hours per patientA caveat to keep in mind is that therehas never been overwhelming data fromrandomized, controlled trials that haveproven the benefit of the current nursingstandard of care. Such a study would notbe possible ethically given that the nursing standard has already been established. However, in essence, such outcome studies have already beeninadvertently performed if one acceptsthat in the specialty bed studies, theircontrol (standard care) population wassimilar to that which we discovered inthis study (i.e., unturned). Their intervention was ultimately the turning of patients, and the results were clearly beneficial.CONCLUSIONSIf turning patients manually accomplishes the same results as specialty beds,it would seem reasonable to simply mandate this practice. But this is already anestablished standard of care and, as such,should be uniformly achieved. A recentsurvey of nursing personnel regardingpatients in a long-term– care facility revealed a prevailing opinion that the goalsfor turning are not realized (18). Theresults of our survey of intensive carespecialists are also quite enlightening. Ofthose responding, the majority (83%)agree that the standard is turning every 2hrs. Furthermore, 90% also believe thatthis standard helps to prevent the complications of immobilization. However,the respondents were less confident thatthe goals were met with any regularity.Only half of the critical care specialistsbelieved that the standard is achieved atleast 50% of the time. So, despite turningevery 2 hrs being an expected standardand accepted as beneficial and necessaryfor proper care of patients, it is a goal thatCrit Care Med 2002 Vol. 30, No. 11remains elusive, even when part of a rigorous protocol as in the previously mentioned study by Traver et al (17).There has been some investigationinto reasons why turning is not performed. In the survey study by Helme(18) of nursing personnel at long-term–care facilities, the chief reason given bynurses aides for not performing turningroutinely was a lack of specific assignment to the task and a lack of time andstaff. Head nurses and directors of nursing also acknowledged these problems,adding that excess paperwork also prevented them from adequately monitoringcompliance with policies. Given the wayin which our present healthcare climateattempts to stretch the already thinlyspread nursing resources, it is no surprise that many important nursing dutiesare overlooked for more pressing concerns.Although educati

ICU physicians. Design: Prospective longitudinal observational study. E-mail survey of ICU physicians. Setting and Participants: Convenience sample of mixed med-ical/surgical ICU patients at three tertiary care hospitals in two different cities in the United States. Random sampling of ICU professionals from a directory.

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