Critical Care Plus: Special Beds: Boon to Patients or High-Profit Boondoggle?

Continuous rotation appears beneficial, but it’s certainly not cheap

Several medical manufacturers have made huge amounts of money by renting or selling specialized beds that provide continuous lateral rotation therapy (CLRT) to prevent complications of immobility associated with bed rest such as atelectasis, lower respiratory tract infection, and pneumonia. Manufacturers say these beds improve outcomes in critically ill patients and their claims appear to be substantiated by research to some degree.

Using former ICU nurses in their marketing force has undoubtedly helped companies convince ICU nursing staffs that critically ill patients need these special and expensive beds. Paula Jurewicz, RN, MS, Nurse Manager for the Intensive Care Unit at Yale-New Haven Hospital, acknowledges that ICU nurses were indeed the driving force behind the hospital’s purchase of 96 TotalCare SpO2RT™ Pulmonary Therapy System beds earlier this year. The beds, manufactured by Hill-Rom of Indiana, provide continuous lateral rotation therapy, feature percussion and vibration therapy and have a turn-assist feature that makes it easier for nursing staff to position patients for back care, linen changes, and routine nursing procedures.

Eighty-six of Yale—New Haven’s special beds are in the adult ICU, with the remaining 10 are on floors with pulmonary patients.

Jurewicz says the primary reason for the purchase was not advocacy by the nursing staff, but simply that the hospital’s ICU beds were old and needed to be replaced, "We knew we had to upgrade our beds and we wanted to reduce rental costs," Jurewicz says. "Sometimes we’ve had as many as 80 rental therapy beds on our floors at one time. "We felt by purchasing the Hill-Rom units we’d be reducing operating expenses by using a capital cost."

Expect to Pay Either Way

Buying special beds may indeed be more cost-effective in the long run than renting them, but the initial outlay is steep. The beds purchased by Yale-New Haven cost about $36,000 when fitted with the three modules that provide the various therapies. Hill-Rom declined to provide specific price information to anyone other than actual purchasers and a spokesperson said that hospitals belonging to a general purchasing group can get a better deal.

However, staff at Yale-New Haven, a 944-bed primary teaching hospital for the Yale University School of Medicine, appear pleased with the new equipment. Michael Parisi, PT, operations director for rehabilitation services and respiratory care, says he’s happy with the beds thus far. One of the biggest advantages Parisi sees is that the beds convert easily into chairs, making it much easier for patients to get to their feet.

"The nursing staff don’t have to have a special lifting team and can mobilize patients easily, and can fulfill physicians’ "out-of-bed" patient orders by pushing a button," Parisi says.

The Body of Evidence

Nancy Price, senior product manager of pulmonary and ICU therapy for special bed manufacturer Kinetic Concepts, Inc., in San Antonio, TX, says that the body of evidence supports her company’s claims that special beds improve outcomes. More than 50 studies have been done on rotational therapy, and most of these involved rotating the patient laterally to greater than 40°, the minimum angle defined by the CDC as necessary to achieve a positive pulmonary outcome, she says.

Price’s company manufactures a special bed originally developed in the mid-1960s by Francis Keane, MD, an Irish physician who liked to tinker and wanted to find a way to reduce patients’ pressure ulcers. Keane believed a very slow angular rotation redistributed pressure. Jim Liniger, an entrepreneurial emergency room physician now at Kinetic Concepts, became a distributor for Keane and later purchased the U.S. distribution rights for the product.

However, some research on rotational therapy raises questions about outcomes improvement between patients manually rotated and those on rotating beds. One study showed that nursing staff provided more respiratory care to patients who had pneumonia and were on the oscillating bed than they did to patients with pneumonia who received standard care.1

One possible explanation for the disparity in nursing attention is that the oscillating bed enabled patients to loosen mucus more frequently, which in turn required nurses to provide more suction to remove it.

Another study2 found that 22% of the 51 patients treated on the standard ICU bed acquired pneumonia as compared to only 6% of patients treated with continuous oscillation.

A study3 that used KCI therapy beds and prone positioning to test oxygenation and hemodynamics in patients with ARDS found both the beds and the prone positioning improved PaO2/FiO2 and intrapulmonary shunt fraction after patients received inhaled nitric oxide, and after the first 72 hours of positioning therapy.

Weighing the cost of CLRT against benefits to patient outcomes has also been studied.4 In one example that used Kinetic Concept beds, the authors found the cost of bed rental was offset by shortened ICU stay. Researchers suggested that patients who received CLRT for one to four days had decreased duration of both mechanical ventilation and ICU stay compared to patients on standard beds.

The researchers also reported that patients treated with CLRT needed fewer antibiotics and experienced much lower rates of lower respiratory infection. However, the study authors also said such results may not be generalizable to other patient populations and suggested that future studies stratify subjects by underlying disease or degree of dysfunction.

For more information, contact Paula Jurewicz at (203) 688-2406; Michael Parisi at (203) 688-2251; Nancy Price at (210) 255-6037; and Hill-Rom at (800) 445-3730.

References

1. Traver G, et al. Continuous oscillation: Outcome in critically ill patients. J Crit Care. 1995;10:97-103.

2. deBoisblanc BP, et al. Chest. 1993;103:1543-1547.

3. Staudinger T, et al. Crit Care Med. 2001;29(1):51-56.

4. Whiteman K, et al. Effects of continuous lateral rotation therapy on pulmonary complications. Am J Crit Care. 1995;4:133-139.