Effect of standardized orders and provider education on head-of-bed positioning in mechanically ventilated patients

Objective: Semirecumbent head-of-bed positioning in mechanically ventilated patients decreases the risk of developing ventilator-associated pneumonia (VAP). The purpose of this study was to determine whether the addition of a standardized order followed by the initiation of a provider education program would increase the frequency with which our patients were maintained in the semirecumbent position. Design: Prospective, pre-, and postintervention observational study. Setting: A tertiary care, U.S. Army teaching hospital. Patients: Mechanically ventilated medical and surgical intensive care unit patients. Interventions: The first intervention involved the addition of an order for semirecumbent head-of-bed positioning to our intensive care unit order sets. This was followed 2 months later with a second intervention, which was a nurse and physician education program emphasizing semirecumbent positioning. Measurements and Main Results: Data regarding head-of-bed positioning were collected on 100 patient observations at baseline and at 1 and 2 months after each of our interventions. The mean angle of head of bed increased from 24 ± 9 degrees at baseline to 35 ± 9 degrees (p < .05) 2 months after the addition of the standard order. The percentage of observations with head of bed >45 degrees increased from 3% to 16% 2 months after the standardized order (p < .05). Two months after our provider education program, the mean angle of the head of bed was 34 ± 11 degrees and the percentage of patients with head of bed >45 degrees was 29% (p = NS compared with values after the first intervention). Data collected 6 months after completion of our education programs showed that these improvements were maintained. Conclusions: Standardizing the process of care via the addition of an order specifying head-of-bed position significantly increased the number of patients who were placed in the semirecumbent position. In an era of cost-conscious medicine, interventions that utilize protocols and education programs should be emphasized.