The Benefits of CLRT Continuous Lateral Rotation Therapy

for the patient at risk for pulmonary complications.

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When a patient is immobilized….

“Unlike inanimate machines that deteriorate with use, the human body improves with use, and deteriorates…with lack of movement. Immobility promotes progressive deterioration of normal body functions…”

Gonzales-Arias, S.M., Baumgartner, R., Goldberg, M.L., Hoopes, D., Ruben, B. “Analysis of the Effect of Kinetic Therapy on Intracranial Pressure in Comatose Neuro Surgical Patients.” Neurosurgery 13.6 (1983): 654-656

In the Body…

Immobility has a dramatic effect on the respiratory system:

• Decreased Respiratory Movement

• Ventilation/Perfusion Mismatch• Decreased Ciliary Action• Dependant edema• 30% decreased FRC (functional

residual capacity) in the supine Position

Craig, D.B., Wahbaum, Don H.F. “Airway Closure and Lung Volumes in Surgical Positions.” Canadian Anesthesia Society Journal 18 (1971): 92-99.

In one study bed rest resulted in…

Decreased aerobic capacity by 1% daily over 10 days in healthy adults.

These changes in the pulmonary system contribute to:• episodic hypoxemia• reduced ventilatory reserve capacity• increased dyspnea

This adds to the difficulty in weaning ICU pts. from vent.

Convertino VA, Cardiovascular consequences of bed rest: effect on maximal oxygen uptake.Med Sci Sports Exerc. 1997;29:191-196

The Position of the Body Matters

• Alters the normal distribution of air & blood

• Supine position - overall lung volumes are decreased by 30% functional residual capacity is decreased due to alveolar closure in dependent

lung zones.

• Supine: Gravity effects perfusion. More uniform blood flow from base to apex but greater flow is now present in the dependent (dorsal) region.

• In a lateral position: blood flow is directed toward the dependent lung.

• Unilateral lung process “Good lung down” can increase PaO2 by improving perfusion and

ventilation of dependent (good) lung

Craig, D.B., Wahbaum, Don H.F. “Airway Closure and Lung Volumes in Surgical Positions.” Canadian Anesthesia Society Journal 18 (1971): 92-99.

Pulmonary Complications

The V/Q ratio is a delicate balance with normal breathing and normal cardiac index…what if a problem develops???

• ALI (acute lung injury)• ARDS (acute respiratory distress syndrome• VAP (ventilator associated pneumonia)

Incidence of ARDS

Approximately 150,000 cases per year1

• 25% -38% septic patients develop ARDS • 15-30% of trauma patients develop ARDS2

•Incidence of Adult ALI in the US has been estimated at 64.2 cases per 100,000 which appears to be higher than previously reported.³

• Pediatric calculated ALI incidence of 12.8 cases per 100000 person-years4

Reporting may be underestimated when based on either diagnostic coding or physicians notes5

1 National Health Lung and Blood Institute – NIH. What is ARDS?. 2 Clark P, Miller P, Morton K. PET scans predict development of lung disease following trauma. Released at Society of Nuclear Medicine’s 52nd annual meeting June 2005. 3 Goss C, Brower RG, Hudson LD, Rubenfeld G, Incidence of Acute Lung Injury in the United States Crit Care Med. 2003 Jun;31(6):1860-1Crit Care Med. 2003 Jun;31(6):1860-1. 4 Zimmerman JJ, Akhtar SR, Caldwell E, Rubenfeld GD, Incidence and outcomes of pediatric acute lung injury. Pediatrics. 2009 Jul;124(1):87-95 5Howard A, et al. Comparison of 2 methods of detecting acute respiratory distress syndrome: clinical screening, chart review and diagnostic coding. AJCC 2004;13:59-64

ARDS clinical presentation

About 50% of patients who develop ARDS do so within 24 hours of the inciting event

• Tachypnea, dyspnea with normal auscultatory lung findings– May precede appearance of infiltrates on chest radiograph

At 72 hours, 85% have a clinically apparent ARDS

• Tachycardic with mild cyanosis later develop course rales

• Progress to respiratory distress, diffuse rhonchi and signs of consolidation

1 Udobi K, Childs E, Touijer K. Acute respiratory distress syndrome. American Family Practice. Jan 2003;67:315-322 ,

ARDS Mortality

Overall mortality is 32-45% today vs. 53-68% in the 1980’s¹• Aggressive management of initiating factors, concurrent

infections and improved nutrition may play a role in declining mortality

• Higher mortality elderly, immunosuppressed, liver disease• Age < 55 and trauma etiology have more favorable outcome• Death usually from progressive multi-system failure vs. ARDS¹

