Effect of Frequency of Manual Turning on Pneumonia

Lynn Schallom, Norma A. Metheny, Jena Stewart, Rene Schnelker, Janet Ludwig, Glenda
Sherman and Patrick Taylor
Am J Crit Care 2005;14:476-478
2005 American Association of Critical-Care Nurses
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AJCC, the American Journal of Critical Care, is the official peer-reviewed research
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SHORT COMMUNICATION
EFFECT OF FREQUENCY OF MANUAL TURNING ON PNEUMONIA
By Lynn Schallom, RN, MSN, CCNS, CCRN, Norma A. Metheny, RN, PhD, Jena Stewart, RN, MSN, CS, M-SCNS,
CCRN, Rene Schnelker, RN, GM-SCNS, Janet Ludwig, RN, MSN(R), CS, Glenda Sherman, RN, MSN, and Patrick
Taylor, RN, BSN. From St Louis University School of Nursing (LS, NAM, JS, RS, JL, GS, PT), St Louis, Mo.
C linicians have long recognized that patients
should be turned at least every 2 hours.1 In
fact, routine turning of critically ill patients is
viewed as a standard of care to prevent pneumonia.2
Although a 2-hour manual turning schedule is widely
embraced in theory, it is unclear if it alters pulmonary
function3 or if it is uniformly practiced. In a study4 of 74
critically ill patients from 3 hospitals, only 2 patients
had position changes every 2 hours. Even if a 2-hour
turning schedule is enforced, it is unclear if this fre-
quency of turning would be sufficient to prevent pul-
monary complications.5
It is unclear if turning patients every 2
hours is sufficient to prevent pulmonary
complications.
Although Traver et al6 found no difference in the
incidence of pneumonia between patients cared for on
oscillating beds and patients who had manual turning
every 2 hours, other investigators3 found that kinetic
therapy beds were superior to manual turning in reduc-
ing pulmonary complications in critically ill patients.
Whether the benefit derived from kinetic therapy beds
is due to the frequency of turning or to a turn angle of
40 or greater is not clear. Despite the efficacy of kinetic
therapy beds, it is doubtful that they can be made avail-
able to all patients who might need them. Thus, the
extent to which manual turning, which presumably is
available to most patients, can prevent pulmonary com-
plications warrants further study.
The objective of this descriptive study was to com-
pare the frequency of bihourly turning in critically ill
tube-fed patients receiving mechanical ventilation in
whom pneumonia did or did not develop after 3 con-
secutive days of data collection.
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476 AMERICAN JOURNAL OF CRITICAL CARE, November 2005, Volume 14, No. 6
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Methods
The study was approved by the appropriate insti-
tutional review body and was carried out in accordance
with the standards set forth in the Helsinki Declara-
tion of 1975. The study reported here is a component
of a larger project designed to determine the fre-
quency of aspiration and pneumonia during the first 3
days of tube feedings in critically ill patients receiv-
ing mechanical ventilation. For this segment of the
larger study, 284 critically ill tube-fed patients receiv-
ing mechanical ventilation were recruited from a variety
of intensive care units (trauma/surgery, neurosurgery/
neuromedicine, general medicine, and cardiac medicine/
surgery). Most (n = 279) patients had endotracheal
tubes in place at the time of entry into the study; the
remainder had tracheostomy tubes. A total of 176
patients had nasally inserted tubes, 96 had orally
inserted tubes, and 12 had gastrostomy tubes. The
patients mean age was 51.8 years (SE 1.1, range 18-
95). More men than women participated in the project
(60.6% vs 39.5%, respectively). Exclusion criteria
were use of kinetic therapy beds and diagnosed pneu-
monia at the time of entry into the study.
For a period of 3 days, from 8 AM until midnight,
a research nurse made hourly observations of the
body positions of the 284 patients; thus, a total of
13 632 observations (48 x 284) were made. A turn
was defined as movement from supine to either side,
either side to supine, one side to the other side, or
from the bed to a chair. No attempt was made to
quantify the degree of each turn. None of the patients
observed during the study was in the prone position.
Weight in kilograms was recorded for each
patient at time of entry into the study. Levels of con-
sciousness and sedation were measured 5 times daily
for each of the 3 days (days 1-3). A pneumonia score
was calculated at the end of the 3-day study period
(day 4). Instruments used to make the measurements
were as follows.
A version of the Glasgow Coma Scale modified
for intubated patients was used to assess level of con-
sciousness (possible scores, 3-15). The Vancouver
Interaction and Calmness Scale was used to measure
the level of sedation.7 This scale was designed for
patients receiving mechanical ventilation; the possible
range of scores is 10 to 60 (the lower the score, the
higher is the level of sedation). The Clinical Pul-
monary Infection Score (CPIS), as described by Pugin
et al,8 was used to assess for pneumonia; this scale
uses a combination of 6 variables: oxygenation, body
temperature, white blood cell count, radiographic evi-
dence of infiltrates, cultures of tracheal aspirates, and
volume/appearance of tracheal aspirates. Analysis of
arterial blood gases was used to calculate the oxy-
genation component of the CPIS. The lowest possible
score on the CPIS is 0, and the highest is 12; a score
of 7 or greater is considered positive for pneumonia.
Turning frequency and data on individual compo-
nents of the CPIS were collected by the research
nurses. One full-time and 2 half-time nurses collected
most of the data; however, an additional 10 nurses
were hired to provide coverage for data collection (16
h/d, 7 d/wk) during the 2-year study period of the
larger project. Each data collector underwent a 1-week
training period; in addition, the project director
observed all of the research nurses at frequent inter-
vals to monitor the accuracy of data collection and
reporting. The project director calculated all of the
CPIS scores; she did not collect data.
