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A Prospective Observational Study of Patient Positioning in a Saudi Intensive Care Unit Nahla Tayyib (1) Peter Lewis (2) Fiona Coyer (3) (1) Nahla Tayyib BN RN MN School of Nursing Queensland University of Technology, Victoria Park Rd, Kelvin Grove, Queensland, Australia 4059 (2) Peter Lewis BN Cert.CC MN.Ed PhD Senior Lecturer, Undergraduate Course Coordinator School of Nursing Queensland University of Technology, Victoria Park Rd, Kelvin Grove, Queensland, Australia 4059 (3) Associate Professor Fiona Coyer RN, PhD Director of Academic Programs School of Nursing, Queensland University of Technology. Research Fellow, Department of Intensive Care Medicine, Royal Brisbane & Women’s Hospital. Correspondence: Nahla Tayyib BN RN MN School of Nursing Queensland University of Technology, Victoria Park Rd, Kelvin Grove, Queensland, Australia 4059 Tel: +61 423529438 Email: [email protected]

Abstract Aim: To describe the positioning of patients managed in an intensive care unit (ICU); assess how frequently these patients were repositioned; and determine if any specific factors influenced how, why or when patients were repositioned in the ICU. Background: Alterations in body position of ICU patients are important for patient comfort and are believed to prevent and/or treat pressure ulcers, improve respiratory function and combat the adverse effects of immobility. There is a paucity of research on the positioning of critically ill patients in Saudi Arabian ICUs.

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Design and Methods: A prospective observational study was undertaken. Participant demographic data were collected as were clinical factors (i.e. ventilation status, primary diagnosis, co-morbidities and Ramsay sedation score) and organizational factors (i.e. time of day, type of mattress or beds used, nurse/patient ratio and the patient’s position). Clinical and some organization data were recorded over a continuous 48 hour period. Result: Twenty-eight participants were recruited to the study. No participant was managed in either a flat or prone position. Obese participants were most likely to

be managed in a supine position. The mean time between turns was two hours. There was no significant association between the mean time between turns and the recorded variables related to patients’ demographic and organizational considerations. Conclusion: Results indicate that patient positioning in the ICU was a direct result of unit policy - it appeared that patients were not repositioned based upon evaluation of their clinical condition but rather according to a two-hour ICU timetable.

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Background

Patients managed in intensive care units (ICU) are most frequently immobile and ventilated for extended periods of time. Such prolonged immobility is unnatural and uncomfortable for the patient. Further prolonged immobility often contributes to complications with muscle groups and multiple body organs including the skin, the cardiovascular system and the respiratory system (Vollman, 2010). Therefore, the practice of repositioning patients has been proposed in order to overcome the effects of immobility, thereby preventing common complications such as pressure ulcers, and promoting patient comfort. Despite the recognition of its benefits, the optimal frequency of patient repositioning is yet to be determined. Routine standard nursing practice in the ICU often dictates that patients are repositioned every two hours. For multiple reasons, such as patient instability, need for patient procedures or further investigations requiring ‘off unit’ time, unit staffing etc., it is recognized that the two hour standard is regularly not achieved. Further evidence identifying repositioning timeframes and specific factors influenced how, why or when patient repositioning in the ICU is required.

Literature review Patients are admitted to an ICU for a multiplicity of reasons, including but not limited to respiratory distress, bacteremia, multi-injury trauma, multi-organ dysfunction or complex disease conditions (Estenssoro et al., 2006). These conditions make patients vulnerable to complications and hemodynamically unstable. However, repositioning of patients has been shown to have benefits in not only improving patient comfort but also in the prevention of pressure ulcers, support of limbs and musculoskeletal alignment and therapeutic benefits with pulmonary dysfunction. There are a number of positioning practices for critically ill patients. These include the supine