*Decrease in overall mortality rates of approximately 1.1%/yr over the period analyzed (1994 to 2006)²

1 Udobi K, Childs E, Touijer K. Acute respiratory distress syndrome. American Family Practice. Jan 2003;67:315-322 ,

² Zambon M, Vincent JL, Mortality Rates for Patients With Acute Lung Injury/ARDS Have Decreased Over Time CHEST 2008 May;133(5):1120-7

ARDS Mortality con’t

• Mortality is not related to the initial severity of lung injury, but to the severity of lung injury 72 hours after the initial onset of the syndrome!

• Patients with ARDS who develop the complication of pneumonia have a 90% mortality rate.

Hudson, L. “The Prediction and Prevention of ARDS.” Respiratory Care 2 (1990):161-173.

1 NNIS Data as Reported to CDC: Weighted Average per Jan ‘02-June ‘04. Issued Oct 2004;

2 Ibrahim EH, Tracy L, Hill C, et al. The occurrence of ventilator associated pneumonia in a community hospital: risk factors and clinical outcomes. Chest 2001;

3 Rello JR, Ollendorf, DA, Oster, G, et al. Epidemiology and Outcomes of Ventilator-Associated Pneumonia in a Large US Database. CHEST 2002; 122:2115-2121

Ventilator Associated Pneumonia

• Second most common hospital acquired infection1

• Leading cause of death from a hospital acquired infection2

• VAP Hospital mortality is 46% vs. 32% of vented patients2

• Increases ICU, vent & hospital LOS 6 - 11.5 days respectively3

Are we making progress?

2004 NNIS 2006-2007 NHSN1

VAP Rates1 7.1 3.8

Ventilator Days1 41.3 39.4

1 The 2006-2007 National Healthcare Safety Network (NSHN) published Nov 2008 replaces the 2004 National Nosocomial Infections Surveillance (NNIS) . Reported per 1,000 vent days (VAP cases/Vent Days) x 1,000

2AHRQ. Chapter 17: Prevention of Ventilator-Associated Pneumonia. Current as of July 2001

• Cumulative VAP incidence 1-3% per day of intubation2

Unplanned ICU Re-admissions

• Respiratory complications are the major reason1,2

• VAP occurred in 47% of patients when re-intubated2

• Average ICU re-admission rate of 7%3

• ICU re-admission’s average HLOS twice as long3

• Hospital death rates are 1.5 - 10 times higher3

1 Patients Readmitted to the Intensive Care Unit During the Same Hospitalization: A multi-Center Cohort Study, 1997 SCCM Poster 145. 2 Torres A et al. Re-intubation increases the risk of nosocomial pneumonia in patients needing mechanical ventilation. AJ of Respir Care

Med., Vol 152, No 1, July 1995, 137-141 3 Rosenberg AL and Watts C. Patients Readmitted to ICUs. A systematic review of risk factors and outcomes. Critical Care Reviews. Chest

2000 118: 492 - 502.

In the Research 2002: “One good turn deserves another”

• Evaluated 11 randomized, controlled trials using rotational therapy

• Total of 1073 patients

• 48% reduction of risk of developing pneumonia (p=<.00001)

• 2.1 days reduction in ICU LOS p=<.08

Marik, Paul MD, Fink, Mitchell MD. Critical Care Medicine Sept. 2002 Vol. 30, No. 9 2146-2148

Marik, Paul MD, Fink, Mitchell MD. Critical Care Medicine Sept. 2002 Vol. 30, No. 9 2146-2148

In the Research 2007:

Rotational Bed Therapy to Prevent & Treat Respiratory Complications: A Review and Meta-Analysis

• Reviewed articles on prophylaxis and/or treatment

• Prospective, randomized controlled trials (20)

• Various types of beds were studied

• Cushion and table based therapies

– Kinetic and Continuous Lateral Rotation Therapy (CLRT)

Goldhill, Imhoff, McLean et al. American Journal of Critical Care. January 2007 Volume 16, No. 1

Results

Goldhill, Imhoff, McLean et al. American Journal of Critical Care. January 2007 Volume 16, No. 1

