Positioning practices for ventilated intensive care patients: current practice, indications and contraindications

AN

Australian Critical Care

Positioning practices for ventilated intensive care patients: current practice, indications a n d c o n t r a i n d i c a t i o n s P e t e r J T h o m a s • BPhty (Hans) Physiotherapist, Royal Brisbane a n d Women's Hospital, Brisbane, QLD Phd Candidate, School of H e a l t h a n d R e h a b i l i t a t i o n Sciences, University of Q u e e n s l a n d , Brisbane, QLD D r J e n n i f e r D P a r a t z * MPhty, PhD, FACP, G r a d Cert Ed (Medical & H e a l t h Sciences) Lecturer, Division of Physiotherapy, School of H e a l t h a n d R e h a b i l i t a t i o n Sciences a n d Research Fellow Anaesthesiology a n d Critical Care, School of Medicine, University of Q u e e n s l a n d , Brisbane, QLD D r W a r r e n R S t a n t o n * PhD, MAPS Research Consultant, Physiotherapy, School of H e a l t h a n d Rehabilitation, University of Q u e e n s l a n d , Brisbane, QLD M s R e n a e D e a n s • BNurs, Cert Critical Care Research Coordinator, Burns T r a u m a a n d Critical Care Research Centre a n d D e p a r t m e n t of Intensive Care Royal Brisbane a n d Women's Hospital, Brisbane, QLD • MBBCh, DA (SA), FFA (SA) FFA (CritCare) (SA), FFICANZCA, FJFICM Executive Director, Burns T r a u m a a n d Critical Care Research Centre, Brisbane, QLD Director of D e p a r t m e n t of Intensive Care, Royal Brisbane a n d Women's Hospital, Brisbane, QLD Professor of Anaesthesiology a n d Critical Care, University of Q u e e n s l a n d , Brisbane, QLD Professor Jeffrey Lipman

Abstract To investigate the process of providing patient positioning in intensive care units (ICUs), a self-reported survey was distributed to a senior physiotherapist and a nurse in each of the 38 Level 3 Australian ICUs. The survey explored the rationales, aims, type, frequency and duration of directed patient positioning used, and perceived risks that lnay impede the implementation of an effective positioning regime. The response rate was 93%. Fifty nine respondents (83%) agreed that there is an accepted standard of care for the duration of a position change with ventilated patients. Of these respondents, 51 (86%) agreed that the standard is to turn patients every 2 hours, but this was only achievable "more that: 50% of the time" in 47% (n 34) of ICUs. Educational and environmental issues were found to impact on positioning practices. Semi-recumbent and full side-lie positions were recommended in the management of a range of patient conditions. However, full side-lie was less commonly used than supine positioning. The prone and head down tilt positions were the least frequently utilised. Levels of agreement for precautions and contraindications to positioning patients into full side-lie and sitting were high. We conclude that, in Australia, experienced ICU physiotherapy and nursing staff are aware of evidence-based positioning practices and agree on indications and potential risk factors associated with positioning. However, educational and environmental resources are needed to improve the frequency and type of positioning used. Results from this survey can now be incorporated into educational tools to facilitate the safe use of positioning.

However, despite the potential benefits of positioning, recent

Introduction

investigations have indicated that some intensive care units

The act of altering the position of a critically ill patient ca:: have powerful effects on oxygenation and is important in the prevention of nosocomial pneumonia. For example, the prone and semi-recumbent position may improve oxygenation indices and/or decrease the inddence of ventilator-associated pneumonia in patients with acute respiratory failure and/or acute lu:xg injury :3. Kinetic bed therapy may also produce similar improvements in pulmonary function 4.5. In addition to positive effects positioning may have on pulmonary function, 2 hourly repositionlng of patients has been recommended to reduce the risk of pressure area formation 6. Volume 19

Number 4

November 2006

(ICUs) fail to meet accepted standards of care and/or evidence based practice in patient positioning 79. The under utilisation of positioning may be influenced by insufficient awareness of its rationale and benefits. Staff may also be concerned about real or perceived adverse events resulting from position changes. Factors that influence or restrict the choice of body position during critical illness have not been adequately investigated and, subsequently, there is a lack of guidelines directing the use of positioning and/or mobilisation. 122

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Is t h e r e a s t a n d a r d o f c a r e for t h e f r e q u e n c y o f t u r n i n g w i t h v e n t i l a t e d ICU p a t i e n t s ?