position; the semi-Fowler position, which includes head of bed elevation by 30 degrees or more and elevation of heels to 30 degrees; as well as lateral positioning with 30º rotation or less. These positions generate the lower interface pressure (Johnson & Meyenburg, 2009a; Munro & Grap, 2005; Defloor, 2000; Moody, Gonzales & Cureton, 2004). Knox et al. (1994) studied skin color changes, skin temperature, interface pressure and pain measures in 15 critically ill patients over time periods of less than two hours and suggested that two-hourly repositioning was insufficient to prevent the development of pressure ulcers. In contrast, Ousey (2005) argues that pathophysiology and etiology of a patient’s condition are the critical factors that should influence decisions about frequency of repositioning critically ill patients, and recommended two-hourly repositioning (Hagisawa & FergusunPell, 2008).

intervention for preventing pressure ulcers, and patients who moved spontaneously themselves were not measured by the researchers, the findings were described as not statistically conclusive.

Other studies have examined how pressure ulcers for critically ill patients could be prevented when repositioning after longer periods than two hours with other measures adopted. Defloor and colleagues (2005) studied a sample of 838 patients to determine whether repositioning practices and pressure relieving surfaces influenced the development of pressure ulcers. The control group patients were placed on standard hospital mattresses and repositioned every two or three hours. In contrast, other patients were placed on visco-elastic foam mattresses and turned at four or six hours, but all patients were placed in pressure-reducing positions and on seating cushions. The findings showed no difference in the incidence of stage one pressure ulcer, but stage two, three and four pressure ulcers were reduced significantly for patients on the visco-elastic foam mattresses. Also, the incidence of pressure ulcers was less for patients repositioned every two hours, when compared to those repositioned every three hours.

Study Aim

However, as the clinical provider’s decision influenced the choice of

A study by Vanderwee, Grypdonck, De Bacquer and Defloor (2005) comparing repositioning critically ill patients at two-hour and four-hour intervals showed little significant differences with patients in the same position and placed on the same visco-elastic mattresses. The researchers argued that more frequent repositioning on pressurereducing surfaces did not contribute to reducing incidence of pressure ulcers. However, further research is needed to support these findings, as the sample was relatively small (235 patients), and 34% of patients from both groups were observed moving from the lateral position to the supine position spontaneously between the repositioning times.

The purpose of this study was to: describe the positioning of patients managed in three ICUs; determine how frequently these patients were repositioned; and to determine if any specific factors influenced how, why or when patients were repositioned in the ICUs.

Methods Design A prospective observational cohort design was utilized. Setting The study was conducted at the intensive care units at King Abdul-Aziz University Hospital (KAAUH), Jeddah, Saudi Arabia, which is operated by the Ministry of Higher Education. It is a tertiary care hospital with 895 beds and ambulatory services (King AbdulAziz University Hospital (KAAUH), 2009a). The KAAUH is one of the large Saudi hospitals accredited as meeting the international standards of excellence in quality care and health services by The Canadian

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Council on Hospital Accreditation (CCHA) (KAAUH, 2009b). The CCHA is one the founding members of the International Society for Quality in Health Care (KAAUH, 2009c). The three intensive care units at KAAUH provide a total of 45 beds. They include: the medical unit with 25 beds, the surgical unit with 10 beds, and the acute care unit with 10 beds. This facility provides services to patients from the western region of Saudi Arabia and from neighboring regions. Further, 70% of the 5,406 ICU patients admitted each year require mechanical ventilation. A diversity of complex treatments and upto-date equipment are provided for ICU patients to maintain their body system functions. The ICUs also provide continuous intensive monitoring for patients who have a life-threatening illness or after major surgery. Sample All patients admitted to the ICUs at KAAUH between 15 and 16 June 2011 who met the inclusion criteria were recruited to participate in this study. The inclusion criteria were patients managed in ICUs during the period of data collection and aged above 18 years. The sampling framework consisted of a time period of 48 consective hours and the inclusion criteria. Data collection tool The data collection tool was a chart audit tool. It was specifically designed for this study to collect appropriate data on every patient managed in a KAAUH ICU during the period of data collection. The tool recorded participants’ demographic characteristics (i.e. age, sex, weight, height, primary diagnosis, length of stay in ICU prior to data collection and co-morbidities). To facilitate a description of KAAUH ICU data related to practices specific to patient management in the ICU were collected (i.e. patient/nurse ratio, type of bed and mattress on which the patients were managed). Hourly data collected was patient 28

