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          "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Device used for the measurement of the head-of-bed elevation and technique for the measurement of the backrest elevation &#40;Bosch<span class="elsevierStyleSup">&#174;</span> GLM 80&#41;&#46;</p>"
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HOBE significantly decreased the incidence of broncoaspiration when compared to supine position at 0&#176;&#46; Later&#44; a randomized controlled trial comparing backrest patients positioned at 45&#176; with patients positioned at 0&#176; found a 76&#37; decrease in VAP incidence in the 45&#176; group&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> On the one hand&#44; only these two randomized trials have prospectively demonstrated the effectiveness of HOBE at 45&#176; for VAP prevention&#46; On the other hand&#44; other studies with more realistic control groups&#44; such as HOBE of 25&#176; or 10&#176;&#44; did not find any significant differences in VAP incidence compared to the 45&#176; group&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;11</span></a> Regarding observational studies&#44; a multivariate logistic regression analysis showed that keeping patients on at least 30&#176; during the first 24<span class="elsevierStyleHsp" style=""></span>h of mechanical ventilation &#40;MV&#41; was independently associated with lower VAP incidence and mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Due to lack of conclusive evidence supporting HOBE&#44; the European Society of Intensive Care Medicine &#40;ESICM&#41; recommends elevating the head-of-bed from 20 to 45&#176;&#44; preferably &#62;30&#176;&#44; unless it interferes with patient care or wishes&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p><p id="par0200" class="elsevierStylePara elsevierViewall">However&#44; compliance is a factor that may limit the effectiveness of this recommendation&#46; In fact&#44; a common issue in all of the previously mentioned studies is low compliance<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;11</span></a> or even non-report of compliance&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#8211;9</span></a> For instance&#44; in the study performed by Van Nieuwenhoven et al&#46;&#44; the patients were positioned to 45&#176; or 10&#176; and compliance was monitored continuously&#46; The investigators found that the group at 45&#176; did not achieve this position for 85&#37; of the time&#44; being the median HOBE &#40;M-HOBE&#41; 28&#176;&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> Studies particularly focusing on compliance have found that M-HOBE ranges from 19&#46;2&#176; to 28&#176;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#8211;15</span></a> and that HOBE compliance is below the optimal value&#44; from 22&#46;3&#37; to 40&#46;9&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15&#8211;18</span></a></p><p id="par0205" class="elsevierStylePara elsevierViewall">Many strategies have been described that aim to increase compliance to HOBE&#44; such as training sessions&#44;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#44;19</span></a> devices to remind staff of the importance of the HOBE<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> and even considering HOBE a clinical monitoring parameter&#46;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21&#44;22</span></a> However&#44; maintaining patients positioned at 30&#8211;45&#176; still seems challenging&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">Some studies evaluated the main factors associated with low compliance and concluded that airway device type&#44; nursing shift&#44; nursing experience&#44; enteral nutrition&#44; weaning and haemodynamic status of the patients were factors associated with low compliance&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14&#44;15&#44;17&#44;18</span></a></p><p id="par0215" class="elsevierStylePara elsevierViewall">Most of the studies that evaluated HOBE compliance were performed during a 7-days period&#44; regardless of whether they evaluated or not the relationship between HOBE and VAP&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#44;13&#44;15&#44;18&#44;23</span></a> For the assessment of compliance during longer periods of time&#44; self-reported checklists may be regarded as an alternative as they might be easier to implement compared to direct observation&#46; Checklists have been demonstrated to be useful in improving adherence to patient&#39;s care<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> and might have an impact in patient outcomes&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> However&#44; the effectiveness of this measuring technique has not been yet evaluated for HOBE compliance&#46; The aim of the present study was to assess the real HOBE compliance in a 14-bed Intensive Care Unit &#40;ICU&#41;&#44; to compare direct-observation with self-reported compliance using a daily checklist &#40;checklist-reported&#41; and