Adherence to Head-of-Bed Elevation in Traumatic Brain Injury: An Audit

Abstract

Background An important factor affecting the outcome of traumatic brain injury (TBI) is the early management of raised intracranial pressure (ICP). Head-of-bed elevation (HBE) is a simple and effective method to reduce ICP and prevent aspiration in head injury.

Methods This audit was carried out in a level one trauma center. All adult TBI patients were included in the study except patients who had relative contraindication to HBE, managed in prone or Trendelenburg position or who were able to be seated themselves. Patients were observed twice daily, to check adherence to HBE. Adequate HBE angle was referred as an angle of 20 to 30 degrees. A digital protractor was used to measure the head-end angle. Following the first audit cycle, after discussion with nursing staff, a bedside checklist was formulated and two postintervention audit cycles were carried out.

Results The first cycle showed that 40.35% of patients had inadequate HBE. Following implementation of the checklist, this percentage dropped to 11.27 and 7.5% in the second and third cycles, respectively. Agitation (p-value = 0.038) and Glasgow coma scale at admission (p-value = 0.028) were found to be confounders for adherence to HBE.

Conclusion Agitation among mild and moderate TBI patients contributed to noncompliance for HBE. There was an increasing trend in adherence to maintaining adequate HBE following the use of a bedside checklist. Sustainability of improvement was confirmed with third audit cycle.

Keywords

head-end elevation - audit - neurocritical care - raised intracranial pressure - traumatic brain injury

Introduction

Traumatic brain injury (TBI) is a leading cause of mortality and morbidity in resource-scarce low- and middle-income countries and the incidence is expected to increase in the future.[1] [2] Head injury is a complex entity to manage and it requires strict observance of standardized protocols for a good outcome.[3] [4] One of the critical factors affecting the outcome of head injury is the early management of raised intracranial pressure (ICP).[5] Head-of-bed elevation (HBE) is an integral part of ICP reducing strategies in an intensive care unit (ICU).[6] [7] [8] [9] Moreover, aspiration is minimal with HBE, making it a vital component of ventilator-associated pneumonia care bundle too.[10] Hence, compliance with this nursing measure is used as a quality indicator of an ICU.[11]

HBE aids in the redistribution of cerebrospinal fluid from the cranium to spinal subarachnoid spaces and increases cerebral venous return and reduces ICP.[4] [6] In addition, HBE aids in reducing the incidence of ventilator associated pneumonia and also prevents aspiration.[12] [13] As literature does not provide conclusive evidence of one particular angle being ideal for all patients, it is recommended to tailor the optimal HBE based on an individual patient, ensuring that the head is above the level of the heart.[14] [15] The best reduction in ICP and improved cerebral perfusion pressure was seen with HBE at 15 to 30 degrees.[16] Pragmatic trials looking at the feasibility of HBE at 30 degrees have found head end to be in 20 degrees most of the day.[17] Therefore, we considered the ideal nursing position for TBI patients to be with a HBE of 20 to 30 degrees and head above heart level. We conducted this audit to assess the adherence to adequate HBE in our neurocritical care unit with an aim to improve the quality of care.

Materials and Methods

Study Population and Data Collection

The audit was carried out at a level one trauma center in South India from January 1, 2022 for 6 weeks. We included adult patients (16–80 years) admitted to neurocritical care unit with mild, moderate, and severe TBI. The data for the audit was prospectively collected and included patient-specific data such as age, gender, and variables such as measured backrest angle, airway status (whether intubated or not), and Richmond agitation sedation scale score (RASS). The data collected was analyzed at the end of each audit cycle.

Inclusion and Exclusion Criteria

All TBI patients of any severity, with raised ICP or prone to have a rise in ICP, were included in the audit. All patients who had relative contraindication to HBE namely, hemodynamically unstable, with spine injury, on lumbar subarachnoid drain, with cerebrospinal fluid rhinorrhea and syndrome of trephined, were excluded. Patients who could be ambulated on bed and could be seated themselves were also excluded as they no longer needed semirecumbent positioning. Only patients above 16 years of age were included in the audit.

Design

Visual observation of head positioning of TBI patients admitted to neurocritical care unit was carried out by two principal investigators, every day between 1100 to 1115 hours in the morning and 1900 to 1915 hours in the evening. The timing of observations was chosen so as not to coincide with the time of patient ambulation or nursing care.

A protractor was used to measure the angle of head-end elevation and spirit level (long scale with fluid filled chamber in the center, used in carpentry) to note if the tragus is above the midaxillary line. HBE was considered adequate if the tragus was above the fourth intercostal space in midaxillary line (phlebostatic axis).[6] [9] This was measured using spirit level, while the numeric value of angle of head end of bed was measured using a digital protractor.

Following this, a team comprising of doctors, nurses, and critical care therapists undertook a root cause analysis with the aid of fishbone representation to identify causes for noncompliance. An intervention in the form of an awareness session was conducted for nurses, and they were given a checklist for hourly monitoring of the head position of patients. The audit cycle was repeated after the intervention.

Intervention

Following the first cycle, the nursing staffs were alerted to the probable causes for poor compliance and an hourly checklist with checkboxes was formulated. The checklist was added to the nursing booklet for routine care.