specific (i.e. ventilation status, Ramsay sedation score, patient position, mattresses). Ventilation status was defined as whether the patient was mechanically ventilated or not. Rotating beds were defined as a bed turning automatically on its longitudinal axis and a pressure mattress was a patient’s bed which had an interface pressure device to prevent pressure ulcer formation. The Ramsay sedation score categorizes patient sedation in six ways: awake; anxious and restless; awake, cooperative and orientated; awake and responding to commands only; asleep, brisk response to touch and loud sounds; asleep, sluggish response to touch and loud sounds; or asleep and no response (Ramsay et al., 1974). Procedure Participants for this study were identified by the researcher meeting with the unit manager for the KAAUH ICUs in Saudi Arabia. All patients admitted to the units at the time of data collection were included in the audit. The researcher and a research assistant, who was trained in the data collection tool and procedures, each collected data over two continuous 12-hour periods alternatively. Re-identifying participant information was possible only during the time of data collection. This was necessary to ensure the researcher/research assistant were able to correctly record each participant’s position against the correct observation form. At the conclusion of the 48-hour data collection period, the form identifying which observation sheet correlates to which intensive care bed was shredded to ensure all data was deidentified. Data analysis All data were de-identified, subjects assigned a study number, and data entered into the Statistical Packages for Social Sciences (SPSS) (Version 18, Chicago, IL, USA). Ten percent of the data were double-entered and all extreme values were evaluated by the investigators to ensure accurate data entry. Descriptive and correlation statistical maneuvers

were used to analyze the dataset. Descriptive statistics were calculated for all variables (means and standard deviations for continuous variables; frequencies and percentages for categorical variables). Data were first analyzed to describe all subjects that were screened. Level of statistical significance was set at p-value less than or equal to 0.05. The association between mean time between turns and participants’ demographic and clinical characteristics and organizational structures were assessed using the Pearson product-moment correlation coefficient test. The relationship between the ventilation status and the Ramsay sedation score of the participants was also tested using the chi-square test. Ethical considerations Ethical approval to conduct the study was obtained from the Unit of Biomedical Ethics of King Abdul-Aziz University Faculty of Health, Jeddah, Saudi Arabia and the Queensland University of Technology (QUT) Human Research Ethics Committees. Patients were recruited to this study using an “optout” approach. There is evidence for studies with low participant risk, an ‘opt-in’ approach results in selection bias and poor recruitment rates (Junghans et al., 2005). Informed consent can be difficult to achieve in the critically ill patient population. In this study, complete patient numbers were crucial to address the study aims. In particular, failure to include patients may result in underestimation or overestimation of patient repositioning practices and result in a biased assessment of the magnitude of the study aim. As this study posed a ‘low/negligible’ risk to participants an ‘opt-out’ approach was used.

Results

This study recruited 28 participants. The mean age of participants was 62 years; the majority were male (n=16, 57.1%) and half the sample (n=14, 50%) had a BMI which classified them as overweight, obese or severely obese. Demographic characteristics of the study participants are presented in Table 1.

