Date of Award


Document Type


Degree Name

Doctor of Philosophy (Ph.D.)

Institution Granting Degree

University of Central Florida

Cedarville University School or Department


First Advisor

Mary Lou Sole


Pneumonia, pediatric, backrest elevation, ventilator


Elevating the head of bed (HOB) reduces risks for aspiration and ventilator associated pneumonia (VAP) in the adult population. Educational interventions have resulted in improvements in achieving a target HOB elevation of 30° in adults. Limited research has addressed this intervention in the pediatric intensive care unit (PICU). The aim of this study was to determine if an educational intervention for the PICU staff would result in improvement in the HOB elevation in the PICU. Four research questions were studied: (1) What is the common practice related to the elevation of the HOB in the PICU? (2) Is there a difference in the mean HOB elevation before and after an education intervention? (3) Is there a difference in the percent of time the HOB is at or above 30° after the intervention? and (4) What factors influence HOB elevation in the PICU?

A quasi-experimental, pre, and post measurement, with nonequivalent comparison group design was used. The angle of the HOB elevation was measured with the “Pitch and Angle Locator” (PAL) (Johnson, Mequon, WI). Baseline measurements (n = 99) were obtained for patients admitted to a PICU at various days and times over a 2-week period. An educational intervention was done for the staff members in the PICU, with a focus on the importance of keeping the HOB up and strategies for measuring the HOB elevation. Posters to reinforce the information were placed on the unit. Post-intervention, measurements (n = 98) were obtained for another 2-week period. At the time of data collection, staff members caring for the PICU patients were asked to provide responses for what influenced them to place the patient at the documented HOB elevation.

Children were older in the post-intervention group than in the pre-intervention (8.8 yrs, vs. 3.7, yrs, respectively, t = -6.67, df = 195, p = .000). The children also weighed more in the post-intervention group than in the pre-intervention (32.0 kg vs. 19.7 kg, respectively, t = -4.19, df = 195, p = .000). The mean HOB elevation was 23.5° before the intervention. After the intervention, the mean HOB increased to 26.5° (t = -1.19, df 195, p = .033). For ventilated patients, the mean HOB elevation went from 23.6° to 29.1° (t = -3.25, df 95, p = .001), and for patients mechanically ventilated and in an adult bed, the mean increased from 26° ± 7.89°, pre-intervention to 30° ± 8.59° post-intervention (t = -1.80, df 63, p = .038). The percent of the time the measures were greater than 30° increased from 26% to 44% pre- and post-intervention respectively (χ2 6.71, df 1, p = .005). Responses (n = 230) related to the factors that influenced positioning were categorized as follows: physician order (3%), safety (7%), found this way (11%), therapeutic intervention (16%), comfort (24%), and patient condition (39%).

An educational intervention can impact the practice of elevation of the HOB in a PICU, thus decreasing the risks of developing aspiration and VAP. Although the mean HOB increased statistically, the HOB was less than 30° in more than half of the post intervention measurements, indicating the need for ongoing reinforcement of the education. The PAL device was a new, reliable method for recording HOB elevation in both adult beds and cribs. Follow-up research is needed to determine if these gains in HOB elevation have been sustained over time and their impact on VAP.


© 2007 Randall L. Johnson. All rights reserved.



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