to identify the factors that might influence HOBE compliance&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Patients and methods</span><p id="par0035" class="elsevierStylePara elsevierViewall">A prospective&#44; observational study was performed in a 14-bed polyvalent ICU&#44; in a tertiary hospital&#46; Study was undertaken from January 2012 to March 2013&#44; during four time periods of one month in length each&#46; HOBE was recorded from all patients requiring MV with no absolute contraindications for HOBE&#46; Absolute contraindications for HOBE were pelvic fracture&#44; suspected or confirmed spinal injury and anti-Trendelemburg and prone positioning&#46; Study investigators registered HOBE three times daily &#40;once per nursing shift&#41;&#44; when the nurse was not in the patient room&#46; For each nursing shift there were two study investigators responsible for data collection&#46; The first evaluation period was over January 2012 &#91;&#40;Blinded period &#40;BP&#41;&#93;&#44; where HOBE was audited without the awareness of the nursing staff in order to minimize the Hawthorne effect&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> To achieve this blinding&#44; data were collected during the nurses&#8217; break time&#46; At the end of the BP&#44; an intervention was implemented to all the health care workers&#46; It consisted of presenting &#40;1&#41; the results of the BP evaluation&#44; mainly median-HOBE &#40;M-HOBE&#44; &#40;&#176;&#41; and HOBE compliance &#40;&#37;&#41;&#44; and &#40;2&#41; the research project and the rationale for implementing HOBE&#46; Afterwards&#44; HOBE evaluation was continued using the methodology described above for another month &#91;period 1 &#40;P1&#41;&#93;&#46; The follow-up observations were performed six and 12 months after BP&#44; corresponding to P2 and P3 respectively&#46;</p><p id="par0220" class="elsevierStylePara elsevierViewall">Variables recorded for each measurement were&#58; degrees of HOBE&#44; airway device type &#40;endotracheal tube &#40;ET&#41; or tracheostomy&#41;&#44; type of bed &#40;with or without HOBE measuring device&#41;&#44; day of the week &#40;weekday or weekend&#41;&#44; nursing shift &#40;day&#44; evening or night&#41; and checklist-reported compliance&#46; The ICU has two types of beds&#44; 7 beds with HOBE measuring device &#40;Hill-Room Total Care<span class="elsevierStyleSup">&#174;</span>&#41; and 7 beds without the device&#46; The device available to measure the HOBE consists of a protractor with a small sphere inside&#46; This bed has no alarm but the angle of elevation can be monitored continuously in an approximate manner&#46;</p><p id="par0225" class="elsevierStylePara elsevierViewall">Direct-observation compliance was defined as HOBE between 30&#46;0&#176; and 45&#46;0&#176;&#46; Data were collected as observations rather than as individual patients&#46;</p><p id="par0230" class="elsevierStylePara elsevierViewall">The study investigators measured HOBE when patients were not undergoing clinical procedures in order to avoid position changes that may affect reliability of the data&#46; HOBE was assessed at the mattress&#8217; base of the bed&#44; always using the same device &#40;BOSCH GLM80<span class="elsevierStyleSup">&#174;</span>&#41; regardless of bed type &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; All the study investigators were properly trained by the principal investigator&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0235" class="elsevierStylePara elsevierViewall">For comparing direct-observation with self-reported compliance&#44; a checklist that included several VAP preventive measures was used&#44; including HOBE between 30&#46;0&#176; and 45&#46;0&#176;&#46; In the study unit&#44; this checklist has been used routinely during three years before the onset of the study&#44; and consists of 5 evidence-based interventions for VAP prevention&#44; including HOBE&#46; This checklist was completed at the end of every working shift&#46; For each marked item&#44; it was assumed that the intervention had been performed during the whole time period&#46; In the present study&#44; checklist-reported compliance was defined as whether or not the nurse marked in the checklist the accomplishment of HOBE recommendation during her working shift&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Ethical considerations</span><p id="par0060" class="elsevierStylePara elsevierViewall">The study was designed according to the ethical standards stated in the Helsinki Declaration and following the good clinical practices and it was approved by the local ethics committee&#46; The informed consent was waived for all study subjects&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Data analysis</span><p id="par0065" class="elsevierStylePara elsevierViewall">Statistical analysis was performed using SPSS v15 for Windows &#40;SPSS Inc&#46;&#44; Chicago&#44; USA&#41;&#46; Results are expressed as absolute and relative frequencies for categorical variables and as