VAP Getting Started Kit - Safer Healthcare Now!

Safer Healthcare Now! Prevent Ventilator Associated Pneumonia Getting Started Kit
The potential for harm associated with HOB elevation has been addressed in the published
literature. Pressure ulcers are more likely to occur at higher HOB elevation in critically ill
patients 46 as well as in normal subjects. 47 Of note is that the Wound, Ostomy and Continence
Nurses Society recommends maintaining the HOB at 30 0 elevation for supine positions. 48 Other
factors similarly impede bedside practitioners’ adherence to higher degrees of HOB elevation 49
decreased systolic blood pressure, SOFA score 50 , sliding down the bed, skin shearing, insomnia,
inability to accurately estimate back rest elevation. 51 In order to address these issues, the
American Association of Critical Care Nurses issued a Practice Alert for VAP prevention in 2004
which was revised in 2007 to include evidence-based Practice Alert Statements and tools. 52
A systematic review on the benefits and disadvantages of semi-upright position in ventilated
patients was done by a European expert panel. 53 Based on their results, they recommended that
ICU caregivers “elevate the head of the bed of mechanically ventilated patients to a 20 to 45°
position and preferably in a ≥30° position as long as it is does not pose risks and conflicts with
other nursing tasks, medical interventions or with patients’ wishes”.
It thus appears that:
• the optimal semi-recumbent HOB elevation position that reduces the development of
aspiration and VAP, while deriving the least risk to patients is not known.
• the level of evidence for the use of lower HOB elevation to prevent the most
controversial complication - sacral pressure ulcers- is not as strong as that for HOB
elevation to prevent aspiration and VAP. 54
We conclude that until further evidence becomes available, patients without contraindications
to HOB elevation should be kept at 45°, and when this is not possible, keeping the head of the
bed above 30° should be considered. In all cases, the exact angle strategy is determined on a
patient-to-patient basis according to individual patient needs.
What changes can we make that will result in improvement?
Hospital teams across Canada and the United States have developed and tested process and
system changes that allowed them to improve performance on elevation of HOB. These
measures support the implementation of the VAP bundle. Some of these changes are:
• Identify local implementation challenges (e.g. insufficient awareness of the benefit of
the 45 0 backrest elevation, disagreement about who is responsible for patients' bed
positioning, difficulties in enabling and reinforcing such strategies) to tailor improvement
strategies to the environment in your ICU. 55
• Be aware of other practical challenges in maintaining head of bed elevation throughout
the day and night such as: 1) patients sliding down the bed if overly elevated, 2) bed
often needs to be lowered for procedures such as line placement, bathing, wound care,
patient turns, etc., 3) caregivers forget to re-elevate the head of the bed following these
procedures.
• Determine what constitute valid contraindications for semi-recumbency in your ICU
population (e.g. recent spine surgery or spinal cord trauma, abdominal wound, unstable
pelvic fracture, mod-high-grade sacral ulcer, hemodynamic instability, increased
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