This survey aimed to document the positioning practices in use across Australian ICUs. It also sought to examine Me rationale and clinical reasoning used by staff for Me selection of patient positioning. The information gained may be useful in providing consensus-based education guidelines, which may complement positioning practices supported by clinical research.

Fifty nine respondents ( ~ % ) agreed Mat Mere is an accepted standard of care (SOC) for the duration of a position d~ange wiM ventilated patients who are restricted in bed. Of Mese respondents, 51 (86%) agreed that Me SOC is to turn patients every 2 hours (SOC 2), while eight (14%) indicated Me SOC is longer (SOC>2). In Mese cases, Me median SOC was 4 hours (range 3-4).

Materials and methods A survey was drafted in consultation wiM five senior ICU staff from the medical, nursing and physiotherapy professions. Face/ content validity was further achieved Mrough discussion and trial of Me survey with ICU nursing and physioMerapy staff who had not been involved with its initial development. After Mis process, improvements to Me survey were made. The final version consisted of 23 semi-closed response questions Mat explored the type, frequency and duration of position changes used for ventilated ICU patients. The rationales, aims and perceived precautions and contraindications to positioning were also investigated.

Respondents who indicated Mat Me SOC 2 reported the primary determinant of this was Me prevention of pressure necrosis (82%). Patient comfort (61%) and a plateau in beneficial responses in oxygenation or respiratory function (53%) were also frequently reported rationale. All respondents who indicated Mat the accepted SOC>2 reported environmental issues (e.g. workload management and availability of wardspersons) as Me most important determinant (100%), followed by pressure necrosis prevention (88%) and patient conffort (88%).

The Australian and New Zealand Intensive Care Society was approached and provided a database of all 38 Level 3 ICUs in Australia. These ICUs are tertiary referral centres capable of providing complex, multi-system life support for indefinite periods L0. The intent was to distribute the survey to a nurse and a physiotherapist within each of these ICUs. Initial contact with each institution was via telephone contact with the ICU nurse mlit manager and director of physiotherapy. They were invited to complete the survey and/or nominate a physiotherapist/nurse with current and extensive ICU experience who might complete the survey. Surveys were mailed to participants. If it was not returned within 2 weeks, a second letter

Twelve respondents (17%) indicated that there is no SOC for the duration of a position change. Reasons for this were cited as dependence on individual patient responses in oxygenation or respiratory function (100%), haemodynamic stability (92%), and the type of pressure relieving mattress in use (75%). Patient comfort (42% ), environmental issues (42% ) and assessment of an individual's risk to pressure areas (17%) were also reported as determinants. Compliance to Me practice of repositioning patients every 2 hours was reported to occur "more Man 50% of the time" in 47% (n 34) of Australian ICUs. Where Me accepted SOC wiMin an ICU was SOC>2, a higher, but not statistically significant, rate of compliance

of invitation was mailed. Final contact via telephone occurred if no response was received after 5 weeks. The University of Queensland ethics committee approved the protocol and all participants provided written informed consent. Surveys were de-identified of personal/hospital information and were mailed back to the

was reported (SOC>2=88%, SOC=2=67%, X2(2)=3.8,p=0.15).

P o s i t i o n i n g p r a c t i c e s i n v e n t i l a t e d ICU p a t i e n t s Table 2 outlines Me frequency and duration of use of a range

investigator separately to Me consent form, allowing complete anonymity of responses.

of positioning techniques. Full side-lie, prone and head down tilting are less commonly used positioning techniques. The lower utilisation of full side-lie was reportedly due to a lack of staff training and education (39%) or its select use only wiM certain

Results are presented according to Me frequency of responses (expressed as a percentage). Fishers exact tests (FET) (2x2 tables, two sided) or Chi-square tests (equal proportions) were used to compare difr)'rences in categorical variables. A significance level

Table 1.

of <0.05 was chosen.

Demographic profile of respo~Siers.

Results

Physiotherapy n---36

A total of 71 surveys were returned (response rate 93%). The demographics of respondents are presented in Table 1. The ICUs had a mean bed number of 15 (range 5-36). Reported caseloads included general medical (99%) and surgical achnissioils (97%), trauma (80%), neurosurgical (73%), cardiac surgery (58%), spinal injuries (45%), transplants (30%) and burns (24%). Forty-eight respondents (68%) reported a daily role in advising on patient positioning and also assisting in its physical implementation. Eighteen (25%) indicated Mey had a consultative role only and four (7%) reported a limited or no daily role in Me positioning of ventilated ICU patients. There was no diff?'rence in reported roles between nursing and physiotherapy respondents (FET, p 0.80).

