Effects of Raising the Head of the Bed on Reducing Ventilator-acquired Pneumonia - Research Paper Example

INTRODUCTION Ventilator –Acquired Pneumonia (VAP) is a hospital acquired infection of the lungs that develops after an intubated individual is hospitalized for not less than 48 hours (Mietto, Pinciroli, Patel, & Berra, 2013). Patients with VAP often present with the following symptoms; increase in body temperature, altered sputum colour and thickness as well as leukocytosis. Other signs used for confirming diagnosis include; low saturated pressure of oxygen and radiological confirmation of lung infiltrates. VAP has become an issue of concern in Intensive Critical care Unit (ICU) with incidents approximated to be 65%. Some of the problems associated with VAP include; lengthy hospitalization, increased mortality rate ranging from 20%-70% ,depending on the patients’ medical condition, rise in hospital cost of health care ranging from $5,880 to over $20000 for every incidence (Muscedere et al., 2008). VAP makes up to half of all cases of nosocomial pneumonia incidents with nearly 50% of all antimicrobial agents administered in ICU for treating VAP. Studies show that manipulating the patient’s position by raising head of bed plays a crucial role in preventing VAP (Mietto et al., 2013). Besides helping the intubated patient to assume certain positions of comfort, elevating the head of bed plays the modest role in lowering risk of ventilator –acquired pneumonia. Raising head of bed is seen as the cheapest preventive measure for VAP that must be adopted in ICU and any other hospital unit nursing intubated patients that require a long hospital stay to recover. It is less costly to employ such type of preventive measure than to wait for the infection to occur then treat it. Critically ill patients have compromised respiratory function; hence VAP will worsen their conditions leading to poor patient outcome. Purpose Exploring on the effect of raising the head of the bed on reducing ventilator-acquired pneumonia reveals more than just the art of positioning, but also the scientific rationale behind it (Keeley, 2007). This study seeks to dig up existing information on the importance of patient positioning in preventing respiratory complications during hospitalization. The main purpose is to find out the effect of raising the head of the bed on the cases of VAP (Keeley, 2007). Significance of Head of Bed Elevation to Nursing Understanding the effects of raising head of bed as a way of preventing VAP help nurses to achieve patient satisfaction, increased quality outcome and shorten the period of hospitalization (Keeley, 2007). Nurses are able to accurately apply concepts of patient position as early as possible to prevent any unwanted patient outcomes, especially to those who are unconscious and on mechanical ventilation. (Bassi & Torres, 2011)For example, nurses who correctly apply the art of elevating the head of the bed for intubated patients reduce the chances of resuscitating these patients due to infective gaseous exchange and airway obstruction related to tracheal obstruction. Justification It is with the expectation of the health care providers, the patient and significant others that intubation should help the patient with compromised respiratory function meet his or her gaseous exchange needs and enhance quick recovery with shortest stay possible in the hospital. However, hospital complications and infections prolong patient hospitalization and even cause death (Bassi & Torres, 2011). It has been noted that most of the patients on mechanical ventilation die due to hospital acquired infection rather than the underlying medical condition that they were hospitalized with. (Keeley, 2007) Ventilator Acquired Pneumonia is a preventable nosocomial infection that comes as a result of neglecting the role of positing patients in nursing practice. Studying the effects of elevating the head of bed on reducing VAP will act as an eye opener to the nursing fraternity. Once nurses and other medical practitioners get to appreciate the role of patient positioning, it will be easier to prevent VAP through use of proper patient positioning technique. THEORETICAL FRAMEWORK Descriptive Theory Notably, inappropriate handling of an intubated patient on mechanical ventilators is likely to cause nosocomial infection. (Shmueli & Koppius, 2011)The descriptive theory purports that according the intubated patient required care, especially changing of position, elevation of head of bed and administering antibiotics significantly prevents VAP. It is worth mentioning that the descriptive theory applies the concept of modification and proven statistic to reducing ventilator Acquired pneumonia. It can be described that by elevating the head of the bed when nursing an intubated patient greatly reduces chances of VAP by simply enhancing proper ventilation, mobilization of secretion and scaling down reintubation incidents. Descriptive theory uses the available clues to dig deep into the factors that precipitated to VAP,how using the techniques of elevating the head of the bed can help prevent VAP as well as shedding more light on positions used in nursing intubated patients that run concurrently with elevating the head of the bed from 35 degrees to 45 degrees. (Dryer, 2006) Descriptive theory plays a