PROCEDURE FOR INITIATING CONTINUOUS
LATERAL ROTATION THERAPY (CLRT)


  1. Select Patient
  2. Obtain Equipment
  3. Prevent Nausea
  4. Hand Hygiene
  5. Position Patient
  6. Prepare Bed
  7. Adjust Bed
  1. Ensure Safety
  2. Set Pause Times
  3. Set Percentage of Rotation
  4. Monitor Patient
  5. Document
  6. Maintain Standard for Skin Care
  7. Re-evaluate

PROCEDURE

RATIONALE FOR PROCEDURE

 1.

Select Patient

The Clinical Nurse or Physiotherapist identifies appropriate patients for CLRT according to guidelines in the Standard for Nursing Care for CLRT.

 1.

To ensure resources are used on appropriate patients and applied consistently. The Clinical Nurse and Physiotherapist are the most suitable health care professionals to apply guidelines.

 2.

Obtain Equipment

Obtain rotation module from the Charge Nurse. Install module into Sport(TM) bed.

 2.

This provides a tracking record via the Charge Nurse to monitor module usage and availability. Therapy should be reevaluated q24h.

 3.

Prevent Nausea

Consider administration of an anti-emetic prior to starting treatment if patient is awake or prone to nausea/vertigo.

 3.

Rotation can trigger nausea or vertigo. Prophylaxis before nausea begins is often more successful than treatment after nausea develops. Nausea can limit the ability to deliver therapy.

    4. Hand Hygiene        4. In accordance with the MoHLTC 4 moments of hand hygiene and LHSC infection control policies   in an effort to reduce risk of transmission of microorganisms and secretions

 5.

Position Patient

Position the patient into the centre of the bed. Ensure that the patient's shoulders are aligned with the label on the inside, upper siderail.

 5.

This ensures the patient is aligned in the bed centrally to accommodate safe and appropriate rotation.

 6.

Prepare Bed

Weigh the patient.

 6.

The cushion pressure is automatically adjusted according to the patient's weight and rotation set-up.

 7.

Adjust Bed

Elevate the head of the bed to > 30 < 40 degrees. If Head of Bed elevation is contraindicated, position the bed <30 degrees as required and document the rationale.

Position the foot of the bed <30 degrees.

 7.

The rotation feature will not work if the head of the bed is >40 degrees, if the foot of bed is > 30 degrees, or if the bed is in the chair position. This is a safety feature of the bed.

All intubated patients or patients being enterally fed require head of bed elevation > 30 degrees to reduce the risk for Ventilator Associated Pneumonia (VAP). If head of bed elevation is contraindicated, the Standard of Nursing Care in CCTC requires documentation of the reason for a lower head of bed placement.

8.

Ensure Safety

Ensure all siderails are up.

Scroll to Rotation/Perc./Vib. and press "Enter".Now scroll to Rotation Therapy and press Enter. Now rotation settings can be entered.

 8.

The bed will not rotate if siderails are down.

 

Allows customizing of rotational set-up.

9.

Set the Pause Time

Set the pause time to 2 minutes. This is the pause time goal.

If the patient does not tolerate turning well , increase the pause time. Select the lowest pause time duration that the patient is able to tolerate. As the patient adjusts to the bed rotation, gradually begin to decrease the pause time until the goal of 2 minutes is achieved.

 9.

The pause time is the duration of time that the bed rests in each position. For example, if the bed is set to rotate to the left and right side with a pause time of 2 minutes, the bed will rotate to the left, pausing for 2 minutes when the patient is fully rotated to the left. The bed will then rotate to the centre, pausing for 2 minutes with the patient in the supine position. Following rotation to the right, the bed will pause for 2 minutes at full right rotation, then complete the full cycle with a 2 minute pause following rotation to the centre again.

Intervals refer to the number of full cycles. One interval consists of rotation to the left, to the centre (supine), to the right and back to the centre again. The interval frequency is calculated automatically by the bed, and is based on the pause time and the time it takes for the bed to turn. The interval frequency will increase if the pause time is decreased.

Currently, the optimal treatment strategy has not been established. Hill-Rom recommends that patients rotate at least 18-20 hours out of every 24 hour period. This 18-20 hours refers to the total duration of time when the bed is in rotation mode. Hill-Rom recommends that the patient be given a rest period when the rotation is turned off for a period of at least one hour out of every 24 hour period. This one hour period may include times when nursing care is provided (e.g., baths, dressings) or procedures are performed (e.g., line insertions, xrays).

The bed always rotates to the right first.

10.

Set the Percentage of Rotation

Set the rotation at 20% for the right and left side.

Increase the degree of rotation by 10% each hour as tolerated, until the goal of 100% rotation is achieved. Monitor the patient after each rotation change.

 10.

The percentage rotation refers to the percentage of a 90 degree rotation being delivered. For example, setting the bed to a rotation of 100% to the left means that the bed will rotate to the left to 90 degrees. Setting the bed to rotate to 0% to the right means that the bed does not rotate to the right.

11.

Monitor Patient

Monitor the patient for signs of intolerance. Monitor for nausea, restlessness, decreased oxygen saturation, tachycardia, tachypnea or changes in blood pressure.

If signs of intolerance develop, return the patient to the previously tolerated rotation percentage.

If nausea develops, obtain an order for antiemetics. Consider sedatives to achieved desired VAMASS score.

Monitor for asymmetrical intolerance, for example, desaturation during rotation on one side. Consider modifications to the percentage rotation on the affected side. Rotation may need to be modified to one side if rotation affects central lines or drainage tube placement.

 11.

The final goal for rotation is 100% rotation to the left and right sides. Some patients may experience nausea or vertigo. When a patient is turned to a position that puts their diseased lung down, increased blood flow to areas of decreased ventilation can worsen an existing shunt and cause the patient to desaturate.

12..

Document

Document the percentage of rotation (left and right) and the pause time in the graphic record q1h. Document patient response to therapy in AI record q shift and prn.

 12.

To communicate and record findings.

13.

Maintain Standard for Skin Care

Continue to turn patient manually to inspect skin q2-4h.

 13.

To prevent/monitor for evidence of skin breakdown.

14.

Re-evaluate

Re-evaluate every 24 hours or when patient's condition changes.

     14.  Evidence of improvement or change in code status to a less aggressive management  warrants re- evaluation of the need for continued CLRT.

References:

Goldhill (2007). Rotational bed therapy to prevent and treat respiratory complications: A review and meta-analysis,
American Journal of Critical Care,16(1), 50-61.

Ahrens, T. et al. (2004). Effect of kinetic therapy on pulmonary complications. American Journal of Critical Care, 13, 376-383.

Davis, K. et al. (2003). The acute effects of body position strategies and respiratory therapy in paralyzed patients with acute lung injury. http://ccforum.com/content/5/C81

Krishnagolpalan, S, et al (2002). Body positioning of intensive care patients: clinical practice versus standards. Critical Care Medicine, 30, 2588-2592.

Raoof, S, et al (1999). Effect of combined kinetic therapy and percussion therapy on the resolution of atelectasis in critically ill patients. Clinical Investigations in Critical Care, 115, 1658-1666.

User Manual Total Care Bed System from Hill-Rom, 11th. Edition 2009.

Developed by: Gina Case RN, Clinical Educator CCTC

Last Update:March 23, 2010.

LHSCHealth Professionals

Last Updated April 15, 2010 | © 2007, LHSC, London Ontario Canada