Continuous Lateral

Rotation Therapy (CLRT)

Yasmel Garcia, RN
Diana Lopez, RN & Luis Nieves, RN

S
 Evidence Based Practice
Question?

For adult patient in the ICU; does the use of the

CLRT decrease ventilator complications?
 PICO

P- Critically ill patients with decreased lung compliance who are immobile

I- The integration of a continuous lateral rotation therapy

C- Compared to standard protocol

O- Decrease the amount of time being intubated and decrease the # of

VAE over a 5 day time frame
 Project Timeline
Identify problem in the unit
Research EBP articles
September
October Feedback from Unit Managers and NRP staff

Review Literature
Analyze & collect data from available literature
Identify possible barriers at unit level, hospital & nation wide

Partake in education ie. ABCDEF bundle, Hill Rom presentation

Create and modify questions to assess nurses point of view regarding mobility protocols

Revise questions pre-implementation of the protocol

Collect feedback from peers regarding early mobility

Implement protocol at unit
Collect data using different strategies
 Meeting with unit manager
CLRT research with HillRom representative
Unit data collection

Analyze data collected

Divide data into subgroups
Meetings with respiratory therapy and infection control

Design CLRT protocol

Create comparative graphs and tables
Provide protocol to management for review and approval

Implementation of CLRT protocol in the unit

Assist management with education during unit meetings and huddles
 Adult Respiratory Distress
Syndrome (ARDS)

o Lung injury arising from from different etiologies all having the
same characteristics of
o Bilateral diffuse infiltrates on X-Ray
o Hypoxemia
o Non-cardiogenic pulmonary edema
o Low lung compliance
o PF ratio <100 mmHg (signifies lung compliance and degree of
hypoxemia)

o Main causes seen at UMC include; sepsis, aspiration pneumonia,

major trauma , mass transfusion and narcotics.
 Treatment

o Treat the underlying cause

o Aspiration, pneumonia, shock

o Aggressive Mechanical Ventilation

o Bilevel ventilator setting ( high/low PEEP)

o Specialty beds
o Rotorest, Rotoprone, Progressa beds

o Nutritional support
 Hillrom Progressa Beds

o Progressa bed responds to evolving needs of caregivers and

critical patients.

o Has features that support early mobility and is intended to

prevent and treat pulmonary and/or other complications.

o CLRT and progressive upright mobility (PUM)

 Continuous Lateral Rotation
Therapy (CLRT)

o Goals of CLRT include

o maximize optimal pulmonary outcome
o Reduction of of critical care and hospital length of stay
o Decreases # of days on ventilator
o Reduces overall cost of treatment

o The goal is to initiate CLRT within 24 hours of identification of

patient for therapy
o In order for CLRT to be effective patient must be on for a
minimum of 18 hours/ day
Who is a Candidate for CLRT ?

o Patient should be assessed no greater than 48 hours after

being intubated
o FiO2 of 50% or greater for longer than 1 hour
o PEEP of 8 or higher
o P/F ratio less than 300
o Upon intubation
o A Predicus score of 5 or more
 Contraindications

o Exclusion Criteria for Early Mobility

o Hemodynamic Instability
o Cardiac arrest or active ischemia
o Spinal cord injury or trauma
o Post arrest hypothermia
o Open chest/abdomen
o Uncontrolled bleeding
o Critical airway
o Comfort care
o Unstable intracranial pressure (> 20 mmHg)
Total ICU Ventilators-2016

600
Jan-16
500 Febuary 2016
Mar-16
400 Apr-16
May-16
300 Jun-16
Jul-16
200
Aug-16
Sep-16
100
Oct-16
0 Nov-16
Total ICU Vent Days Dec-16
Total ICU Ventilators- 2017

700

600
Jan-17
500
Feb-17
400 Mar-17
Apr-17
300 May-17
200 Jun-17
Jul-17
100

0
 VAE Criteria

On or after calendar day 3 of mechanical ventilation and within 2 calendar days

before or after the onset of worsening oxygenation, the patient meets both of the
following criteria:
1) Temperature > 38 C or < 36C, OR white blood cell count 12,000
cells/mm3 or 4,000 cells/mm3. AND
2) A new antimicrobial agent(s)* is started, and is continued for 4 calendar
days.
 IVAC Criteria
On or after calendar day 3 of mechanical ventilation and within 2 calendar days
before or after the onset of worsening oxygenation, ONE of the follow- ing criteria
is met:
1) Purulent respiratory secretions (from one or more specimen collections)
Defined as secretions from the lungs, bronchi, or trachea that contain > 25
neutrophils and < 10 squamous epithelial cells per low power field [lpf, x100].
If the laboratory reports semi-quantitative results, those results must be
equivalent to the above quantitative thresholds.
2) Positive culture (qualitative, semi-quantitative or quantitative) of sputum*,
endotracheal aspirate*, bronchoalveolar lavage*, lung tissue, or protected specimen
brushing*
*Excludes the following:
Normalrespiratory/oralflora,mixedrespiratory/oralfloraor equivalent
Candida species or yeast not otherwise specified
Coagulase-negativeStaphylococcusspecies
Enterococcusspecies
 PVAC