• Little evidence on what rotation parameter is effective

• Some awake patients do not tolerate steep angle rotation

• Effectiveness should also consider

• Frequency and duration of rotation

• Underlying disease

• Size and weight of patient

• Use of vibration, percussion, or pulsation

Findings

Goldhill, Imhoff, McLean et al. American Journal of Critical Care. January 2007 Volume 16, No. 1

Conclusion

“Rotational therapy may be useful for preventing and treating respiratory complications in selected critically ill patients receiving mechanical ventilation”– Goldhill, Imhoff, McLean et al. American Journal of Critical Care, January 2007, Volume 16,

No. 1

This is in agreement with:– One Good Turn Deserves Another. Marik P, Fink M.

Critical Care Medicine. Sept 2002 Vol 30, No 9:2146-2148.

– Kinetic Therapy in Critically Ill Trauma Patients. Nelson LD, Choi SC. Clin Intensive Care. 1992;3:248-252.

CLRT: Nurse-driven, evidence-based outcomes

Pulmonary Outcomes

Continuous lateral rotation therapy for acute hypoxemic respiratory failure: timing matters. Fleegler B, Grimes C, Anderson R. Dimens Crit Care Nurs. 2009;28(6):283-287.

14% in vent days and hospital LOS

20% in standard mortality rate (SMR)

Lag times <5 days exhibited significant in vent, ICU and hosp LOS, Standard Mortality Ratio(SMR)

The impact of continuous lateral rotation in overall clinical and financial outcomes of critically ill patients. Swadener-Culpeper L, Skaggs, AACN/NTI Research Award

R. AJCC 2005, Crit Care Nurs Q. 2008; 31: 270-279

Hospital and ICU LOS

Vent days

Cost to treat

ICU readmissions

Evaluation of outcomes: The effects of continuous lateral rotation therapy. Washington GT, Macnee ML. J Nurs Care Qual July-Sept 2005 Vol 20, No 3: pgs 273-282.

ICU LOS

ICU and hospital costs

As the bed turns: Clinical and cost management of lateral rotation. Riggs L. AACN/NTI presentation 2005.

Significant in cost savings and VAP rate.

Wound Outcomes

Implementing a Pressure Ulcer Prevention Program and Enhancing the Role of the CWOCN: Impact on Outcomes. Hiser BJ, Lowerhouse N, Philbin S. OWM Feb 2006:52(2):48-59.

MICU facility acquired ulcers to 0% from 29.5%. Conservative minimum cost savings of $317,000.

Effect the Outcome….

Rapid identification & aggressive treatment is

vital to patient survival and positive outcome!!!

Ventilator Bundle…or….. BYOBundle?

VAP BUNDLE

Peptic ulcer prophylaxis

DVT prophylaxis

HOB elevation

Sedation lightening, daily

awakening

IHI Additional therapy?

Oral Care

Daily weaning trials

Mobility

CLRT

Proning

The VEST

No CLRT Protocol??? 2 days lost!!!

Pt admittedon the 21st

???patient mayContinue to deteriorate!

The research referenced in this presentation supports early identification and early intervention for patients at risk for pulmonary complications.

Mobility Protocols -examples

Progressive Mobility Algorithm for Critically Ill Patients - Ahrens, T,Burns, S, Phillips, J, Vollman,K, Whitman, J,

Early Intensive Care Mobility Therapy-Peter Morris

Univ of Kansas Self Directed Study, Progressive Mobility Therapy in the ICU

Continuous Lateral Rotation Therapy(CLRT)

Progressive Upright Mobility(PUM) April 2008

- Akiko Kubo RN

Goal of CLRT . . . Improve Patient Outcomes

Evaluate the impact of the implementation of and compliance to a developed clinical practice guideline to . . .

Decrease:

• Pulmonary complications related to immobility

• ICU and hospital length of stay

• Cost of care

The Medical Center of Central Georgia (MCCG)

Swadener-Culpepper, L, Skaggs, R. The impact of continuous lateral rotation in overall clinical and financial outcomes of critically ill patients. Crit Care Nursing Quarterly. July –Sept 2008. Vol 31, No 3. pp 270-279. AJCC 2005, AACN/NTI Research Award – Oral presentation and abstract published 2005.

More in-depth view of a CLRT protocol

MCCG: Keys to Success . . .