Nursing n---35

Employment - n (%) Senior physiotherapist Physiotherapist ICU nurse unit manager Nurse educator Research nurse Clinical nurse specialist Registered nurse

33 (92) 3 (8) 17 (49) 7 (20) 2 (6) 8 (23) 1 (3)

Experience Professional experience (years)* ICU experience (years)* *

12g

Mean

±

10.8±6.6 5.4±4.6

17.1±6.8 12.1±5.2

standard deviation

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Number4 November2006

AN Australian Critical Care

Table 2.

Main responses * to the average frequency and duration of posltionlng for providing respiratory and pressure care management t o ICU patients (n=71).

Quarter turn from supine

Daily (63%)

Supine, with head elevated 30 °

Daily (61%)

<2 hours (37%) or 2-4 hours (55%)

Semi-recumbent sitting (head up >45 °)

Daily (54%) or sometimes (46%)

2-4 hours (59%)

Sitting out of bed

Daily (55%) or sometimes (45%)

2-4 hours (63%)

Supine

Daily (49%) or sometimes (40%)

<2 hours (44%) or 2-4 hours (46%)

Full side-lie

Sometimes (62%)

<2 hours (42%) or 2-4 hours (51%)

Prone

Sometimes (62%)

>4 hours (44%)

Head down tilt for pastural drainage

Sometimes (41%) or rarely/never (54%)

< 2 hours (52%)

* 1" A

2-4 hours (67%)

Main responses determined using Chi-square tests (equal proportions) Response options = daily, sometimes, rarely~never Response options= <1 hour, 1-2 hours, 2-4 hours, 4-8 hours, >8 hours

patient groups (32%) (e.g. unilateral collapse/consolidation, low Glasgow coma score and compliant and/or well sedated patients). Except for head down tilt and prone positioning, respondents indicated that ventilated ICU patients were positioned around 2-4 hours on average.

Table 3.

Fifty respondents (70%) reported that, in their ICU, prone positioning was not routinely used for patients with acute respiratory distress syndrome (ARDS). The main reasons for this included the

Pastural drainage/secretion mabilisation

86

74

t97

Prevent ventilator associated pneumonia

82

83

80

Improve patient comfort

76

~86

67

Prevent pressure ulceration

75

~86

64

Improve arterial blood oxygenation

70

63

78

Decrease the work of breathing

61

60

61

Improve tidal volume

59

51

67

Facilitate weaning from mechanical ventilation

59

57

61

Improve thoracic compliance

51

54

47

Aims of positioning ventilated ICU patients

Prevent gastro-esophageal reflux

42

51

33

Table 3 outlines general aims provided for the use of positioning in ventilated ICU patients and compares nursing and physiotherapy responses. From the list of aims in Table 3, respondents were also asked to indicate the single most important aim. The most important was listed as postural drainage and secretion mobilisation

Prevent soft tissue cantractures

42

40

44

Increase patient arousal

27

6

t47

Improve haemodynamic stabilisation

23

23

22

Prevent deep vein thrombosis

17

t29

6

Reduce muscle tone

14

6

~22

Other: improve ventilation perfusion relationships 1

O

3

Other: Improve functional residual capacity

O

3

Frequency of responses t o "What are your aims when positioning mechanically ventilated patients?"

Aim of positioning

Overall %

(n=71)

perception that its potential complications were greater than the potential benefits (50%), a lack of staff training and education on prone positioning (16%), its use predominantly when "all else has failed" (16%), inadequate staffing levels to acquire enough assistance with the positioning of patients into prone (12%), a lack of evidence for improved long-term outcomes (12%), and its use being predominantly determined by medical staff"(10%).

(28%), followed by the prevention of ventilator-associated pneumonia (20%) and pressure ulceration (14%), improving arterial blood oxygenation (12%), improving patient comfort (8%), and facilitating weaning from mechanical ventilation (8%). There was no difference between nursing and physiotherapy respondents in the reported most important aim of positioning

1

Nursing

PT*

%

%

(n -~35) (n=36)

*

~ (physiotherapy).

1" A

significant difference between nursing and PT responses (FET: p
(X2(6)=4.0, p=0.68).

Determinants in selection of appropriate patient positioning

sputum production (12%). Pressure area assessment was not reported as a clinical finding that is used in selecting a patient's positioning.

