Preventing Ventilator-Associated Pneumonia

Elevating the head of the bed is crucial.

Ventilator-associated pneumonia (VAP) is the second most common cause of nosocomial infection in the United States and the leading cause of death from pneumonia. It occurs in 9% to 24% of patients on mechanical ventilation and is associated with a 54% to 71% mortality rate. Mary Jo Grap, PhD, RN, ACNP, a researcher and professor at Virginia Commonwealth University, took an interest in preventing VAP in mechanically ventilated patients. She noted that aspiration is more likely when patients are in a supine position for a long time. In fact, one independent predictor of VAP and mortality is a supine position in the first 24 hours on a ventilator. The Centers for Disease Control and Prevention recommends backrest elevation of 30[degrees] to 45[degrees] to prevent aspiration and VAP in mechanically ventilated patients, and the Joint Commission on Accreditation of Healthcare Organizations is requiring institutions to report the number of days that such patients have back-rest elevation of 30[degrees] or higher.

In a longitudinal, nonexperimental study funded by the National Institute of Nursing Research, Grap enrolled 66 patients within 24 hours of intubation. None had evidence of pneumonia or a history of prior intubation during the current hospitalization. Backrest elevation was measured continuously with a transduced measurement system applied to the bed. The research revealed that the average backrest elevation among all patients was 22[degrees]; it was 30[degrees] or less 72% of the time and 10[degrees] or less 39% of the time. About one-fourth of the patients (26%) developed VAP by the fourth day and almost a third (31%) did so after one week. The best predictor of VAP was a combination of illness severity (as assessed according to the APACHE II score) and the percentage of time with a backrest elevation of less than 30[degrees] during the first 24 hours of intubation.

Graf points out that on the first day of intubation, patients are likely to be more ill and less stable, and they may not tolerate much backrest elevation. She says that more research is necessary to understand "what happens to comfort and skin breakdown when patients have the head of their bed elevated for long periods of time." Graf encourages hospital bed manufacturers to incorporate methods of measuring and tracking backrest elevation into the design of hospital beds so that nurses can monitor it in vulnerable patients. She also encourages nurses to avoid the supine position in ventilated patients if hemodynamically tolerable and to continuously evaluate the patient's position to ensure adequate (greater than 30[degrees]) elevation. -DJM

Care of Patients with Congestive Heart Failure

APN-directed collaborative model.

Congestive heart failure is a costly and serious condition affecting more than 1 million older Americans. It frequently results in disabling symptoms and multiple rehospitalizations. That is why the National Institute of Nursing Research funded a randomized clinical trial, conducted under the direction of researcher Mary Naylor, PhD, RN, FAAN, of the University of Pennsylvania, to test a home care intervention. An advanced practice nurse (APN), in a collaborative care protocol with the patient's physicians, made home visits for the first three months after the patient's discharge (hospitalization was for acute heart failure). Patients in the control group received discharge planning, home care, and physician follow-up according to the hospital's standard procedures.

Patients in the intervention group experienced significantly fewer rehospitalizations and incurred lower costs of care. Furthermore, adherence to the Agency for Healthcare Research and Quality heart failure guidelines was better among physicians in the collaborative care model, compared with those who managed patients alone, findings that were consistent among both APN-generalist physician teams and APN-cardiologist teams, suggesting that APN-directed collaborative care during the posthospitalization period improves both practice and patient outcomes.

Patients in the intervention group received more home visits than did patients in the control group who had been referred to a traditional agency. These findings may have implications in the management and reimbursement of home care services provided to patients with heart failure. -LF