NR 528 Week 2 Practice Problem Brief Example

Practice Problem Brief: Head-of-Bed Elevation of 30 to 45 Degrees for Every Patient on Continuous Tube Feeding, Fixed in Wording Precise Enough That Every Later Step Can Be Dated Against It

Student Name

College of Nursing, Chamberlain University

NR 528: Leading and Managing Evidence-Based Change in Nursing

Instructor Name

Month Day, Year

Practice Problem Brief: Head-of-Bed Elevation of 30 to 45 Degrees for Every Patient on Continuous Tube Feeding, Fixed in Wording Precise Enough That Every Later Step Can Be Dated Against It

The Practice, in One Sentence

For every adult patient on the progressive care unit who is receiving continuous enteral tube feeding, the head of the bed stays between 30 and 45 degrees at all times, including at night and after repositioning and bathing, unless a physician or advanced practice provider order documents a reason it must be lower; when the bed must be lowered for care, the feeding pump is paused and the bed is returned to at least 30 degrees before the feeding is restarted.

Every later step of this project, the teaching, the equipment, the audit and the sustainability plan, is written against that sentence. Each phrase in it was chosen to prevent a particular misunderstanding, and the choices are explained below.

Why Each Phrase Is There

"Every adult patient ... receiving continuous enteral tube feeding." The practice applies to continuous feeding because that is when stomach contents are always present. Patients receiving intermittent or bolus feeds are important, but their risk and care routine differ; including them would double the scope and blur the audit. They are excluded from this project, not from good care.

"30 to 45 degrees." A range, not a single number, so that a bed at 40 degrees is compliant and nobody lowers it to exactly 30. The lower bound is the one that matters for aspiration; the upper bound acknowledges that higher angles increase shear on the sacrum.

"At all times, including at night and after repositioning and bathing." These words exist because our spot check found beds lowered after linen changes at night. Without them, a nurse could reasonably read the practice as a daytime goal.

"Unless a ... order documents a reason." Some patients cannot have the head raised, for example with unstable spinal injuries or severe hypotension. Requiring a documented order makes the exception visible to the next nurse rather than a private judgment.

"The feeding pump is paused and the bed is returned ... before the feeding is restarted." Care sometimes requires a flat bed. This clause tells nurses exactly what to do during those minutes, so the practice does not break every time a patient is turned.

Wordings Considered and Rejected

Three shorter versions were drafted and rejected. "Keep the head of the bed elevated for tube-fed patients" named no angle, so nurses would each decide what elevated meant. "Head of bed at least 30 degrees for patients at risk of aspiration" left the question of who is at risk to each nurse's judgment, which is how the original change drifted. "Head of bed 30 degrees at all times" was precise but set a single number that nurses would treat as a ceiling and that ignored the need to lower the bed for care. The final sentence is longer than any of these, and that length is the price of a practice two nurses on different shifts would carry out the same way.

The Support, Stated Once

Clinical practice guidelines for nutrition support in critically ill adults advise elevating the head of the bed by 30 to 45 degrees in intubated adults fed enterally and in anyone judged at high aspiration risk (McClave et al., 2016). A nursing practice alert on aspiration prevention recommends keeping the head of the bed elevated to at least 30 degrees for patients at risk of aspiration unless medically contraindicated (American Association of Critical-Care Nurses, 2016). In a study of critically ill tube-fed patients, a risk-reduction protocol achieved head-of-bed elevation of at least 30 degrees in almost 90% of patients compared with 38% in usual care, and aspiration and pneumonia were much less frequent in the protocol group (Metheny et al., 2010). Our patients are progressive care rather than intensive care patients, but many are recently transferred from intensive care, have had strokes or have impaired swallowing, placing them in the high-risk group the guidance describes. The brief does not argue the evidence further; its purpose is to fix the practice.

The Current State

Over two weeks before this brief, a charge nurse and I checked head-of-bed angle with a bed-mounted angle indicator for every patient on continuous feeding at four set times: 1000, 1600, 2200 and 0400. Of 112 observations, 46, or 41%, were at 30 degrees or higher. By shift, 52% of day observations and 28% of night observations met the practice. The observations did not record reasons, so some low angles may have been appropriate, but only two patients had a documented order to keep the head of the bed lower.

Who Owns the Practice

The bedside registered nurse is responsible for the head-of-bed angle for each patient on continuous feeding, including when nursing assistants reposition or bathe the patient. Nursing assistants are responsible for returning the bed to 30 degrees after care and telling the nurse if they cannot. The charge nurse checks the angle for every tube-fed patient during the shift safety round. Providers are responsible for documenting a contraindication when one exists. Writing ownership into the brief matters because the first attempt at this change named no one, and a practice everyone shares is, on a busy night, a practice nobody checks.

What Is Out of Scope

This project does not change feeding tube placement, gastric residual volume checks, oral care or swallowing assessment, all of which affect aspiration risk and have their own policies. It does not apply to intensive care, where a separate protocol exists. It does not address patients on bolus or intermittent feeds. Keeping these out is deliberate: the unit has one practice to fix, and fixing it well is more likely than fixing five practices partly.

What Success Would Look Like

The measure that matters is the proportion of observations at 30 degrees or higher, by shift. The unit will consider the practice established when at least 85% of observations meet it on both day and night shifts for three consecutive months. Aspiration events and pneumonia will also be tracked, but they are rare on a 24-bed unit and will take longer to move.

Success would also mean the angle is checked without anyone being asked: a charge nurse glancing at the indicator during rounds, or a float nurse raising the bed before restarting a pump because the label says so. Those small unprompted checks are what the audit is really watching for.

References

American Association of Critical-Care Nurses. (2016). Prevention of aspiration in adults [Practice alert]. Critical Care Nurse, 36(1), e20-e24. https://doi.org/10.4037/ccn2016831

McClave, S. A., Taylor, B. E., Martindale, R. G., Warren, M. M., Johnson, D. R., Braunschweig, C., McCarthy, M. S., Davanos, E., Rice, T. W., Cresci, G. A., Gervasio, J. M., Sacks, G. S., Roberts, P. R., & Compher, C. (2016). Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). Journal of Parenteral and Enteral Nutrition, 40(2), 159-211. https://doi.org/10.1177/0148607115621863

Metheny, N. A., Davis-Jackson, J., & Stewart, B. J. (2010). Effectiveness of an aspiration risk-reduction protocol. Nursing Research, 59(1), 18-25. https://doi.org/10.1097/NNR.0b013e3181c3ba05