Descriptive statistics were used to report the data.
A 2-sample t test was used to determine the extent to
which the frequency of turning during the 3-day
observation period affected the pneumonia score on
day 4. Nonparametric statistics and logistic regression
were used to examine the effects of specific types of
injuries and medication use.
Results
Although 23 bihourly turns were possible for each
patient during the observation period, the mean num-
ber of turns observed per patient was 9.64 (SE 0.32,
range 0-23). Patients included in the study were rela-
tively dependent on others for repositioning; for exam-
ple, the patients mean score on the Glasgow Coma
Scale was 6.9 (SE 0.17), and the mean score on the
Vancouver Interaction and Calmness Scale was 35.6
(SE 0.24), indicating a high level of sedation.
Pneumonia, as defined by a CPIS of 7 or higher, had
occurred in 49% of the patients at the end of the 3-day
study. CPIS values ranged from 0 to 6 (mean 4.25, SE
0.04) for the patients without pneumonia and from 7 to
12 (mean 7.71, SE 0.08) for the patients with pneumo-
nia. Patients with pneumonia were turned less frequently
(mean turns 8.67, SE 0.43) than were those without
pneumonia (mean turns 10.62, SE 0.45; P = .003).
AMERICAN JOURNAL OF CRITICAL CARE, November 2005, Volume 14, No. 6
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An attempt was made to determine if selected
clinical factors such as degree of elevation of the head
of the bed, frequency of supine positioning, type of
injury, and use of paralytic agents influenced the rela-
tionship between frequency of turning and pneumonia.
Mean elevation of the head of the bed was signifi-
cantly lower in patients with pneumonia (21.9) than
in those without pneumonia (24.9; P = .04). However,
the relationship between frequency of turning and
pneumonia remained significant when this variable
was controlled for in the analysis (P = .01). The mean
percentage of time that patients were in the supine
position was significantly greater in those with pneu-
monia (72.6%, SE 1.6%) than in those without pneu-
monia (65.2%, SE 1.8%; P = .002). The supine
position was used significantly more often in patients
receiving vasopressors (P = .04) and in those with
spinal cord injury (P = .007), pelvic fractures (P = .01),
multiple fractures (P < .001), and elevated intracranial
pressure (P = .02) than in patients without these char-
acteristics. However, the relationship between fre-
quency of turning and pneumonia remained
significant when these variables were controlled for in
the analysis (P = .01). Patients who received paralytic
agents had a higher incidence of pneumonia than did
patients who did not receive these agents (P = .02);
however, when frequency of turning was controlled
for in the analysis, the relationship between use of
paralytic agents and pneumonia was not significant
(P = .12). In summary, frequency of turning was inde-
pendently related to the development of pneumonia.
Even after factors such as backrest
elevation, supine positioning, and use
of paralytic agents were accounted for,
pneumonia was more likely to develop
in patients who were turned less often.
Possible barriers to turning every 2 hours were
examined. Although heavier patients and those who
received vasopressors tended to be turned less often
than were patients who weighed less or did not receive
vasopressors, the differences were not significant.
However, specific types of conditions, such as spinal
cord injury (n = 30), pelvic fracture (n = 10), multiple
extremity fractures (n = 26), and high intracranial
pressure (n = 29), were associated with significant
decreases in frequency of turning (P < .01). Also, the
84 patients who received a paralytic agent at least
477
once during the study period were turned less often
than were the 200 who received no paralytic agents
(P < .001). Patients with nasally inserted tubes were
turned significantly more often than were patients
with orally inserted tubes (P = .05). Possibly, the type
of illness or injury influenced this finding; for exam-
ple, 70.6% of the patients with orally inserted tubes
had actual or suspected head injuries. The difference
in frequency of turning between patients with nasally
or orally inserted tubes and patients with gastrostomy
tubes was not significant (P = .24).
Patients who received paralytic
agents were turned less often than
were patients who did not receive
paralytic agents.
Strengths and Limitations of the Study
The major strength of the study was the large
number of observations (n = 13 632) made on the 284
patients during the 3-day study period. A limitation
was our inability to observe the frequency of turning
between midnight and 8 AM. However, because the
bedside nurses all worked 12-hour shifts, we were able
to observe the evening nurses patterns of turning dur-
ing the first 5 hours of their shifts. Most likely, these
patterns were representative of their turning patterns
during the 8 hours of missed observations. Another
limitation was lack of precision in the CPIS in diag-
nosing pneumonia. Although many investigators9-13
have found the CPIS useful in clinical studies, others14-16
have cautioned that it has low diagnostic accuracy
when compared with quantitative cultures of bron-
choalveolar lavage fluid. Despite our efforts to control
for the effect of selected clinical conditions on the
relationship between frequency of turning and devel-
opment of pneumonia, important interactions might
have been missed. Finally, caregivers knowledge of
patients enrolled in the study may have influenced the
frequency with which turning was performed. How-
ever, because comparisons were limited to patients
enrolled in the study, this factor most likely had no
effect on the findings.
478 AMERICAN JOURNAL OF CRITICAL CARE, November 2005, Volume 14, No. 6
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Conclusions
Findings from this study support the premise that
the more frequently a critically ill patient is turned, the
less likely pneumonia is to develop. Although turning is
contraindicated in critically ill patients in some situa-
tions, most likely most patients can tolerate (and profit
from) a regular turning schedule. Additional studies are
needed to assess the most desirable frequency of man-
ual turning to minimize pneumonia in critically ill tube-
fed patients receiving mechanical ventilation. To reduce
complications of immobility, critical care nurses need
to address the barriers to turning.
ACKNOWLEDGMENT
This research was funded by a grant (R01 NRO 5007) to Norma A. Metheny from
the National Institute of Nursing Research.
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