medians with percentiles 25&#8211;75 &#40;IQR 25&#8211;75&#41; for continuous variables&#46; U-Mann Whitney test was used for non-normally distributed variables&#44; and Chi-square test was used for categorical variables&#46; ANOVA analysis was performed to compare HOBE compliance across the four periods&#46; A multivariate logistic regression model was developed in order to identify the factors independently associated with HOBE compliance&#46; The variables were included in the multivariate analysis if they were significant in the univariate analysis &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46; The logistic regression models were assessed for goodness of fit using the method of Hosmer and Lemeshow&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> The significance level for all the analyses was defined as <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#46;</p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Results</span><p id="par0070" class="elsevierStylePara elsevierViewall">From a total of 3254 possible observations&#44; 2639 observations were obtained &#40;81&#46;1&#37;&#41;&#46; Of these&#44; 557 were obtained during BP&#44; 773 during P1&#44; 590 during P2 and 719 during P3 &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; The remaining 18&#46;9&#37; observations were not obtained due to absence of study investigators or too high workload during some shifts&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0240" class="elsevierStylePara elsevierViewall">Overall compliance was 24&#46;0&#37; with a M-HOBE of 24&#46;0&#176; &#40;IQR 18&#46;8&#8211;30&#46;0&#41;&#46; During the BP&#44; M-HOBE was 21&#46;1&#176; &#40;IQR 16&#46;3&#176;&#8211;25&#46;4&#176;&#41; with a compliance of 13&#46;8&#37;&#46; During P1 M-HOBE increased to 24&#46;3&#176; &#40;IQR 18&#46;8&#176;&#8211;30&#46;2&#176;&#41; &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#44; with a compliance of 25&#46;5&#37; &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; During P2 M-HOBE was 24&#46;4&#176; &#40;IQR 18&#46;9&#176;&#8211;29&#46;6&#176;&#41; and compliance was 22&#46;7&#37;&#46; Finally&#44; during P3 M-HOBE was 26&#46;7&#176; &#40;IQR 21&#46;3&#176;&#8211;32&#46;6&#176;&#41; with a compliance of 31&#46;4&#37;&#46;</p><p id="par0245" class="elsevierStylePara elsevierViewall">When comparing BP&#44; P1&#44; P2 and P3&#44; significant differences were found among periods for M-HOBE and HOBE compliance&#44; except for P1 versus P2&#46; ANOVA showed statistical significance when comparing M-HOBE across the study periods &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> and <a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0250" class="elsevierStylePara elsevierViewall">When comparing HOBE compliance by direct-observation with self-reported compliance using the checklist&#44; 50&#8211;60&#37; differences were observed&#46; Checklist-reported compliance was 89&#46;2&#37; &#40;BP&#41;&#44; 86&#46;0&#37; &#40;P1&#41;&#44; 86&#46;4&#37; &#40;P2&#41; and 90&#46;7&#37; &#40;P3&#41; while direct-observation compliance was 13&#46;8&#37;&#44; 25&#46;5&#37;&#44; 22&#46;7&#37; and 31&#46;4&#37; respectively &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46;</p><p id="par0255" class="elsevierStylePara elsevierViewall">Factors associated with an increased HOBE compliance differed depending on the periods in the bivariate analysis&#46; During BP only the shift had an influence on HOBE compliance&#44; being higher during night shift &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; During P2&#44; morning shift and presence of ET were associated with higher HOBE compliance &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46; During P3&#44; morning shift and bed without HOBE measuring device were associated with an increased HOBE compliance &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05 and <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001 respectively&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; When considering data as a whole&#44; bivariate analysis found that morning shift&#44; presence of ET and bed without HOBE measuring device were associated with an increased HOBE compliance &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46;</p><p id="par0260" class="elsevierStylePara elsevierViewall">Factors associated with an increase of M-HOBE also differed according to the different study periods&#46; Nursing shift was associated with increased M-HOBE&#44; although it changed through study periods &#40;night shift in BP&#44; and morning shift in P2 and P3&#41; &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#59; the presence of ET was associated with higher M-HOBE in all periods except P3 &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#59; the presence of bed without HOBE measuring device was associated with a higher M-HOBE in all periods except P2 &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; When considering data as a whole&#44; morning shift&#44; presence of ET and bed without HOBE measuring