Adherence to Head-of-bed Elevation in Critically Ill Patients Who are Mechanically Ventilated

INTRODUCTION: Head-of-bed elevation is an important and integral part of Ventilator associated pneumonia (VAP) bundle.(1–4) Hence, compliance to this measure is used as a quality indicator of an intensive care unit. OBJECTIVES: To assess the adherence of proper head-of-bed elevation in critically ill patients who were mechanically ventilated for more than 48 hours. MATERIAL AND METHODS: The study was carried in one ICU from 1(st) December 2023 to 7(th) January 2024. All patients >18 years of age who were mechanically ventilated for more than 48 hours were included. Demographic data like age, gender etc. was collected. Sedation score was analysed using RASS. Observation of head position in these patients was carried by 2 observers daily between 1000 hours and 1015 hours and then between 1800 hours and 1815 hours. These timings did not clash with the timings of nursing care or ambulation of patients. Head-of-bed elevation 20–30 degrees was considered as an ideal position in mechanically ventilated patients.(2,5) Protractor was used to measure the angle of head end elevation and fluid filled chamber was used to measure whether the tragus was well above the mid-axillary line. We excluded patients who were in trendlenberg postion, prone position, who had cervical spine injury or surgery, hemodynamic instability, ambulated within 48 hours of intubation and pregnant patients. Observations were noted in two cycles. In first cycle, the observations including head position were noted for one week. As a part of study, a training session was conducted for one week which included junior doctors, nurses and physiotherapists regarding importance of head end elevation of bed in these patients. A checklist with hourly monitoring of head position of these patients was included in monitoring protocol of nurses, doctors and physiotherapists. After two weeks, second cycle of observations was conducted by same observers for a week. SPSS software was used statistical analysis. Chi square and Fischer's test was applied for categorical data. P value <0.005 considered as statistically significant. RESULTS: CONCLUSION: Compliance of head-of-bed elevation in critically ill patients who are mechanically ventilated for more than 48 hours can be improved by setting targets and vigilant nursing care. Objective protocols and checklists and regular awareness program amongst nurses, junior doctors and physiotherapists can improve the compliance.