repositioning oscillator pts question

[Zookeeper3]

Can you all share with me what your current practice is with oscillator patients and repositioning? We are running quite a few of these vents with the "season" in full swing. As long as respiratory has a full "wiggle" if you will, and peak airway pressures recover quickly, why not turn these patients with pillow propping to the left and right?

Simply put, my patient is on 100% fio2 on an oscillator, we're maxed.... yes he does desaturate to 86% with movement, but recovers in 30 minutes... why go through all this and have the pt. die from massive pressure wounds if you can prevent them with turning, even Q4 hrs.

Like prone positioning, the patient desats initially but recovers and benefits from the turning therapy. I believe we cause patients to become intolerant to turning based upon lack of turning.

So if we still have a full "wiggle" and quickly resolving mean airway pressure, why not turn these guys? Our pulmonologist wrote a specific order not to turn my patient, so what gives? If my patient recovers in a safe amount of time, why set him up to die from preventable wounds?

Now I know how complex this is and I am really dumbing it down, but it really IS that simple. Please share your current practice as I'm having a hard time finding evidenced based practice as to what policy or practice is occurring in other facilities. When I polled my peers almost half said they would turn and half not, so we have to resolve this quickly. While each patient situation is at the discretion of the RN (we've all been there), surely, some of you have a policy in place that addresses immobility and skin protection protocols?

Lastly and thank you for your patience, medicaid/medicare does not reimburse therapy from hospital acquired wounds.... I'm hoping to use this as an additional incentive to just simply prop some pillows and tilt a patient which only improves lung recruitment and can benefit my patients overall recovery.

Final words, my pt. is hemodynamically stable, beautiful vs, just desats with the initial turn, we can't do anything else from an RT standpoint, maxed on 100%fio2, I can argue both sides. "don't dare turn, airway and o2 is the priority" but the decompensation is brief. Massive skin ulcers, which can result in a secondary morbidity and lack of compensation in pay is a huge concern as well.

How are you practicing? Lets keep this simple please, we all understand the complexity involved.

[meandragonbrett]

What are you going to do when you do turn the patient that one time and they don't recover from their de-compensating? Just a thought.

[RNperdiem, RN]

Does you bed have a rotation module?

I know it is not a substitute for turning, but it would be better than nothing.

[kimmie518]

Well what's worse. The possibilty of a pressure sore, or the possibility of a hypoxic injury?

[FlyingScot, RN]

Are you talking about disconnecting them from the ventilator when turning or just tilting their bodies?

[detroitdano]

I've had some issues with things like this where you know what is in the best interest of the patient, but there's also what policy and orders say, and sadly sometimes you've gotta cover your own butt and just go with what you're allowed to do and don't play super nurse.

If they desatted, coded and passed after you turned them, it's your license on the line for not following orders, not the doctor's. True you can say it's on both you and the doctor if they get a pressure ulcer, but you were following orders and policy and can't really be looked at badly for that. It'll get the hospital in some hot water with a lawsuit, but you'll still have a job.

[highlandlass1592, BSN, RN]

Like someone else said, look into specialty beds to help. At this point, you should be able to argue for payment for specialty beds...they would really help.

[rghbsn, BSN, RN]

There are a few beds out there that reduce or eliminate the need for turning. They are usually used when people have pressure ulcers that are so far gone that there is nothing else to do. Like many therapies, they are utilized later than they should be, often based on cost and/or insurance repayment. The reality is, there should be a protocol in place that requires a specialty bed either with the order to put the patient on the oscillator, or when an order is written not to turn a patient.

And no, it's not okay to turn them if an order has been written not to.

I see your point about recovering from the initial turn. And I can see your relating it to proning (also used too late most of the time), but the oscillator is not regular ventilation, and the loss of recruitment that manifests itself as desaturation with the initial turn is not always recoverable. In fact, you can end up losing alveoli that were recruited prior to the turn as well, then the patient won't recover even when placed back in the original position.

[FlyingScot, RN]

That's what I was thinking. As soon as you lose your MAP you lose your recruitment and there's no way to know how much you will get back. When I worked PICU we turned but it was a huge process involving literally clamping off the ETT with padded hemos prior to disconnecting. The thought being that the clamped tube maintained the MAP. Like I said it was a huge process though. The patient was deeply sedated (by Anesthesia), paralyzed and there were 2 RT's whose sole responsibility was keeping the ETT in, one for the ventilator, the intensivist, fellow and just about every nurse that could be spared depending on the patient size. It wasn't just babies but teenagers as well.The process was mapped out ahead of time with exactly who was doing what and in what order. If the vent needed to be on the other side we had a second one set up and running on a test lung so that we didn't have to wait for the first to be repositioned. We had some "butt-sweat" moments I must say.

[FOCKER0014]

you should try placing the patient on a rotorest bed....best thing for them as far as turning goes

[dorimar, BSN, RN]

Sometimes in nursing you have to let some things go. This is where Maslow's hierarchy comes into play. remember your ABCs: airway, breathing, & circulation... rghsbsn explained the loss of alveolar recruitment that can occur very well. My thoughts are that I think it is great you have a physician covering your for not turning your patient when it is in the patient's best interest.

[Zookeeper3]

Well what's worse. The possibilty of a pressure sore, or the possibility of a hypoxic injury?

This type of reply is unnecessary:angryfire With 15 years of ICU including heart transplant I am not spending my time here looking for flip answers. My question is not what you think the priority is or explain lung recruitment to me, I'm good.

Is anyone kind enough to share their current practice, what their policy states for repositioning? Thank you for the rotational bed ideas, we have a pulmonologist working with hillrom to determine the best type of beds.

Anyone out there from Duke or UNC? Lung patients waiting for transplant are regularly proned on the oscillator and certainly turned. I need feedback from those that usually do this (move patients on oscillators).

Thank you in advance for your help.