There are three criteria that can be used to meet the PVAP definition:

oCriterion 1: Positive culture meeting specific quantitative or semi-quantitative

threshold (Table 3);

oCriterion 2: Purulent respiratory secretions AND identification of organisms

NOT meeting the quantitative or semi-quantitative thresholds specified in Table 3;

oCriterion 3: Organisms identified from pleural fluid specimen, positive lung

histopathology, and positive diagnostic test for Legionella species or selected
respiratory viruses.
 Trauma Patients- 2016

5
Ouarter 1
4
Ouarter 2
3 Quarter 3
Quarter 4
2

0
VAC IVAC PVAP
 Trauma Patients-2017

4
Quarter 1
3 Quarter 2
Quarter 3
2 Quarter 4

0
VAC IVAC PVAP
 Medicine Patients-2016

12

10

8
Quarter 1
6 Quarter 2
Quarter 3
4 Quarter 4

0
VAC IVAC PVAP
 Medicine Patients-2017

4
Quarter 1
3 Quarter 2
Quarter 3
2 Quarter 4

0
VAC IVAC PVAP
 Unit Compliance

o It is proven that patients that have been on CLRT function

for patient to have higher P/F ratios

o Lack of communication between nurses during report to

have patients on CLRT for at least 18/24 hours.

o Education of different bed functions and benefits for

patients
Title: Continuous Lateral Rotation (CLRT)
Patient Outcomes:
1. Patient will have decreased ventilator days.
2. Patient will have decreased incidence of respiratory complications.
3. Patient will not experience a decrease in level of deconditioning related to immobility.
Standards of Practice:
Assessment & Initiation of CLRT
1. Assess the patient for CLRT upon admission, then every shift, initiate CLRT if the
patient is immobile/has ineffective mobility, plus one or more of the following:
Lobar collapse/atelectasis or excessive secretions, and/or
PaO2/FiO2 ratio <300, and/or
Hemodynamic instability with manual turning.
2. Assess the patient for contraindications to CLRT such as activity restrictions due to:
Diagnosis or Condition e.g. spinal cord injury, unstable intracranial
pressure, etc.
Devices e.g. traction, ventriculostomy while draining, etc.
Therapies e.g. during CRRT, hemodialysis, etc.
Comfort Care
3. Obtain physician order for initiation of CLRT.
4. Document date and time of CLRT initiation and criteria met for CLRT in the nursing
notes.
Management of Care during CLRT
1. Implement the following goals for rotational therapy to ensure optimal pulmonary
outcomes:
Set % rotation to achieve one lung above the other (minimum 70%; ideal
100%).
Ensure patient is rotated a minimum 18 out of 24 hours.
Set pause times of 2 minutes each for left, center, and right.
Ensure rotation is not stopped for more than 45minutes at a time or a
maximum of 6 hours within 24 hours for procedures/interventions.
2. Assessvital signs, ECG,SpO2 for two complete rotations when (re)initiating therapy and
with every change in rotation parameters. Allow a 5 to 10-minute equilibration period
before determining hemodynamic instability after any position change
3. Assess patients tolerance to therapy and adjust plan of care to manage agitation,
intolerance, or desaturation as follows:
Educate and reassure patient
Increase pause times (first, before attempting to decrease rotation %)
Title: Continuous Lateral Rotation (CLRT)
Patient Outcomes:
1. Patient will have decreased ventilator days.
2. Patient will have decreased incidence of respiratory complications.
3. Patient will not experience a decrease in level of deconditioning related to immobility.
Standards of Practice:
Assessment & Initiation of CLRT
1. Assess the patient for CLRT upon admission, then every shift, initiate CLRT if the
patient is immobile/has ineffective mobility, plus one or more of the following:
Lobar collapse/atelectasis or excessive secretions, and/or
PaO2/FiO2 ratio <300, and/or
Hemodynamic instability with manual turning.
2. Assess the patient for contraindications to CLRT such as activity restrictions due to:
Diagnosis or Condition e.g. spinal cord injury, unstable intracranial
pressure, etc.
Devices e.g. traction, ventriculostomy while draining, etc.
Therapies e.g. during CRRT, hemodialysis, etc.
Comfort Care
3. Obtain physician order for initiation of CLRT.
4. Document date and time of CLRT initiation and criteria met for CLRT in the nursing
notes.
Management of Care during CLRT
1. Implement the following goals for rotational therapy to ensure optimal pulmonary
outcomes:
Set % rotation to achieve one lung above the other (minimum 70%; ideal
100%).
Ensure patient is rotated a minimum 18 out of 24 hours.
Set pause times of 2 minutes each for left, center, and right.
Ensure rotation is not stopped for more than 45minutes at a time or a
maximum of 6 hours within 24 hours for procedures/interventions.