Interventions included measuring the head-end elevation using a digital protractor to attain 20 to 30 degrees and ensuring that the HBE resulted in the tragus being above the level of midaxillary line, position the patient in such a way that they do not slide down the bed and ensure that neck is not flexed.

A week after implementation of the checklist, the second cycle was carried out for 7 days. After a fortnight since completion of the second cycle, the third cycle was undertaken to confirm sustainability of the intervention.

Statistical Analysis

The number of patients and percentage were presented for categorical data. The chi-squared and Fisher's exact test (less cell count) were applied to find association between categorical variables. All tests were two-sided at α = 0.05 level of significance. All analyses were done using Statistical Package for Social Sciences (SPSS) software Version 21.0 (IBM Corp, Armonk, NY, New York, United States). A p-value less than 0.05 was considered significant.

Results

The study population ranged from 18 to 78 years with a predominant male representation (70% males and 30% females).

Baseline Measurements

The compliance was compared with level of consciousness measured by the Glasgow coma scale (GCS) score and restlessness as measured by the RASS and intubation status.

The first audit cycle was conducted for 1 week, during which 57 patient observations were recorded. The results were analyzed, and factors affecting compliance were identified. It revealed that compliance for keeping the head-end elevated between 20 and 30 degrees was observed in 34 out of 57 (59.65%) patients. About 40.35% of patients had improper head positioning ([Table 1]) with an average angle of backrest being 20.49 degrees. Moreover, it was also observed from the first cycle that 86.96% of patients with improper positioning had a backrest angle lesser than 20 degrees. Airway status, whether secured by intubation or not, did not contribute to adherence to HBE ([Table 2]). This ruled out any likely organic cause of hypoxia attributed to agitation.

Table 1 Correct head end of bed elevation in three cycles

	n	%
Cycle 1
Correct positioning	34	59.65
Incorrect positioning	23	40.35
Total	57	100
Cycle 2
Correct positioning	63	88.73
Incorrect positioning	08	11.27
Total	71	100
Cycle 3
Correct positioning	74	92.5
Incorrect positioning	6	7.5
Total	80	100

Table 2 Comparison of airway status among patients with correct and incorrect head positioning

	Cycle 1 Head positioning				Cycle 2 Head positioning				Cycle 3 Head positioning
	Correct	Incorrect	Total	p-Value	Correct	Incorrect	Total	p-Value	Correct	Incorrect	Total	p-Value
Intubated	4 (100%)	0 (0%)	4	0.140	19 (86.36%)	3 (13.64%)	22	0.696	31 (93.94%)	2 (6.06%)	33	1.000
Not intubated	30 (56.60%)	23 (43.40%)	53		44 (89.8%)	5 (10.2%)	49		43 (91.49%)	4 (8.51%)	47
Total	34 (59.65%	23 40.35%)	57		63 (88.73%)	8 (11.26%)	71		74 (92.5%)	6 (7.5%)	80

Among the patients with improper head positioning, 60% had a RASS more than or equal to 1, suggesting that agitation was a key reason for failure to adhere to required head elevation with statistical significance (p-value = 0.038; [Table 3]). The compliance improved to 87.5% in the audit following intervention and raising awareness among nurses.

Table 3 Comparison of RASS among patients with correct and incorrect head positioning

	Cycle 1 Head positioning				Cycle 2 Head positioning				Cycle 3 Head positioning
RASS	Correct	Incorrect	Total	p-Value	Correct	Incorrect	Total	p-Value	Correct	Incorrect	Total	p-Value
≥1	8 (40%)	12 (60%)	20	0.038	42 (87.5%)	6 (12.5%)	48	1.000	25 (92.6%)	2 (7.4%)	27	0.518
0	23 (74.19%)	8 (25.81%)	31		11 (91.67%)	1 (8.33%)	12		23 (88.46%)	3 (11.54%)	26
≤ − 1	3 (50%)	3 (50%)	6		10 (90.9%)	1 (9.1%)	11		26 (96.3%)	1 (3.7%)	27
Total	34 (59.65%)	23 (40.35%)	57		63 (88.73%)	8 (11.26%)	71		74 (92.5%)	6 (7.5%)	80

Abbreviation: RASS, Richmond agitation sedation scale score.

However, this was not the only cause as 50% of drowsy (RASS < − 1) patients too did not have HBE. This implied that the lack of awareness or attention to positioning among the nurses was also a major contributory factor in nonadherence to HBE. Introduction of checklist and inclusion of HBE monitoring in hourly assessment improved compliance in this group as well.

Postintervention

The compliance for HBE improved by 29% from 59.65% in the first cycle to 88.73% in the second cycle. The average backrest angle was now observed to be 24.63 degrees. Among the eight patients still found to be incorrectly positioned, agitation continued to be the main cause as 75% of them had RASS more than 1. However, unlike in cycle 1, noncompliance for HBE was observed more in moderate TBI group (62.5%) in cycle 2. The severe head injured group (GCS: 3–7) had the best compliance at 90% ([Table 4]).