pivotal role in guiding data collection with an impressive level of accuracy, convenience and reliability. Furthermore, this theory can be used to make provide tentative answers to the problem under study. The final results are then used to justify the stated hypotheses. In most cases, hypotheses curved out of descriptive theory turn out to be justified (Shmueli and Koppius 2011). Therefore, predictive theory has an impressive degree of relevancy in determining the effects of elevating the head of bed in reducing VAP. Application of Theory VAP has been a common problem among the patients on mechanical ventilation. With determination to find lasting solutions to this problem, health care team must seek first of all describe the factors influencing the increased rates of VAP in intubated patients (Shmueli & Koppius, 2011). For instance,descriptive theory elaborates on factors such as patient positioning and raising the head of bed in details. Each of these factors must be critically analyzed and this is only achieved if appropriate description is followed (Dryer, 2006). Through description, the health care team comes to understand that elevating the head of head has several implications, especially when nursing an intubated patient on a mechanical ventilator in ICU. Once the head of the bed is elevated, the position which he patient assumes helps in enhancing effective long expansion and compliance (Dryer, 2006). As examined, only description can be useful in pointing out the effects of elevating the head of bed. With effective ventilation and thoracic functioning chances of VAP are greatly reduced as no excessive accumulation of respiratory sections that harbor microorganisms that cause pneumonia. To have decided to determine the effect of raising the head of bed on reducing the rate of VAP, there must be tentative solutions to the problem. The theory through comprehensive description of factors influencing VAP foretells the outcome of compliance to the practice of elevating the head of the patient’s bed. (Dryer, 2006) Using the existing knowledge on the physiology and the mechanics of the respiratory system, the theory supplies several answers to the problem. The reason for elevating the head of bed is described after which solution are coined out of the available information. RESEARCH QUESTIONS 1. What is the effect of raising the head of the bed on Ventilator Acquired Pneumonia rates? LITERATURE REVIEW Introduction Ventilator –Acquired Pneumonia (VAP) is a nosocomial infection of the lungs that develops after an intubated patient is hospitalized for not less than 48 hours. Patients with Ventilator Acquired Pneumonia usually present with the following manifestations; increase in body temperature, altered sputum colour and thickness and leukocytosis (Mietto, Pinciroli, Patel, & Berra, 2013). Other signs used for confirming diagnosis include; low saturated pressure of oxygen and radiological confirmation of lung infiltrates. VAP has become an issue of concern in Intensive Critical care Unit (ICU) with incidents of prevalence estimated to be 65%. Some of the problems associated with VAP include; lengthy hospitalization, increased mortality rate ranging from 20%-70%, depending on patients medical condition, rise in hospital cost of health care ranging from (Muscedere et al., 2008) $5,880 to over $20000 for every incidence. VAP makes up to half of all cases of nosocomial pneumonia incidents with nearly 50% of all antimicrobial agents administered in ICU for treating VAP. Research has revealed that manipulating the patient’s position by raising head of bed plays a crucial role in preventing VAP (Mietto et al., 2013). Besides helping the intubated patient to assume certain positions of comfort, elevating the head of bed plays the influential role in lowering risk for ventilator –acquired pneumonia. Elevating the head of bed is seen as the cheapest preventive measure for VAP that must be adopted in ICU and any other hospital unit taking care of intubated patients that require long hospital stay to recover. It is less expensive to employ such type of preventive measure than to treat the infection itself. Critically ill patients have compromised respiratory function; hence VAP will worsen their conditions leading to poor prognosis. The effect of raising the head of the bed on Ventilator Acquired Pneumonia rates Patients on mechanical ventilation must be nursed with head of bed elevated from 30 degrees to 45 degrees except when medically advised against elevation (Morris et al., 2011). Head of bed elevation is a special component of ventilator bundle aimed at reducing Ventilator Acquired Pneumonia. There is a wealth of benefits associated with simple elevation of head of bed when nursing an intubated patient on mechanical ventilation. Elevating the head of the bed is important in enhancing mobilization and draining of excessive respiratory secretions. In most cases intubated patients are unconscious meaning that their ability to expectorate is compromised. (Morris et al., 2011)Once the head of the bed is elevated it becomes easier to suction and drain excessive secretions that when left to accumulate harbor pathogens that cause pneumonia. When the patient is elevated to a stable bed position, incidents of extubation are greatly decreased. (Hiner, Kasuya, Cottingham, & Whitney, 