2. Assessvital signs, ECG,SpO2 for two complete rotations when (re)initiating therapy and
with every change in rotation parameters. Allow a 5 to 10-minute equilibration period
before determining hemodynamic instability after any position change
3. Assess patients tolerance to therapy and adjust plan of care to manage agitation,
intolerance, or desaturation as follows:
Educate and reassure patient
Increase pause times (first, before attempting to decrease rotation %)
 Decrease % rotation or use Training mode for gradual increases
(increase rotation by 10% every hour).
Address sedation and pain needs
4. Obtain ABGs with patient in center position.
5. Assess skin every 2 hours by temporarily stopping lateral rotation. Inspect the posterior
surface and at-risk areas. If pressure relief is indicated, offload the sacrum or other
surfaces with positioning device (e.g. wedge) to allow for circulatory recovery. Remove
the positioning device prior to restarting therapy. Wedges are not to be used during
rotation.
6. Evaluate patient response to treatment and progress towards expected outcomes, every
shift, by assessing and documenting ABGs, P/F ratio, and improvement of deterioration
in pulmonary assessment.
7. Document when appropriate, in the nursing notes: Patient tolerance, adjustments to
therapy/interventions, rationale for any periods in which rotation was stopped more than
6 hours in 24 hours.
Discontinuation of CLRT
1. Evaluate every shift for discontinuation of CLRT and discontinue CLRT if any one
of the following 4 criteria is met:
Therapy goals have changed to comfort care only
Contraindication(s) have developed
Patient is transferring out of the ICU
Cardiopulmonary stability and mobility is evident by chest x-ray shows
improved/resolving infiltrates, P/F Ratio >300, hemodynamically
stable, improved secretion management, and/or patient turns self.
2. Document date and time CLRT discontinued, including the criteria met for
discontinuation.
3. Continue to assess for re-initiation of CLRT every shift.
References
Ahrens T, Kollef M, Stewart J, Shannon W. (2004). Effect of kinetic therapy on pulmonary
complications. American Journal of Critical Care, 4(13), 376-383.
Davis, K (2001). The acute effects of body position strategies and respiratory therapy in
paralyzed patients with acute lung in jury. Critical Care, 5, 81-87.
Goldhill, DR (2007). Rotational bed therapy to prevent and treat respiratory complications: A
review and meta-analysis. American Journal of Critical Care, 16(1), 50-61.
Kirschenbaum, L. et al. (2002). Effect of continuous lateral rotational therapy on the prevalence
of ventilator-associated pneumonia in patients requiring long-term ventilatory care. Critical Care
Medicine, 30(9), 1983-1986.
Pierce, L. (2007). Lung expansion, positioning, and secretion clearance in Management of the
Mechanically Ventilated Patient. Philadelphia: Elsevier Saunders, pp. 140-180.
Vollman, K (2005). Progressive mobility guidelines for critically ill patients. Website: Kathleen
Vollman Advancing Nursing. Retrieved from http://www.vollman.com/pdf/SugGdlns.pdf.
Swadener-Culpepper, L. (2004, September). Continuous lateral rotation therapy (CLRT):
Development and implementation of an effective protocol for the ICU. Medical Center of
Central Georgia, Macon, GA.
 Sources
AhrensT, Kollef M, Stewart J, Shannon W. (2004). Effect of kinetic therapy on
pulmonary complications. American Journal of Critical Care, 4(13), 376-383.
Davis, K (2001). The acute effects of body position strategies and respiratory
therapy in paralyzed patients with acute lung in jury. Critical Care, 5, 81-87.
Goldhill, DR (2007). Rotational bed therapy to prevent and treat respiratory
complications: A review and meta-analysis. American Journal of Critical Care, 16(1),
50-61.
Kirschenbaum, L. et al. (2002). Effect of continuous lateral rotational therapy on
the prevalence of ventilator-associated pneumonia in patients requiring long-term
ventilatory care. Critical Care Medicine, 30(9), 1983-1986.
Pierce, L. (2007). Lung expansion, positioning, and secretion clearance in
Management of the Mechanically Ventilated Patient. Philadelphia: Elsevier
Saunders, pp. 140-180.
CDC (2017) Ventilator-associated event (VAE). Device-associated module VAE.
Retrieved from https://www.cdc.gov/nhsn/pdfs/pscmanual/10-vae_final.pdf
Vollman, K (2005). Progressive mobility guidelines for critically ill patients.
Website: Kathleen Vollman Advancing Nursing. Retrieved from
http://www.vollman.com/pdf/SugGdlns.pdf.
Swadener-Culpepper, L. (2004, September). Continuous lateral rotation therapy
(CLRT): Development and implementation of an effective protocol for the ICU.
Medical Center of CentralGeorgia, Macon, GA.