Heads Up Twenty UP! Innovative Practice Changes for Ventilator-Associated Pneumonia Prevention

Purpose:
The difficulty of maintaining patients at 30 degrees prompted fears that friction or shearing forces could lead to pressure ulcers. The purpose was to review research literature for strategies to minimize shear and friction forces and allow sufficient HOB elevation for both VAP prevention.

Relevance/Significance:
Clinical nurses in a 33-bed pediatric intensive care unit (PICU) struggled to achieve and sustain compliance with the ventilator-associated pneumonia (VAP) bundle components, though the PICU maintained zero VAP in 2014, 3 and 5 incidents in 2013 and 2012, respectively. In the VAP prevention bundle, head of bed (HOB) elevation to 30 to 40 degrees was 79% compliant.

Strategy and Implementation:
PICU nurses and managers reviewed wound care literature. To minimize shear and friction forces, HOB elevation should not be greater than 30 degrees. The quality of evidence for HOB elevation to 30 to 45 degrees was found to be low (Grade III); based only on expert consensus without rigorous study conduct. The PICU VAP task force implemented an innovative practice change to 20 degree HOB elevation for patients on ventilators. Education was created and a slogan was created: Heads Up Twenty Up, based on the childhood game, Heads Up Seven Up.

Evaluation:
Since early 2014, PICU nurses have averaged 95% bundle compliance with elevating HOB to 20 degrees for ventilated patients with zero VAP rate since November 2013.

Implications for Practice:
Despite recommendations from various entities to elevate the ventilated patient's HOB to 30 degrees, our ventilator-associated pneumonia rates continue to remain at zero, staff satisfaction in maintaining proper positioning has increased and we have not seen a rise in pressure ulcers.