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Table 1 (Part B) : Demographic and clinical characteristics of study participants (N=28)

Table 2: Frequency of participant repositioning The time range for patient repositioning occurred as early as one hour post previous turn and as late as five hours post previous turn (Table 2). The mean number of turns observed per participant over the 48 hour observation period was 15 turns. While 41.6% of all turn events (175 out of 420 turns) were observed to occur every two hours, 3.6% of the turns (15 out of 420 turns) were noted to occur five hours after the last position change. Twelve of 15 turns occurred during nurse changeover between night- and dayshift - 10 turns night to day shift, two turns from day to night); one turn occurred during the medical round time; and two turns occurred during medical procedures such as blood tests, X-rays. 30

Of the 28 participants, none were managed in a flat or prone position at any point in the 48hour observation period. During the study period the participants were always moved in a sequence from one side to the other: left lateral, back and then right lateral, or vice versa. Participants with a primary respiratory diagnosis were positioned more frequently in a semiFowler’s position when compared with participants of other diagnoses (p= 0.005). Frequencies of different patient positions, percentage and mean time between turns on the bed are illustrated in Table 3 (opposite page). It was found that there was a positive correlation between the different

groups of the body mass index (BMI) of participants and duration of time in the supine position. Obese participants in comparison with participants with a normal or low BMI were more likely to be managed in a supine position (F (28) = 3.45, p= 0.024). No significant association was found between the time interval of patient repositioning and age, gender, height, weight, present illness, pressure mattress, rotation of bed and nurse-patient ratio.

Discussion

When compared with other international ICU patient datasets, the demographic characteristics of the KAAUH study participants are similar (Dupre, Gu, Warner, & Yi, 2009; Higlett et al., 2005; McLean,



Table 3: Hourly patient position observations (n=1344*) Huang, Nalos, Tang, & Stewart, 2003; Mayr et al., 2006; Scheinhorn et al., 2007). KAAUH adheres to the general guidelines established worldwide for the care of bedbound patients who are at risk for pressure ulcers (Williams, Flanders & Whitcomb, 2007). For example, KAAUH managed all ICU patients on pressure relieving devices such as air mattresses, which help in reducing the development of skin ulcers. Indeed, KAAUH’s nursepatient ratio of one-to-one (one nurse to one ventilated patient) meets the guidelines set by the American Association of Critical Care Nurses (AACCN, 2003).

This study revealed that most patient turns or repositioning (41.6% of turns) in the KAAUH ICU were observed to occur every two hours. Further examination of this relatively structured phenomenon saw that the KAAUH ICU unit policy required second-hourly positioning of all patients. Some studies have identified that turning patients every two hours is more effective than four-hour interval turns, in reducing the development and/or progression of pressure ulcers (Krapfl & Gray, 2008; Vanderwee et al., 2005). Turning protocols, therefore, need to be investigated in greater depth, not only for pressure ulcer prevention but also for other patient comfort,

body positioning and mobilization benefits. Further, KAAUH reported pressure ulcer prevalence in the ICUs is 3% (King Abdul-Aziz University Hospital, 2010). This outcome is likely as this is related to registered nurse adherence to the unit turning protocol and therefore the frequency of turning. This finding contrasts to other studies such as Clark (1998) who found that there was no significant evidence to suggest that frequent repositioning could actually reduce the incidence of pressure ulcer development among bed-bound patients. This finding was again affirmed in a more recent study by Rich et al. (2011). However, these studies suggest

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that the clinical recommendation for specific time intervals for manual turning are not well founded. Therefore, it is difficult to suggest that the nursing practices observed in this study were informed by evidence. The current study also examined positions in which the patients were placed. The results of the study reveal that the largest percentage of body position changes (57.7%) were lateral (either left or right lateral position) and greater than a 30? turn; and that 42% of positions observed were supine. Lateral positioning has been recommended as among the most effective positions in preventing the development of pressure ulcers, followed by the supine position (Defloor, 2000). The combined use of supine and lateral positioning by the KAAUH staff is supported by existing evidence. A review conducted by Anders et al. (2010) found that alternating positions is an effective strategy for reducing pressure on the bony prominences of the body, thereby reducing the patient’s risk for pressure ulcer development. However during this study, observed participants were most often turned to the left lateral position than to the right lateral position, regardless of their diagnoses. This practice may be related to ventilator placement (i.e. the participants were most often turned toward the ventilator). No studies have examined the relationship between positioning patients toward the ventilator and the physiological response of the patients. Another important finding of this study is that ICU registered nurses repositioned patients with respiratory diagnoses more frequently to a position of 45 degrees or more. This finding is supported by a considerable amount of published literature on the benefit of head of the bed elevation in ventilated patients in intensive care. (Collard et al., 2003; Drakulovic et al., 1999; Orozco-Levi et al., 1995). While care in the KAAUH ICUs seems driven by protocol, it is interesting to note