Table 4 Comparison of GCS among patients with correct and incorrect head positioning

	Cycle 1 Head positioning				Cycle 2 Head positioning				Cycle 3 Head positioning
GCS	Correct	Incorrect	Total	p-Value	Correct	Incorrect	Total	p-Value	Correct	Incorrect	Total	p-Value
13–15	21 (63.64%)	12 (36.36%)	33	0.399	18 (90%)	2 (10%)	20	1.000	13 (76.47%)	4 (23.53%)	17	0.028
9–12	12 (60%)	8 (40%)	20		36 (87.8%)	5(12.2%)	41		35 (97.22%)	1 (2.78%)	36
3–8	1 (25%)	3 (75%)	4		9 (90%)	1(10%)	10		26 (96.3%)	1 (3.7%)	27
Total	34 (59.65%)	23 (40.35%)	57		63 (88.73%)	8(11.26%)	71		74 (92.5%)	6 (7.5%)	80

Abbreviation: GCS, Glasgow coma scale.

In the third cycle, sustenance of intervention measures was evident with even better compliance at 92.5% with an average bed rest angle of 25 degrees. The presenting GCS was found to be the factor statistically correlating (p-value = 0.028) ([Table 4]) with adherence to HBE with mild head injury group being the least compliant.

Discussion

Head-end elevation, an integral part of neurocritical care nursing, had a compliance rate of only about 60% in our neurocritical care unit. The audit was effective in improving the compliance rate using a cost-effective and straightforward hourly checklist.

Most of the literature recommend HBE of 30 degrees for the reduction in ICP and prevention of ventilator-associated pneumonia.[9] [10] While the beneficial angle of HBE has been found to vary on daily basis,[15] feasibility of maintaining HBE has been observed to be between 20 and 30 degrees in several studies.[17] [18]

Inadequate sedation and agitation were found to be the prime cause of nonadherence. The RASS scores a patient's agitation from +4 (combative) to −5 (unarousable). A score of 0 (alert and calm) to −1 (drowsy) is recommended for patients in ICU. A RASS more than 1 (restless: anxious or apprehensive but movements not aggressive or vigorous) contributes to a large extent in noncompliance for adherence to HBE, as was observed with statistical significance (p-value = 0.038) in the first cycle of our study. Patients with high RASS are unlikely to maintain the desired position despite good nursing practice. This may erroneously affect the compliance. Patients with low GCS are likely to be sedated and ventilated, and will have better compliance with nurse-adjusted HBE as seen in the third cycle of our audit where most noncompliance was observed in the mild head injured group. However, incorrect positioning in 75% of severe head injury patients too makes the role of checklist very important in improving compliance.

Patient-related factors like agitation are not the only cause, as evident from our results. While in the first cycle RASS more than 1 was definitely the group noncompliant to HBE, it was the calm group with RASS 0 in the third audit that was most noncompliant, despite a noteworthy improvement in HBE at 92%. This also implies that it is work in progress and the staffs have to be regularly appraised on the topic.

Our observations revealed that patients with GCS 13 to 14 and RASS more than 1 (n = 12) were more likely to not maintain 20 to 30 degrees HBE. Educating the nurses on the importance of proper positioning and incorporating an hourly patient-position-monitoring checklist into the nursing monitoring booklet of the ICU were the most effective tools that helped in improving adherence. Other factors that helped in good patient positioning were establishing objective protocols such as ensuring all patients were positioned such that their tragus was placed above the midaxillary line, which corresponds to the head being above the heart level. Moreover, the objective numerical target of 20 to 30 degrees backrest elevation also helped.

Checklists play an integral role in complementing human cognitive actions in high-intensity environments such as the ICU and help improve adherence to standards.[18] [19] In addition, checklists also help enhance the quality of patient care, reducing mortality and morbidity.[20] [21] [22]

Providing objective targets and educating the nursing staff to maintain these targets on a long-term basis also helped. Treatment of TBI is expensive, and in resource-stricken low- and middle-income countries, noninvasive measures such as therapeutic HBE can significantly help in improving patient outcomes. Moreover, there was no pharmacological intervention carried out, which could have interfered with the GCS of the patient. Therefore, ensuring adherence to proper head positioning by employing a bedside checklist can significantly improve the quality of care provided to TBI patients.

The highlight of our study has been the revelation of low adherence to HBE among TBI patients in a specialized neurointensive care. Root cause analysis revealed that the lack of attention to positioning and agitation are leading causes for noncompliance. A simple step of implementing a checklist in nursing protocol not only improved the adherence but was also found to be a sustainable measure.

The major limitation of this study has been that the study was designed as a quality improvement initiative and was not planned for long enough duration to observe any change in outcome. An observational prospective study design in future shall be planned to observe change in outcome parameters.

Conclusions

Compliance with HBE in patients with TBI can be achieved by improving nurse-led vigilance and setting objective targets. Managing agitation among mild and moderate TBI patients can improve the adherence to HBE. The sustainability of improvement was confirmed by the third quality improvement cycle, which proved the intervention to be viable.

Conflict of Interest

None declared.

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Artikel online veröffentlicht:
20. Januar 2023