Begin CLRT within 24 hours of meeting criteria

Target high risk patient populations

• Predicus Tool

• Fi02 50% or more longer than one hour

• PEEP 8cms or more

• P/F ratio < 300

Secretions and dependent edema (interfering with ventilation) settling in bases, (where perfusion is best) inhibiting optimal gas exchange – V:Q mismatch

Begin CLRT before this starts to happen

Pulmonary Risk Assessment

MCCG: Keys to success . . .

Implement protocol

• Rotate minimum 18 out of 24 hours/day

• Customize “%” rotation to maximum amount tolerated

• Ideal goal: 100% rotation, minimum 70%

• Use ‘Rotation Training’ to begin therapy

• Frequency of turn: Pause times 0.5 mins

• Assess need for percussion and vibration

• Turn and conduct skin assessment every 2 hours

• Patient is extubated with stable ABG’s x 24hrs

• Patient is increasingly more mobile

• CXR shows resolving infiltrates, improvement

• Paralytics and sedatives are being discontinued

• Patient is vent dependent

• Aggressive measures withdrawn

• Patient does not tolerate rotation 18hrs/24hrs

MCCG: Keys for success . . .

Establish discontinuation criteria

MCCG: Keys to Success . . .

Documentation

CLRT

• Number of hours in rotation/24 hours

• % of rotation, rationale for changes in amount of turn

• Toleration of CLRT

Percussion & Vibration

• Frequency, intensity, beats/second and duration

• Positioning for postural drainage

• Tolerance to treatment, secretion clearance

• Pulmonary system training module

• CLRT rental bed inservicing

• CLRT Protocol

• Posted in staff lounge

• Computerized medical information system

• Monitored protocol compliance daily

Education, training, compliance

MCCG: Keys to Success

Critical ComplicationsImmobility

MOVE ME!

References

• Gonzales-Arias, S.M., Baumgartner, R., Goldberg, M.L., Hoopes, D., Ruben, B. “Analysis of the Effect of Kinetic Therapy on Intracranial Pressure in Comatose Neuro Surgical Patients.” Neurosurgery 13.6 (1983): 654-656.• Winkelman C, “Bedrest in Health and Critical Illness:A Body Systems Approach” AACN Advanced Critical Care Vol 20, Number 3, pp 254-266• Craig, D.B., Wahbaum, Don H.F. “Airway Closure and Lung Volumes in Surgical Positions.” Canadian Anesthes Society Journal 18 (1971): 92-99.• Convertino VA, “Cardiovascular consequences of bed rest: effect on maximal oxygen uptake”. Med Sci Sports Exerc. 1997;29:191-196• photo www.medscape.com• National Health Lung and Blood Institute – NIH. What is ARDS?. • Clark P, Miller P, Morton K. PET scans predict development of lung disease following trauma. Released at Society of Nuclear Medicine’s 52nd annual meeting June 2005. • Goss C, Brower RG, Hudson LD, Rubenfeld G, Incidence of Acute Lung Injury in the United States Crit Care Med. 2003 Jun;31(6):1860-1. • Zimmerman JJ, Akhtar SR, Caldwell E, Rubenfeld GD, Incidence and outcomes of pediatric acute lung injury. Pediatrics. 2009 Jul;124(1):87-95. • Howard A, et al. Comparison of 2 methods of detecting acute respiratory distress syndrome: clinical screening, chart review and diagnostic coding. AJCC 2004;13:59-64• Udobi K, Childs E, Touijer K. Acute respiratory distress syndrome. American Family Practice. Jan 2003;67:315-322• Zambon M, Vincent JL, Mortality Rates for Patients With Acute Lung Injury/ARDS Have Decreased Over Time CHEST 2008 May;133(5):1120-7 • Hudson, L. “The Prediction and Prevention of ARDS.” Respiratory Care 2 (1990):161-173.