device were associated with higher M-HOBE &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46;</p><p id="par0265" class="elsevierStylePara elsevierViewall">The multivariate logistic regression model identified presence of tracheostomy &#40;OR 0&#46;69&#44; IC95&#37; &#40;0&#46;57&#8211;0&#46;85&#41; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#44; afternoon shift &#40;OR 0&#46;77 IC95&#37; &#40;0&#46;63&#8211;0&#46;94&#41; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;01&#41; and the presence of HOBE measuring device &#40;OR 0&#46;78 IC95&#37; &#40;0&#46;67&#8211;0&#46;94&#41; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;01&#41; as the factors independently associated with lower HOBE compliance &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Discussion</span><p id="par0105" class="elsevierStylePara elsevierViewall">The present study reports the evaluation of M-HOBE and HOBE compliance during the longest follow-up period in the literature&#46; Moreover&#44; it is the first study that compares direct-observation compliance with checklist-reported compliance&#46; As a summary&#44; compliance lower than 35&#37; was found during the study period&#44; as well as a very significant gap between checklist-reported and direct observation compliance&#46; Moreover&#44; the presence of beds with a HOBE measuring device was not associated to higher compliances&#46;</p><p id="par0270" class="elsevierStylePara elsevierViewall">Our results are in accordance with others reported in the literature that have found a range of M-HOBE of 19&#46;2&#176;&#8211;28&#176;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#8211;15</span></a> as well as low compliances &#40;&#60;40&#37;&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15&#8211;18</span></a> Importantly&#44; we found an improvement of HOBE compliance and M-HOBE after an educational intervention&#44; which was statistically significant and was maintained over time&#46; Similar improvements have been reported in other studies with shorter follow-up times&#46; However&#44; in most of them results were not sustained over time&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#44;19&#44;22&#44;23</span></a></p><p id="par0275" class="elsevierStylePara elsevierViewall">Regarding checklist-reported and direct-observation compliance&#44; we found a 50&#8211;60&#37; difference&#44; which was an unexpected finding&#46; Since HOBE compliance was introduced as a part of the checklist 3 years before the study was performed&#44; this self-reporting tool had been routinely used in every shift by the nursing staff of the study unit&#46; Checklists implementation has been proven to be useful for avoiding human errors and improving patients&#8217; outcomes and safety&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">25&#44;28</span></a> However&#44; checklists used for prolonged periods of time may turn them into a routine tool&#44; failing in its intended purpose&#46; Investigators hypothesize that this may have happened in this study&#46; Published findings regarding hand hygiene compliance found similar results when comparing compliance estimation methods&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> They reported that self-reported compliance and self-administered checklists importantly overestimated hand hygiene compliance&#44; which also happened in our study&#46; For this reason&#44; we believe that checklists are not the optimal method for improving compliance of measures that have to be implemented continuously such as HOBE&#44; and we would recommend complementing them with random audits and feedback of the results to the clinical staff in order to encourage compliance optimization&#46;</p><p id="par0280" class="elsevierStylePara elsevierViewall">When analysing HOBE compliance and M-HOBE&#44; we found that the presence of ET was associated with an increase in M-HOBE and HOBE compliance&#44; which is in accordance with other studies&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> Variations in sickness severity along ICU stay may explain this finding&#46; Tracheostomy is normally performed after a prolonged period of MV&#44; once vital signs are stable&#46; Stabilization may lead to prioritization of nursing attention to other areas of patient care other than backrest position measurement&#44; such as patient&#39;s comfort or weaning&#46;</p><p id="par0285" class="elsevierStylePara elsevierViewall">We also found an influence of nursing shifts in M-HOBE and HOBE compliance&#44; although it differed from period to period&#46; During BP and P1&#44; the night shift exhibited the highest M-HOBE&#44; while morning shift was the highest during P2 and P3&#46; We attribute this finding to a new protocol that has been implemented in our unit for improving patient&#39;s safety that includes HOBE compliance evaluation&#46; The protocol is only performed during the morning shift and started after P1&#59; hence we believe that this might have influenced the increase in HOBE compliance and M-HOBE