There was a high level of agreement between all personnel regarding the most beneficial and most commonly used positions in the management of selected conditions (Table 4). Sixty eight respondents (96%) reported routine use of clinical measurements to determine appropriate positioning of patients. The most comn:on clinical findings used are chest x-rays (96%), auscultation (66%), arterial blood gas findings (47%), SpO~ (24%), haemodynamic stability (19%), and

The frequency of scores in determining factors that indicate precaution or contraindications to positioning patients into full side-lie or seated positions are listed in Tables 5 and 6. While dialysis was listed as a contraindication, seven respondents provided clarifying comtgtents that the risk is dependent on the site of the dialysis catheter, with femoral lines a contraindication and internal jugular and subclavian lines a precaution only.

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R e s o u r c e s a n d p r a c t i c e s to f a c i l i t a t e c o m p l i a n c e

Discussion

with positioning

This is the first multi-disciplinary study surveying positioning practices for ventilated ICU patients. ICU patients are often immobilised due to a number of factors related to their illness and/or treatment, including cardio-respiratory instability, paralysis and sedation. Patient immobility is principal in the development of pressure areas and ICU patients are in a high risk group due to combined factors such as reduced sensory perception, an inability to reposition oneself and decreased nutritional status 11.12. As such, 2 hourly repositioning of patients has long been advocated 6.13.14.

Sixty four respondents (90%) registered that their ICU had established processes to ei~sure regular positioning of ventilated patients.

This incorporated practice defined by policies and

procedures (70%) and/or regular rounds by wardspersons (52%, with median frequency of round reported every 3 hours (rmxge 1-5)). A range of specialised equipment was documented to assist in positioning patients.

This included slide-sheets, hoists, normal

and/or specialised chairs (e.g. Hausted chairs, recliner chairs, water

Is t h e r e a SOC f o r t h e f r e q u e n c y o f t u r n i n g w i t h v e n t i l a t e d ICU p a t i e n t s ?

chairs, roller chairs with/without tilt-in-space mechanisms) and specialised beds that allow positioning of patients from supine to sitting (e.g. Hill-Rom TotalCare Bed System). When questioned

Krishnagopalan et al. 8 were the first to raise concern over the achievement of 2-houdy position changes in ICU patients. They surveyed ICU medical specialists primarily from the United States and, ahhough their response rate was poor (18%, n 72), the results were

on the use of specific equipment, respondents reported little access to continuous rotational therapy beds (80%), Egerton beds (81%) or prone frames (81%).

Table 4.

Responses to "what are the most common positions of choice?" and " W h a t is 'the most beneficial option?" for specific conditions.

Unilateral right sided pneumonia

63

Left full side-lie (84%)

Left full side-lie (94%) Head u p 30 ° (48%) Head u p 45 ° (44%)

Exacerbation of COPD

65

Head u p 45 ° (89%)

Head u p 45 ° (96%) Head u p 30 ° (43%) Right or left side-lie (42%)

Acute Respiratory Distress Syndrome (ARDS)

59

Prone (58%)

Right or left side-lie (72%) Prone (67%) Head u p 30 ° (58%) Head u p 45 ° (43%) Quarter turns from supine (43%)

Post abdominal surgery

58

Head u p 45 ° (60%) Head u p 30 ° (34%)

Head u p 30 ° (71%) Head u p 45 ° (68%) Quarter turns from supine (48%) Right or left side-lie (45%)

Right sided rib fractures

62

Left full side-lie (50%) Head u p 45 ° (40%)

Left full side-lie (83%) Head u p 45 ° (70%) Head u p 30 ° (49%) Quarter turns from supine (42%)

Hypotension

61

Supine (48%) Head down tilt (23%)

Supine (74%) Head u p 30 ° (41%) Quarter turns from supine (39%) Head down tilt (30%)

Obesity (>lOOkg)

60

Head u p 45 ° (67%) Head u p 30 ° (27%)

Head u p 45 ° (79%) Head u p 30 ° (61%) Quarter turns from supine (47%) Right or left full side lie (46%)

Post head injury/neurosurgery

49

Head u p 30 ° (90%)

Head u p 30 ° (98%) Supine (33%) Quarter turns from supine (31%) Right or left full side-lie (29%)

Burns TBSA >40%

18

Head u p 30 ° (56%) Head u p 45 ° (22%)

Head u p 30 ° (91%) Right or left full side-lie (45%) Supine (41%) Quarter turns from supine (36%) Head u p 45 ° (36%)

125

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AN Australian Critical Care

similar to our study. They found that 83% of specialists agreed that the SOC is to turn patient, s every 2. hours but only 57% were satisfied that this was practised in their ICU "more than 50% of the time".

after 4-8 hours. The rationale of respondents who indicated no SOC for the duration of positionii~g appeared to focus on selecting positioning based on a ICU patient's individual response to that position (e.g. improvement of cardiorespiratory function). Additionally, 75% of this group suggested the type of pressure relieving mattress in use would affect the frequency of patient repositioning.

