Pneumonia therapy helps reduce new cases by 43%
Rotation regimen raises hopes of lowering rates
A small but growing legion of critical care professionals believe that a relatively new therapeutic protocol for preventing hospital-acquired pneumonia can significantly reduce the number of new cases in the ICU.
Until now, the orthodox treatment for hospital-acquired, or nosocomial, pneumonia (HAP) largely has been based on the use of antibiotics and monitored respiratory therapy.
But nurses at Western Medical Center in Santa Ana, CA, and other hospitals have been achieving notable results through carefully executed procedures involving physically rotating patients laterally at regular intervals.
When used in conjunction with established protocols, including nutritional therapy and respiratory support, the regimen cut the rate of new diagnosed cases.
Therapy helped cut cases
In the Western Medical study, the hospital cut the rate almost in half (43%) in a year’s time, according to a study released earlier this year in the journal RN and presented at a nursing conference in Chicago. It also shortened length-of-stay for those patients by one day and reduced the average number of days the patient needed ventilator support by 20%.1
"The therapy is beneficial. It’s low risk, noninvasive and fits into most traditional therapeutic regimens," says Cheryl McKay, RN, MSN, an ICU clinical nurse specialist who participated in the Western Medical Center research.
But McKay, who now works at a 43-bed long-term acute care facility operated by Select Medical Corp. in Oklahoma City, OK, says the combination therapy is far from trouble-free, especially for clinicians.
For years, HAP has posed enormous challenges for clinicians in the ICU. Although its prevalence rate in ICUs isn’t exactly known, researchers estimate that the rate may be as high as 10 cases per 1,000 hospital admissions.
Comparisons with other ICU admissions weren’t cited, but the rate is believed to be among the highest in new critically ill patients, according to sources.
Some studies have estimated the number to be 20 times higher for patients on mechanical ventilation. Reported cases have extended inpatient hospital stays by an estimated seven to nine days for each patient. The mortality rate for that population ranges around 30%, the highest of all nosocomial infections.2
HAP is defined as a pneumonia occurring within 48 hours of admission. At Western Medical, nearly half of all cases involved neurosurgical cases. But a third of trauma patients also were likely to develop HAP in the ICU, according to McKay.
To attack the problem, clinicians created a multidisciplinary approach that involved early nutrition, aggressive ventilation, and regular kinetic therapy.
The therapy specifically involved rotating the patient laterally at a 40-degree angle or greater to each side, creating an 80-degree arc.
To accomplish this, the ICU needed to acquire specially engineered beds with the ability to automatically rotate the patient at regular time intervals using a computerized system.
McKay says the protocol was three-pronged:
• nutritional therapy within 48 hours of admission;
• tracheostomy and peg tube insertion by day seven if long-term ventilation is required;
• early use of lateral rotation.
In the rotation segment, the angle and length of time of the rotation was determined by the patient’s condition and tolerance to the therapy, says Gayla Smith, RN, CCRN, a clinical nurse specialist in adult critical care at Western Medical.
"The intervals in which the rotation stopped typically averaged between five and 10 minutes, and were intended chiefly to allow the patient to rest on his back and permit routine nursing care," she says.
Some researchers believe that the rotation’s beneficial effects come mainly from increased oxygenation of the lungs. The rotations stimulate the lungs into receiving increased levels of oxygen.
In the worst cases, McKay says, the patient should be in rotation a total of 18 hours per day with a total of six hours for nursing care.
The procedure also helps to reduce build-up of fluids and mucous, thereby strengthening the ventilator support and preventing potential infection and damage to the lungs, according to Suhail Raoof, MD, who has tested the therapy at Nassau County Medical Center in Long Island, NY.3
"It is likely that the if [kinetic therapy] were used more frequently and aggressively, many more lives could be saved," Raoof asserts in his study.
Troubled by the lack of any formal system for evaluating neurosurgical and trauma cases of HAP, the Western Medical team reviewed conventional nosocomial infection prevention procedures and the pathogenesis of the most common bacteria related to HAP, McKay says.
During rounds, the team also assessed the existing nutritional therapy and tracheostomy and gastrostomy protocols and found in need of changes, McKay adds.
The team soon developed a scoring system to evaluate leading indicators for HAP, including arterial pressure, vital signs, a/A ratio (paO2/ pAO2) and 11 other physiological variables.
McKay says the scoring system, known as a PIRT (Patient Identification for Rotational Therapy) scoring tool was developed using the APACHE II patient classification scoring system, a system widely used in assessing critical care patients. (A sample of a PIRT scoring system is on p. 137.)
The PIRT tool is used within 24 hours of admission. If a patient achieves a PIRT score of less than 20, no intervention is rendered at the time.
If the score ranges between 20 and 30, rotation therapy is implemented within 48 hours, controlled nutrition is started, and the patient reevaluated every 48 hours.
If the score is higher than 30, the multidisciplinary team (made up of physicians, nurses, dietician, and respiratory therapist) discusses other clinical options. (A copy of the PIRT algorithm is on p. 138.)
The PIRT scores were previously developed by pneumonia researchers based on the Acute Physiology and Chronic Health Evaluation (APACHE) classifications, and are themselves arbitrary numbers that imperfectly signify the level of perceived gravity in pneumonia cases.
Therapy has its downside
However, the protocol isn’t without its inherent problems, says Smith. Many times, needed nursing care has to interrupt the rotation cycle, or the therapy forces nurses into competing with the rotation regimen.
There also are contraindications in the patient’s condition — such as an unstable pelvis fracture, skeletal traction, or a spinal cord injury — that make physical rotation ill-advised.
A third problem, Smith says, is the risk that rotating the patient may accidentally pull ventilator tubing and other life-sustaining lines out of the patient when nurses aren’t watching. "Forty degrees is a very steep turn," Smith says.
The rotation also can interfere with patients who require their head to be elevated by more than 30 degrees. McKay says these problems excluded the majority of patients from qualifying for kinetic therapy.
However, of those who did receive the therapy, the protocol was used to both prevent the occurrence of HAP and treat the condition after it was manifested.
Rotation for those patients began after 48 hours of intubation if the PIRT score was between 20 and 30.
Finally, the cost of the specially designed rotation beds can be prohibitive, says Smith. Many hospitals have leased the beds. At Western Medical, the lease rates have been around $125 per day, Smith says.
Meanwhile, results will likely vary between providers, says Smith. "You may not get the same results; that’s why it’s important that you collect the data and determine the effectiveness before you go out and buy a bed," Smith adds.
References
1. McKay C. Best practices: Reducing nosocomial pneumonia. Presented at the First Showcase for Innovation and Best Practices. Chicago; October 1998.
2. Craven DE, Steger KA, Barber TW. Preventing nosocomial pneumonia: State of the art and perspectives for the 1990s. Am J Med 1991; 91(suppl):44-53.
3. Raoof S, Chowdhrey N, Raoof, et al. Effect of combined kinetic therapy and percussion therapy on the resolution of atelectasis in critically ill patients. Chest 1999; 115:1,658-1,666.
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