2010)Habitual intubation and extubation of patients on mechanical ventilation comes as a result of lower head of bed positioning. This poses a danger of intubation related microbial contamination that ultimately travels the respiratory tract causing pneumonia. However, elevating the head of bed to over 30 degrees minimizes the risk of infection by preventing frequent intubation and extubation. Elevating the head of the bed also improves on the patency of upper airway systems besides preventing aspiration of food content into the upper airways. This helps proper ventilation by preventing unnecessary obstruction from kinking of intubation tube and constriction of the trachea. Basically, elevating the head of bed prevents Ventilator acquired pneumonia by enhancing gaseous exchange, promoting patency of the upper airways, promoting mobilization and draining of excessive secretions as well as preventing unwanted extubation and aspiration of food content into the respiratory tract. All these advantages help in minimizing microbial infections that cause pneumonia According to a quality improvement experimental research conducted in Brazil on the effect of elevating the head of the bed, it was determined that elevating the head of bed alongside other routine interventions such as suctioning and patient positioning reduced VAP rates (Sanders, Adhikari, Fowler,2007). The study was done in three experimental phases which entailed manipulation of variables. The third experiment proved effective against fighting VAP. Compliance to HOB and the number of ventilator days were variables used to manipulate the rate of VAP. The third phase, which heavily applied both variables, achieved best results in reducing VAP. According to Sanders et.al 2007 in a randomized study to determine the feasibility of semi recumbent position in lowering VAP, it was found out that this position minimizes aspiration of stomach contents that in most cases carry pathogens that cause pneumonia. Besides preventing aspiration, the semi recumbent position enhanced gaseous exchange through improving on lung expansion. Intubated patients can also be nursed in lateral positions to relieve pressure on the back as well as enhance drainage of respiratory secretions (Hewitt, Bucknall, & Glanville, 2008). The patient is helped to assume left or right lateral position depending on the level of comfort and amount of respiratory secretions produced. Lateral horizontal positioning enhances respiratory functioning by increasing the partial pressure of oxygen. In a different case assessing the attributable mortality of ventilator-associated pneumonia, the purpose was to closely determine the attributable deaths of ventilator-acquired pneumonia as well as possible origins of variations. It is estimated that the associated mortality rate of VAP is 6%. Precise diagnosis is essential in estimating the rightful rate of risk associated with VAP. VAP is a common nosocomial infection, especially among patients in the Intensive Care Unit with the incidence varying from 8%-28%. VAP is a common problem, especially for those patients that have long hospitalization periods. Besides A lengthy hospital stay, antimicrobial treatment also influences VAP incidents. Descriptive theory offers adequate information to help us understand the experiments conducted in various health institutions on the effect of raising the head of the bed on the rates of VAP. According to Drakulovic et.al, 1999, semi recumbent position is used in nursing patients on mechanical ventilation. Combining semi recumbent position with elevation of head of bed to45 degrees helps in reducing gastric reflux and respiratory aspiration of bacteria. Elevating the head of bed reduces the risk of VAP by approximately 34 %, when amalgamated with the semi recumbent position the risk is even reduced further (Drakulovic et al., 1999). Virtually all patients on mechanical ventilation have impaired gastric motility and emptying, which makes the susceptible to aspiration of gastric content into the airways when nursed in supine position. Semi recumbent position promotes effective drainage of respiratory secretions as well as enhancing the patency of the upper airways (Sanders, Adhikari, & Fowler, 2007). It is also easier to percuss the chest of a patient in semi recumbent position than in the supine position. This position also allows for uniform and unrestricted chest expansion for effective ventilation. In a randomized study to determine the feasibility of semi recumbent position in lowering VAP, it was found out that this position minimizes aspiration of stomach contents that in most cases carry pathogens that cause pneumonia. Besides preventing aspiration, semi recumbent position enhanced gaseous exchange through improving on lung expansion RESEARCH DESIGN To find out the effects of elevating the head of bed in reducing Ventilator Acquired pneumonia, quantitative research is appropriate for use (Toledo-Pereyra, 2012). This type of research design is systematic and objective-based on collecting numerical data about the effects of elevating the head of the bed among intubated patients. Information is provided in numerical format and carefully analyzed using statistical methods. (Toledo-Pereyra, 2012) It is very handy in determining and examining the relationship between positioning of