Despite the indoctrinated recommendation for 2-hourly repositioning, our findings suggest this is not achieved in dinical practice and is partly limited by environmental issues (e.g. workload management and availability of wardspersons). Similar environmental issues have previously been reported to impact on the ability of staff to position patients 15.16,even when performed under research conditions 17. For

However, maintaining a patient in one position for a prolonged period, either because of a positive effect on cardiorespiratory function or because a patient is on a pressure-relieving mattress, requires caution. While improvements in oxygenation may occur,

respondents indicating the SOC>2, the median duration of positioning reported was four hours (range three to four hours). Two to four hours was the conunon duration reported for use of selected positions (Table 2). These findings may indicate that, while environmental issues make 2-hourly repositioning difficult to achieve in an ICU, in nlost cases repositioning is occurring at least once every 4 hours. However, in an observational study by Krishnagopalan et al. 8, 97% of ICU patients did not receive a SOC of 2-hourly repositioning. Only 23% were repositioned after 2-4 hours, and the majority (51%) was repositioned Table 5.

repeated, sustained (6 hours) prone positioning has been associated with increased pressure area development 12'1~. The use of pressure relieving devices should not negate the provision of frequent repositioning but rather complement it. In fact, the literature suggests that even 2-hourly positioning is inadequate and, while foam alternatives to standard hospital mattresses tnay reduce the

Determlr~ation of perceived risk according to frequency of responses to " W h a t do you consider is the risk in positioning an I C U patient with the following conditions from supine to full slde.lle?"

Item

Frequency of responses NO %

PC %

C %

NR %

Risk category*

A central venous pressure catheter insitu

92

8

0

0

Negligible/no dsk

Low dose inotropic support (e.g. Dopamine <10mcg/kg/min, Nor/Adrenaline <0.1mcg/kg/min)

80

20

0

0

Negligible/no dsk

Sepsis with adequate fluid resuscitation

72

28

0

0

Negligible/no risk

A pulmonary arterial catheter insitu

61

35

4

0

Negligible/no dsk

Pressure control ventilation

59

39

1

0

No risk or precaution

Chronic arrhythmias

55

39

4

1

No risk or precaution

Patients requiring physical restraint

39

46

14

0

No risk or precaution

1

82

17

0

Precaution

High dose inotropic support (e.g. Dopamine >10mcg/kg/min, Nor/Adrenaline >0.1mcg/kg/min, Dobutamine (any dose))

10

77

10

3

Precaution

Mean artedal blood pressure >130 m m H g

11

76

13

0

Precaution

Heart rate >130 b p m

27

70

3

0

Precaution

High FiO 2 (>0.6) requirement

32

66

1

0

Precaution

Severe sepsis (one or more sepsis induced organ failures)

21

64

14

0

Precaution

Sepsis without adequate fluid resuscitation

11

63

25

0

Precaution

4

63

31

1

Precaution

Labile blood pressure

Acute/new onset arrhythmias High PEEP (>10) requirement

37

62

1

0

Precaution

Acute respiratory distress syndrome

31

62

6

1

Precaution

Heart rate <60 bpm

31

62

6

1

Precaution

Receiving dialysis

27

58

15

0

Precaution

Intracranial pressure <20cmH20

25

56

6

13

Precaution

Nitric oxide requirement

18

55

10

17

Precaution

Mean arterial blood pressure <60mmHg

2

54

44

0

Intracranial pressure >2OcmH2O

1

31

55

13

Contraindication

Unstable spinal fractures

O

7

92

1

Contraindication

* Category determined using Chi-square tests (equal proportions) on frequency of responses (p
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126

Precaution or contraindication

AK Australian Critical Care

incidence of pressure ulcers in high risk groups, the benefit of hightech pressure devices is yet to be established 19.

