Leslie Swadener-Culpepper passes on her tips for implementing CLRT in the ICU.
“We've had to do a lot of education in supporting nurses to show them how to manage the patient's volume status, pressure status, oxygenation status, and show them ways to alter the lateral rotation therapy so that the therapy can continue without destabilizing the patients' hemodynamic status.”
What were the changes that sparked your interest in using continuous lateral rotation therapy in your intensive care unit?
LC. I've long had an interest in mobility as a process to keep lungs clear. With a critically-ill patient who has tubes, wires, IVs and ventilators attached to them, mobility is a challenge. I wanted to find out what kind of mobility was best for the patient, when it should be implemented, how it should be implemented and for how long.
In a study we carried out between 2002 and 2004, we compared lateral rotation for early versus late implementation. The study found that if you apply lateral rotation for at least 18 hours per day in a patient that meets the criteria very early on, within 48 hours, then they have much better outcomes than waiting, or obviously not applying the therapy at all.
Please tell us about some of the protocols and processes have you created to achieve successful CLRT outcomes.
LC. We have a clinical practice guideline in place that is nurse-driven. We believe that it is a nursing function to assess the patient's need for lateral rotation to prevent pulmonary complications just as much as it is to assess for skin complications. You turn a patient every two hours for skin care; if you assess that the patient meets the criteria for needing to rotate for pulmonary care, we believe that's just as much a nursing and allied health responsibility, so we've empowered our nursing and respiratory staff based on inclusion and exclusion criteria. If the patient meets the criteria, then we can place them on lateral rotation without obtaining an additional physician order; our protocol provides a standard that allows us to do that.
What are some of the barriers that could hinder CLRT implementation? What solutions would you pass on to those thinking of implementing CLRT in their ICU?
LC. CLRT has always had its barriers. We call them 'hassle factors'; the things that get in the way of the nurse implementing the therapy. Nurses for example, want to make their patients look good. If their patients are on a continuously moving bed, sometimes the patient isn't as neat as nurses would like them to be and they don't like that.
Another big thing that hinders implementation in CLRT in the clinical setting is patients' hemodynamic status in general. If a patient is unstable and their blood pressure has dropped or their oxygen saturation level has dropped because of their degree of illness, and they're on lateral rotation therapy, the first thing that the staff want to blame is the rotation, and stop the therapy.
We've had to do a lot of education in supporting these nurses to show them how to manage the patient's volume status, pressure status, and their oxygenation status, and show them ways to alter the lateral rotation therapy so that the therapy can continue without destabilizing the patients' hemodynamic status.
How do you measure the success of CLRT therapy in your unit?
LC. We have a variety of ways to measure it. We evaluate compliance to our CLRT protocol as part of our process standards, and our process standards are evaluated with the other elements of the VAP bundle. Respiratory therapy assists with this evaluation. We look to see, on a regular basis, of the patients that meet criteria, how many of them are on CLRT, how many aren't, how many of them have their head elevated to 30 degrees, how many of them have 'evac' endotracheal tubes, for example,
So we look at our standards and we implement changes in order to increase compliance and to make sure that those numbers stay at an acceptable level; we look to see that 'evac' endotracheal tubes are used on all of our intubated patients and that CLRT is implemented within 24 hours of meeting the criteria. Having beds with CLRT capability in the unit makes it a lot easier: Nurses don't have to wait to call for a rental bed, get a bed in, transfer the patient over, which is another big problem for a lot of nurses moving a patient from one bed to another when they've got multiple tubes and lines; if they were to become dislodged during transfer to the specialty rental bed, that would be detrimental to the patient.
Leslie Swadener-Culpepper, RN, MSN, CCRN, CCNS is a clinical nurse specialist for critical care at the Medical Center of Central Georgia in Macon, Georgia. A critical care nurse for 27 years, and a CNS for 15, her practice has included clinical practice, education, process improvement and leadership roles.