title: The use of bed-dials to maintain recumbent positioning for critically ill mechanically ventilated patients (The RECUMBENT study): multicentre before and after observational study.
abstract: BACKGROUND
  Observational studies continue to report poor compliance with positioning recommendations for prevention of ventilator-associated pneumonia. Inability to accurately measure backrest elevation may contribute to this poor compliance.
  
  
  OBJECTIVE
  To determine if provision of an accurate, simple to use angle measurement device with an accompanying education program improved compliance with semirecumbency at 45 degrees over time.
  
  
  METHODS
  Using a prospective pre- and post-design we implemented angle measurement devices and an associated education intervention in three Australian ICUs. Backrest elevation, contraindications to semirecumbency at 45 degrees , mean arterial pressure (MAP), inotrope use, enteral feeding and weaning status were recorded 3-times daily using a pre-determined randomization schedule for 7 consecutive days prior to implementation and again at 1, 3 and 6 months post-implementation. Illness severity and a clinical pulmonary infection score were recorded for each day of ventilation.
  
  
  RESULTS
  Backrest elevation measurements (n=1154) were recorded for 141 mechanically ventilated patients. Contraindications to semirecumbency at 45 degrees were noted for 163/1154 (14.1%) measurements the proportion of measurements at 45 degrees rose from baseline by 10.1% (P=0.03) 1-month following implementation, however this change was not sustained over time. The proportion of measurements 30 degrees increased by 43.8% at 1-month and remained above 70% 6-months after implementation (P<0.001). For measurements recorded in the absence of a contraindication to semirecumbency, and adjusted for covariates (MAP, inotropic support, sequential organ failure assessment maximum score, clinical pulmonary infection score maximum, and indication for ventilation), decreased backrest elevation was associated with higher severity of illness (0.3 degrees [95% CI 0.1-0.5] for every 1-point increase in APACHE II score). Increased mean backrest elevation was noted for older patients (0.8 degrees [95% CI 0.1-1.5] for each 10-year increment) and measurements recorded during weaning (2.7 degrees [95% CI 1.2-4.1]).
  
  
  CONCLUSIONS
  Bedside implementation of an angle measurement device and associated educational intervention did not result in a sustained improvement to compliance with 45 degrees semirecumbency, questioning the clinical feasibility of this nursing intervention. A sustained increased in semirecumbency at 30 degrees or greater was achieved.
authors.affiliation: Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada. louise.rose@utoronto.ca
authors.forename: Louise
authors.initials: L
authors.lastname: Rose
authors.forename: Ian
authors.initials: I
authors.lastname: Baldwin
authors.forename: Tom
authors.initials: T
authors.lastname: Crawford
mesh_terms: D001513:Beds; D016638:Critical Illness; D006801:Humans; D011187:Posture; D011446:Prospective Studies; D012121:Respiration, Artificial