Support for this practice in Australian ICUs is reflected through the reported daily use of head elevated positions and its frequent

Positioning practices in ventilated ICU patients

variety of patient conditions (Table 4). However, with selfLreported

citing as a beneficial or comwto£t choice in the matxagement of a

There was a high level of agreement between all personnel regarditxg the most beneficial and most commonly used positions

surveys, actual practice lnay be overstated, and prior observational

in the management of selected conditions (Table 4). This is the

less than 30 ° in ICU patients, particularly if they are ventilated 7. Reasons reported by staff for non-use of semi-recumbent positions

studies 7.9. 23 have reported mean backrest elevation is commonly

first time a multi-disciplinary team has stated their opinions on positioning. The responses indicate that, in Australia, experienced ICU physiotherapists and nursing staff are aware of evidence-based

have been studied previously and include association with adverse events, inconvenience to nursing staff and inadequacies in decision

positioning practices reported in the literature.

makitxg processes 24. ~5. Additionally, pressure area prevention guidelines often incorporate recommendations to limit the use of

Semi-recumbent posifionin 9

backrest elevation to reduce pressure and shear on sacral tissues *3.26

Although the feasibility and outcomes associated with the use

and lnay impact on the use of semi-recumbency.

of semi-recumbent positioning remains unclear 20, it has been Lateral p ositionin 9

combined with various inrerventiotls to form guidelines aimed at targeting the prevention on ventilator-acquired pneumonia 21. 22

Table 6.

Although not conclusive, there is evidence to support the use of full

Determlr~ation of perceived risk according t o frequency of responses to " W h a t do you consider is the risk in positioning an I C U patient with the following co~itlons from supine to a chalr/sltting o u t of bed?"

Item

Frequency of responses NO %

PC %

C %

NR %

A central venous pressure catheter insitu

72

25

0

3

Negligible/no dsk

Chronic arrhythmias

52

39

7

1

No risk or precaution

Sepsis with adequate fluid resuscitation

42

45

10

3

No risk or precaution

Heart rate >130 b p m

4

77

17

1

Precaution

Heart rate <60 bpm

7

69

23

1

Precaution

17

62

17

4

Precaution

High FiO 2 (>0.6) requirement

8

58

31

3

Precaution

Mean arterial blood pressure >130mmHg

7

56

34

3

Precaution

Low dose inotropic support (e.g. Dopamine
31

55

10

4

Precaution

High PEEP (>10) requirement

11

54

32

3

Precaution

Pressure control ventilation

24

35

38

3

Precaution or contraindication

7

46

44

3

Precaution or contraindication

A pulmonary arterial catheter insitu

21

38

39

1

Precaution or contraindication

Intracranial pressure <2OcmH2O

10

38

35

17

Precaution or contraindication

Receiving dialysis

10

41

46

3

Nitric oxide requirement

4

15

62

18

Contraindication Contraindication

Patients requiring physical restraint

Acute respiratory distress syndrome

Risk category*

Precaution or contraindication

Labile blood pressure

O

35

63

1

Sepsis without adequate fluid resuscitation

1

27

68

4

Contraindication

Acute/new onset arrhythmias

O

30

69

1

Contraindication

Severe sepsis (one or more sepsis induced organ failures)

1

27

69

3

Contraindication

Mean arterial blood pressure <60mmHg

0

18

80

1

Contraindication

High dose inotropic support (e.g. Dopamine >10mcg/kg/min, Nor/Adrenaline >0.1mcg/kg/min, Dobutamine (any dose))

0

17

82

1

Contraindication

Intracranial pressure >20cmH20

0

3

82

15

Contraindication

Unstable spinal fractures

0

0

99

1

Contraindication

* Category determined using Chi-square tests (equal proportions) on frequency of responses (p
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AK A ~ b ' a ~ a n Critical Care

side-lie (90 ° from supine) in preventing pulmonary complications in addition to its use for pressure area management 27?~ For example, in post-operative patients, mucous is known to accumulate it, dependent lung regions and is associated with the formation of atelectasis z7 Khngstedt et a l z~ found that anaesthetised patients, whet, positioned from supine to lateral, had large reductions it, area of atelectasis it, the non-dependent lung Chulay et al 28 turned patients second-hourly

supportive ~:,'?

Howeveu

supine positioning is attributed to a

higher incidence of pneumoniP and we assume that it is unlikely that lateral rotation of less than 30o would significantly alter any proposed mechanisms in its prevention Interestingly, with automated rotational therapy, extreme lateral positioning (>40 °) may be more effective in reducing pulmonary comphcations than conservative lateral rotation (<40 °) 16

for 24 hours after coronary artery bypass surgery and demonstrated a reduction in the incidence of fever and shortened IOU stay compared