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that care appears individualized for specific patients’ needs as is the case with the positioning of the respiratory patients. Patients in this study were predominantly obese (BMI greater than 30) (n=14, 50%). This is not surprising as obesity in the general population of Saudi Arabia has increased by almost 20% in the past five years (World Health Organization [WHO], 2011). This study indicates that overweight and obese patients (classified by this study as patients with a BMI greater than or equal to 25) are more likely to be managed in a supine position than normal or underweight patients. According to many studies the supine position is harmful for obese patients when compared to non-obese patients. Intra-abdominal pressure is excessively elevated in this position, causing a reduction in lung volume leading to hypoxemia (Charlebois & Wilmoth, 2004; Lewandowski & Lewandowski, 2011). However, the lateral decubitus position can often be well tolerated by patients who are obese because the abdomen is relieved from the panniculus, which reduces intra-abdominal pressure and alleviates breathing difficulties (Lewandowski & Lewandowski, 2011). Despite this, patients who are obese, including particularly severely obese patients, should not lie on one side for longer periods of time, because this can result in unilateral pulmonary edema and atelectasis of the dependent lung (Lewandowski & Lewandowski, 2011). This practice was in contrast to findings in other studies where the higher a person’s BMI, then the greater the patient’s risk for developing pressure ulcers and, therefore the more frequent the turning required (Lyder & Ayello, 2008; Camden, 2009). Thus, the predisposition of obese individuals towards the development of pressure ulcers could imply a greater need for more frequent repositioning. In this study, patients were repositioned two-hourly regardless of age, gender, comorbidities, length of stay in ICU, ventilation status,

nurse ratio, or Ramsay sedation score. The rigidity in turning regimes appears to be the result of hospital policy recommendation. During this study, none of the variables mentioned above were considered in repositioning ICUs patients. These findings replicate those of a prospective observational study conducted by Goldhill and team (2008) when the researchers found no correlation between the frequency of turning and patient factors such as weight, age, sex, diagnosis, whether intubated and ventilated, and sedation score, and organizational considerations including nurse/patient ratio, time of day, and day of week.

Conclusion

To sum up, immobility has the potential to influence systemic health during critical illness. This study has demonstrated that the mean time between turns for patients managed in the KAAUH ICUs was two hours. No participants were managed in a flat position; the respiratory patients were managed most frequently in a Fowler’s position; and obese patients were more likely to be positioned in a supine position. No patients were managed in a prone position during the course of the study. In addition, the length of stay in ICUs had a relationship with frequency of repositioning in this study. Even though there is no clinical significance because all patients during this study were turned more frequently, based on the hospital ICUs policy, the mean time interval between turns was two hours (Standard deviation 30 minutes). However, the findings of this study do not support those of previous research which conclude that patient repositioning should be based upon clinical conditions. Owing to the small size of this study, further research is required to describe repositioning in a Saudi ICU. To best manage the positioning of ICU patients, further research is needed to both identify safe positioning interventions specific to the ICU and to optimize frequent manual turning facilitating its



integration into the clinical practice in the ICU. Although this study has contributed to the body of available knowledge surrounding the positioning practices for the critically ill, a larger and longitudinal study is needed to generalize the findings and examine in-depth the associated factors that may influence nurses’ decision-making concerning patients’ repositioning in intensive care. This would further contribute to better care for criticallyill patients in the ICU through a reduction in complications arising from immobility. Acknowledgements Many thanks to King Abdul-Aziz University Hospital ICU staff, patients and families for their assistance during data collection for this study.

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