References

• NNIS Data as Reported to CDC: Weighted Average per Jan ‘02-June ‘04. Issued Oct 2004; • Ibrahim EH, Tracy L, Hill C, et al. The occurrence of ventilator associated pneumonia in a community hospital: risk factors and clinical outcomes. CHEST 2001; • Rello JR, Ollendorf, DA, Oster, G, et al. Epidemiology and Outcomes of Ventilator-Associated Pneumonia in a Large US Database. CHEST 2002; 122:2115-2121• The 2006-2007 National Healthcare Safety Network (NSHN) published Nov 2008 replaces the 2004 National Nosocomial Infections Surveillance (NNIS) . Reported per 1,000 vent days (VAP cases/Vent Days) x 1,000• AHRQ. Chapter 17: Prevention of Ventilator-Associated Pneumonia. Current as of July 2001• Patients Readmitted to the Intensive Care Unit During the Same Hospitalization: A multi-Center Cohort Study, 1997 SCCM Poster 145. • Trres A et al. Re-intubation increases the risk of nosocomial pneumonia in patients needing mechanical ventilation. AJ of Respir Care Med., Vol 152, No 1, July 1995, 137-141 • Rosenberg AL and Watts C. Patients Readmitted to ICUs. A systematic review of risk factors and outcomes. Critical Care Reviews. CHEST 2000 118: 492 - 502. • Ahrens, T,Burns, S, Phillips, J, Vollman,K, Whitman, J, “Progressive Mobility Algorithm for Critically Ill Patients” , Advancing Nursing 2005• Kubo A. (2008). Progressive Mobility™ Therapy in the ICU. Self Directed Study.• Keane, FX. The minimum physiological mobility requirement for man supported on a soft surface. Paraplegia 1979; 16(4):383-389• The Concept of Kinetic Therapy, Ethos. 1989• Nelson and Choi. J of Crit Care 1992;7:57-62• Marik, Paul MD, Fink, Mitchell MD. Critical Care Medicine Sept. 2002 Vol. 30, No. 9 2146-2148• Goldhill, Imhoff, McLean et al. American Journal of Critical Care. January 2007 Volume 16, No. 1• Guidelines for Preventing Health-Care--Associated Pneumonia, 2003. Revised Mar 26, 2004. Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee

References

• Bill Novelli, Pres and CEO AARP. Modern Healthcare August 16, 2004.• Fleegler B, Grimes C, Anderson R., Continuous lateral rotation therapy for acute hypoxemic respiratory failure: timing matters. Dimens Crit Care Nurs. 2009;28(6):283-287.• Swadener-Culpepper, L, Skaggs, R. The impact of continuous lateral rotation in overall clinical and financial outcomes of critically ill patients. Crit Care Nursing Quarterly. July –Sept 2008. Vol 31, No 3. pp 270-279 . AJCC 2005, AACN/NTI Research Award – Oral presentation and abstract published 2005.• Washington GT, Macnee ML. Evaluation of outcomes: The effects of continuous lateral rotation therapy. J Nurs Care Qual July-Sept 2005 Vol 20, No 3: pgs 273-282.• Riggs L As the bed turns: Clinical and cost management of lateral rotation. AACN/NTI presentation 2005.• Hiser BJ, Lowerhouse N, Philbin S. Implementing a Pressure Ulcer Prevention Program and Enhancing the Role of the CWOCN: Impact on Outcomes. OWM Feb 2006:52(2):48-59.• Meeks-Sjostrom D, “ Positive Spin”, ADVANCE for Managers of Respiratory Care issue date 5/16/2007. http://respiratory-care- manager.advanceweb.com/common/Editorial/Editorial.aspx?CC=88710• Wright K, “Justifying CLRT implementation”, Nursing Management 2003:3:34(8) 56 A-D.• Washington GT, Macnee CL, “Evaluation of outcomes: The effects of continuous lateral rotation therapy”, Journal of Nursing Care Quality 2005, 20(3):273-82• Extended time on mechanical ventilator may be indicated for early weaning. J Health Care Finance 2000 23 (3) 73-82.• Rauen CA, Chulay M, Bridges E, Vollman KM, Arbour R. “Seven evidence-based practice habits: putting some sacred cows out to pasture” Crit Care Nurse. 2008 Apr;28 (2):98-124.

References

• Glance LG, et al. Rating the Quality of Intensive Care Units: Is It a Function of the Intensive Care Unit Scoring

System? Published 10/25/2002. www.medscape.com. Accessed 10/17/2009• Schellongowski P, Losert H, Locker GJ, Laczika K, Frass M, Holzinger U, Bojic A, Staudinger T. Prolonged

lateral steep position impairs respiratory mechanics during continuous lateral rotation therapy in respiratory failure.

Intensive Care Med. 2007 Apr;33(4):625-31. Epub 2007 Jan 25. • Turpin P, Pemberton V., “ Prevention of Pressure Ulcers of Patients Being Managed on CLRT: Is Supplemental Repositioning Needed?” J Wound Ostomy Continence Nursing 2006;33;(4) 381-388