Prone positioning

to patients who remained in the supine position

Me ade ~t a[ ~ recently su:~eyed Canadian ICU physicians and found

The experience of the team who developed the sutwey was that full

9% commonly prone all patients, 53% prone selected patients, 23% rarely prone and 16% never prone position patients The reported frequency of prone positioning in our study would suggest a similar

side-he positioning is often under utihsed in [CU and we therefore chose to incorporate sutwey items that specifically 8ddressed this Despite respondents featuring full side-he positioning prominently in re commended positioning for a range of patie nt conditions (ToNe 4), our suspicion was supported by th e findings on th e frequency that

approach to prone positioning among Australian :OUs Its low reported use was primarily attributed to the perception that the risk for complications outweighs potential benefits, but a lack of education and evidence-based evaluations were also influential

supine and a quarter turn from supine positioning were used over full side-he positioning (ToNe 2) The less frequent use of full side-he was reported to be primarily attributable to a lack of stafftraining and education and perceived use only with select patient groups Previous authors have also found high utihsation of supine and a quarter turn from supine positioning among [CUs ~ Shea ~0 suggested that frequent repositioning with minimal physical effort can be achieved if patients are slightly tilted 20-30 ° degrees rather than performing a full 90o turn; subsequent research has been

A range of complications have been attributed to prone The absence of a protocol within an ICU for the use of prone positioning and concern over its potential complications rosy delw its initiation Subsequently, it is implemented only when "all else foils" However, a longer delw from the onset of ARDS to the commencement of prone positioning has previously differentiated responders and non-responders :s':6 While the mqority of small, randomised studies recommend the use of prone positioning to improve oxTgenation:% two large prospective studies hsve found no significant effect of prone positioning on the duration of ARDS, organ f~ilure at,d/or mortality 1'2 Therefore, the current role of prone positioning in [CUs appears to reflect the need for greater research and establishment of long-term outcomes that would balance the risk-benefit decision making process

Head down tilt positions Hesd down tilt positions, while sometimes used in hypotension, M ater Health Services Brisbane boasts several highly r otivat ed and committed Critical Care teams focused on delivering oxcellence through evidence based nursing Winner of the first ~er Queensland Greats Awards for an organisation Mater Health Set, ices er [Ioys around 280 Critical Care nursing staff who care for some 3500 critically ill patiet~s each year We curret~ly have vacancies for proactive [~el 1 & 2 I]e 8istered Ill.tees to pr~ide Critical Careto •

Private and public adults Neonates

•

Paediatrics

This is a suberb career opportunity for oxperience RNs seeking • •

Full support training and promotion; An opportunity to develop a portfolio of skills in a new supportive and friendly environr ot~; and Access to Clinical Nurse Educators that are dedicated and committedt o ensuring less experienced staff developit~o speciality nurses

For further it#ormation on these and other oxcertional opportunities please visit w ~ alatororgav/~l,e or contact the Jollying Critical Care Nurse Managers Vi. ee Gree.sill(M at er Private Hospital Brisbane) phone 0738401075 6hris Smith)Mater Adult Hospital) phone 073[408558 A. cola Sly (Mater M others H ospital Neonat sis[T/) phone 0738401931 Donna Ranl{lin (Mater Children s Hospital) phone 073840 8625

were not reportedly used for any other condition (ToNe 3) and hsd a low overall frequency of use The reasons for this were not explored in this sutwey While peak expiratory flow rates and sputum production m w be increased through the use of hesd down tilt positions during physiotherapy ~, the use of modified postural drainsge positions has also been shown to be as effective in achieving resolution of acute lobar atelectasis ~

A i m s o f p o s i t i o n i n g v e n t i l a t e d ICU p a t i e n t s Our results demot,strated that a high percentage (83%) of physiotherapists and nursing staff agree that there is a 8 0 0 for repositionit,g of patients, that rationales for this are associated with preventing pressure necrosis and improving patient comfort, and that full side-he positions are utihsed less than supine and less extreme lateral positioning (<450 ) Therefore, we were surprised to see postural drainsge and secretion mobilisation reported as the primary aim in utilising directed positioning A sut~ey by King Crowe 40 demonstrated nurses and physicians rated pressure ulceration prevention as the primary aim of positioning, followed by matching ventilation and perfusion However, ventilationperfusion matching was the first aim given by physiotherapists, followed by pressure ulcer preventiom postural drainage was ranked third

A,N Australian Critical Care

Determinants in selection of appropriate patient positioning

established and will assist in the development of clinical practice guidelines.

Factors that influence or restrict the choice of body position during critical illness have not been adequately investigated and only recently has the literature begun to discuss guidelines for mobilisation of the critically ill 41'42. Therefore, consensus-based guidelines regarding precautions or contraindications to positioning ventilated patients are warranted.