intubated patients and risk of VAP. Putting it differently, quantitative research design promotes understanding of cause and effect of associations. It is through quantitative research design that accurate finalization of findings is attained. Deductions from quantitative research are used to either prove or reject the hypothesis. In most cases satisfactory study answers are obtained when using quantitative research design. Basing on the research questions in this research, the most appropriate subcategory of quantitative design to use is experimental research design (Grimes & Schulz, 2002). This kind of research utilizes what is present and may be useful in revealing new concepts and significance of elevating the head of the bed when nursing an intubated patient. Experimental design chiefly focuses on observations, modification and documentation of facts and figures on the subject under study. This also defines the type of tool to be used in collecting data. For instance, when using experimental quantitative research design, the researcher is given a wide range of options to use in collecting data. Commonly used tools for collecting data in experimental research design include; true designs and quasi designs. These methods of collecting data in experimental research design avail information uncontrolled environment for experiences and observations on the effects of elevating the head of the bead on decreasing rates of VAP.Information gathered using experimental research can be used in other research designs to build on knowledge and practice about patient care. Experimental design can be used to answer questions such as; what is the effect of raising the head of the bed on Ventilator Acquired Pneumonia rates? (Grimes & Schulz, 2002) This is the main research question and providing succinct answers require a comprehensive research design which in this case is experimental research design. CONCLUSION Effects of elevating the head of the bed are very evident, according to the experimental study done in Brazil. It is true that patients who have their head of the bed raised and short stay in the hospital have reduced risks of VAP. Applying quantitative experimental research design is very appropriate in revealing the variables that influence the rate of VAP in ICU patients under mechanical ventilation. With the guide of the research question; “What are the effects of raising the head of the bed on the rate of VAP,” we can comfortably say that elevating the head of the bed, proper nursing and medical are synergistic in helping lower the rates of VAP. Manipulating the patient’s environment must be viewed as the first step of controlling hospital-acquired infections such as VAP. The bed being the immediate environment must be supportive and convenient for the patient to recover as fast as possible not to worsen his or her condition. Reference Bassi, G. L., & Torres, A. (2011). Ventilator-associated pneumonia: role of positioning. Current Opinion in Critical Care, 17(1), 57–63. Dryer, M. S. (2006). Descriptive theories, explanatory theories, and basic linguistic theory. In Catching Language: The Standing Challenge of Grammar Writing (Vol. 167, pp. 207– 234). http://doi.org/10.1515/9783110197693.207 Grimes, D. A., & Schulz, K. F. (2002). Descriptive studies: What they can and cannot do. Lancet. http://doi.org/10.1016/S0140-6736(02)07373-7 Hewitt, N., Bucknall, T., & Glanville, D. (2008). Lateral positioning for critically ill adult patients. Cochrane Database of Systematic Reviews (Online), (3). 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. http://doi.org/10.4037/ajcc2010917 Keeley, L. (2007). Reducing the risk of ventilator-acquired pneumonia through head of bed elevation. Nursing in Critical Care, 12(6), 287–294. Mietto, C., Pinciroli, R., Patel, N., & Berra, L. (2013). Ventilator associated pneumonia: evolving definitions and preventive strategies. Respiratory Care, 58(6), 990–1007. Morris, A. C., Hay, A. W., Swann, D. G., Everingham, K., McCulloch, C., McNulty, J., … Walsh, T. S. (2011). Reducing ventilator-associated pneumonia in intensive care: Impact of implementing a care bundle*. Critical Care Medicine. http://doi.org/10.1097/CCM.0b013e3182227d52 Muscedere, J., Dodek, P., Keenan, S., Fowler, R., Cook, D., Heyland, D., … others. (2008). Comprehensive evidence-based clinical practice guidelines for ventilator-associated pneumonia: prevention. Journal of Critical Care, 23(1), 126–137. Nair, G. B., & Niederman, M. S. (2013). Nosocomial Pneumonia. Lessons Learned. Critical Care Clinics. http://doi.org/10.1016/j.ccc.2013.03.007 Sanders, K., Adhikari, N. K. J., & Fowler, R. (2007). Semi-recumbent position versus supine position for the prevention of ventilator associated pneumonia in adults requiring mechanical ventilation. Cochrane Database of Systematic Reviews. http://doi.org/10.1002/14651858.CD006436 Shmueli, G., & Koppius, O. R. (2011). Predictive analytics in information systems research. MIS Quarterly, 35, 553–572. Toledo-Pereyra, L. H. (2012). Research design. Journal of Investigative Surgery : The Official Journal of the Academy of Surgical Research, 25(5), 279–80. http://doi.org/10.3109/08941939.2012.723954 Grimes, D. A., & Schulz, K. F. (2002). Descriptive studies: What they can and cannot do. Lancet. http://doi.org/10.1016/S0140-6736(02)07373-7 Read More