How lapse and slip errors influence head-of-bed angle compliance rates as measured by a portable, wireless data collection system

Geb W Thomas; Priyadarshini Pennathur; Derik M Falk; Jon Myers; Brennan Ayres; Philip M Polgreen

doi:10.1080/19488300.2014.993005

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Journal article

How lapse and slip errors influence head-of-bed angle compliance rates as measured by a portable, wireless data collection system

Geb W Thomas, Priyadarshini Pennathur, Derik M Falk, Jon Myers, Brennan Ayres and Philip M Polgreen

IIE transactions on healthcare systems engineering, Vol.5(1), pp.1-13

01/02/2015

DOI: 10.1080/19488300.2014.993005

PMCID: PMC6546299

PMID: 31168335

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https://www.ncbi.nlm.nih.gov/pmc/articles/6546299View

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Abstract

The recommended protocols to prevent ventilator-associated pneumonia include keeping ventilated patients' head and upper body elevated to an angle between 30 and 45 degrees. These recommendations are largely based on a study that has been difficult to replicate, because studies that have attempted to replicate the original conditions have failed to achieve the necessary bed angles consistently. This work suggests the possibility that two specific types of human error, slips and lapses, contribute to non-compliant bed angles. A novel device provided 83,655 samples of bed angles over a period of 1579 hours. The bed angle was out of compliance 64.2% of the time analyzed. Slips, the accident of raising the bed to an angle slightly less than the desired angle, accounted for most of the out-of-compliance measurements, or 55.9% of the time analyzed. It appears that stochastic variation in the bed adjustments results in the bed being out of compliance. Interventions should be investigated such as increasing the target angle and providing feedback at the moment the bed is raised to close to, but less than, the target angle.

ventilator-associated pneumonia

head-of-bed

monitoring

Protocol adherence

wireless sensors

Details

Title: Subtitle: How lapse and slip errors influence head-of-bed angle compliance rates as measured by a portable, wireless data collection system
Creators: Geb W Thomas - Department of Mechanical and Industrial Engineering, The University of Iowa
Priyadarshini Pennathur - Department of Mechanical and Industrial Engineering, The University of Iowa
Derik M Falk - Department of Internal Medicine, The University of Iowa
Jon Myers - Department of Mechanical and Industrial Engineering, The University of Iowa
Brennan Ayres - Department of Mechanical and Industrial Engineering, The University of Iowa
Philip M Polgreen - Department of Internal Medicine, The University of Iowa
Resource Type: Journal article
Publication Details: IIE transactions on healthcare systems engineering, Vol.5(1), pp.1-13
DOI: 10.1080/19488300.2014.993005
PMID: 31168335
PMCID: PMC6546299
NLM abbreviation: IIE Trans Healthc Syst Eng
ISSN: 1948-8300
eISSN: 1948-8319
Publisher: Taylor & Francis
Language: English
Date published: 01/02/2015
Academic Unit: Infectious Diseases; Epidemiology; Orthopedics and Rehabilitation; Industrial and Systems Engineering; Injury Prevention Research Center; Internal Medicine
Record Identifier: 9984094876502771

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