While this survey had a high response rate and gained information from experienced, senior ICU staff, caution is still required in the

Limitations of the survey

interpretation of its findings. SelfLreported surveys ca:: be prone to bias and the actual work practices regarding positioning may have been overstated. Furthermore, while we have tried to utilise

This survey is the first to gain opinion from senior multidisciplinary staff about comprehensive factors that influence the application of positioning in the ICU. Moderate to high agreement on perceived risks to positioning patients into full sidelie and sitting was demonstrated (Table 5, 6). Contraindications to sitting predominantly reflected an unwillingness to use it with patients displaying severe respiratory and/or haemodynamic compromise. In contrast, lateral positioning had a greater number of responses labelled as precautions compared to contraindications,

clinicians' expertise to develop guidelines and recommendations for positioning practice, these have not been validated through subsequent formal clinical investigation.

Conclusions The positioning practices reported in Australia:: ICUs appear to reflect international practices.

Problems include difficulties

abiding to an established SOC and under utilisation of extreme patient positioning. Review on staffing and environmental factors

demonstrating the greater comfort and perceived safety of its use compared to mobilisation into upright sitting postures. Greater concert: for the presence of a pulmonary artery catheter, dialysis or pressure-control ventilation was also seen with sitting compared to lateral positioning. Seven participants did indicate that concern with dialysis related only to when the dialysis catheter is sited in the femoral vein. However, we cannot clearly discern from the survey whether the perceived contraindication in the use of these modalities reflects concert: for maintenance of lines and/or the artificial airway, or the association of the use of these modalities

that impact on positioning and the development of evidence based and/or consensus driven positioning guidelines is warranted. In addition to describing the current positioning practices used in ICUs, this survey has provided valuable consensus-based infom:ation on appropriate selection, aims and risks in positioning ventilated ICU patients.

Acknowledgements Peter Thomas was supported by a Royal Brisbane and Women's Hospital Research Fellowship. The following sites participated in

in patients with greater respiratory or haemodynamic compromise. If a patient is haemodynamically stable and all support tubing carefully secured, and there are no other contraindications to sitting, then the benefits of mobilisation should outweigh the potential complications of keeping a patient in bed 4:.

the survey: •

ACT

•

NSW ConcordRepatriationHospital;GosfordHospital;John Hunter Hospital; Liverpool Hospital; The Nepean Hospital;

For lateral positioning, all but one of the respiratory and haemodynamic variables was seen to pose as a direct contraindication to a full lateral turning (ICP>20cmH20). This suggests that, in the presence of a sole indicator of potential

The Canberra Hospital.

Prince of Wales Hospital; Royal North Shore Hospital; Royal Prince Alfred Hospital; St George Hospital; St Vincent's Hospital; Westmead Hospital; Illawarra Regional Hospital

respiratory or haemodynamic instability (e.g. high dose inotropes), staff would be willing to implement a lateral turn and closely

•

•

monitor the patient's physiological response. Unfortunately, ICU patients often have two or more potential risk factors evident, and we did not investigate how this would alter responses in perceived risk. Presumably, the presence of two or more haemodynamic risk factors (e.g. labile blood pressure and sepsis without fluid

•

(Wollongong Campus). NT: Royal Darwin Hospital. QLD: Gold Coast Hospital; Nambour General Hospital; Princess Alexandra Hospital; The Prince Charles Hospital; Royal Brisbane Hospital; Townsville General Hospital. SA: Flinders Medical Centre; The Queen Elizabeth Hospital; Royal Adelaide Hospital.

•

resuscitation) would modify participants' responses, and greater risk attributed. Subsequently, in clinical practice, lateral positioning may be avoided or the degree of rotation restricted (e.g. g45 ° ) until haemodynamics are improved.

•

TAS: Launceston General Hospital; Royal Hobart Hospital. VIC: The Alfred Hospital; Austin & Repatriation Medical Centre; Ballarat Health Services; Box Hill Hospital; Barwon Health; Monash Medical Centre (Clayton Campus); The Norther:: Hospital; Royal Melbourt:e Hospital; St Vincent's

Combinations of respiratory and haemodynamic factors (e.g. ARE)S, high PEER high dose inotropes) might also increase attributed risk. However, in the absence of large studies, reporting the effects of positioning and/or identifying risk factors for adverse events, each patient should have potential risk factors considered

Hospital; Westert: Hospital. •

WA: Fremantle Hospital; Royal Perth Hospital; Sir Charles Gairdner Hospital.

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