during morning shifts observed in P2 and P3&#46;</p><p id="par0290" class="elsevierStylePara elsevierViewall">Surprisingly&#44; and contrary to the existing evidence&#44;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">23&#44;30</span></a> we found that patients in beds without a HOBE measuring device had higher backrest elevation than the ones lying on beds with HOBE measuring device&#46; Moreover&#44; absence of HOBE measuring device was independently associated with HOBE compliance in the multivariate logistic regression analysis&#46; When confronted with these results&#44; staff nurses pointed out that visual perception of the beds with the device was somehow higher compared to the ones without it&#46; Multiple explanations might have contributed to this observation bias&#44; such as the pillow&#44; the mattress type&#44; obesity or abdominal perimeter&#59; however&#44; most of them are beyond the investigators control&#46;</p><p id="par0295" class="elsevierStylePara elsevierViewall">We expected to find lower HOBE compliance during weekends compared to weekdays&#46; Frequently&#44; higher percentages of unexperienced nurses work during weekends&#44; and Vinagre et al&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> reported that experience has an impact on HOBE compliance&#46; However&#44; we did not find significant differences in HOBE compliance between weekdays and weekends&#44; but it is unknown whether differences in experience were present across these two periods&#44; as experience was not recorded during the present study&#46;</p><p id="par0300" class="elsevierStylePara elsevierViewall">We acknowledge that our study has several limitations&#46; We included observations rather than patients&#59; therefore we could not assess the impact of HOBE in VAP prevention&#46; The compliance of the HOBE could be overestimated due to the punctual observation of the HOBE as has been demonstrated by Wolken et al&#46; rather than continuous evaluation&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> Moreover&#44; the number of variables studied was limited&#44; and 18&#46;9&#37; of the measures could not be recorded unfortunately due to the lack&#47;unavailability of study investigators during certain periods&#46; Variables related to the nurse responsible for the patient&#44; such as reasons for not following HOBE recommendations&#44; could not be obtained due to the blinded fashion of the study&#46; The blinded fashion also limited very importantly the number of variables that could be evaluated&#44; as data collection was quick for not raising nurse&#39;s awareness&#46; Moreover&#44; this study is a single centre study&#44; what limits the representativeness of the results&#46; However&#44; among our strengths we include the blinded observation to clinical staff&#44; the comparison between checklist-reported compliance and direct-observation compliance and the one-year period follow-up&#46;</p><p id="par0305" class="elsevierStylePara elsevierViewall">According to our results&#44; HOBE compliance is below optimal values and the use of checklist does not reflect the reality&#46; Regarding risk factors for non-compliance&#44; extra efforts are required in the nursing management of tracheostomized patients and in the correct HOBE visual perception by the nurse&#46; The nursing shift should be also considered as an influencing factor and further analyzed to avoid differences in HOBE compliance&#46;</p><p id="par0310" class="elsevierStylePara elsevierViewall">In conclusion&#44; we found an increase in M-HOBE and HOBE compliance after a formative session that remained for a year of follow-up&#46; Checklist-reported compliance is not a good indicator for the evaluation of the HOBE compliance and is associated with important overestimation&#46; Patients with ET had higher backrest elevation and HOBE compliance&#46; The presence of beds with a HOBE measuring device was associated with neither an increased compliance nor M-HOBE&#46; Nursing shift also had an influence in the HOBE compliance and M-HOBE but it changed over the time&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Authorship</span><p id="par0315" class="elsevierStylePara elsevierViewall">All the authors have contributed actively in the data collection and have critically reviewed and approved the manuscript&#44; Maria Jim&#233;nez and Alejandro Rodriguez have contributed to the data analysis&#44; and Mireia Llaurado has participated in all the procedures&#44; analysis and manuscript writing&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Financial support and previous diffusion of the results</span><p id="par0320" class="elsevierStylePara elsevierViewall">Presented partially in the &#8220;Annual National Congress of the Spanish Society of Intensive and Critical Care Nursing&#8221;&#44; 2013 and &#8220;Annual Congress of the European Society of Intensive Care Medicine&#8221;&#44; 2013&#46;</p><p id="par0325" class="elsevierStylePara elsevierViewall">Partially funded by the Research grant &#8220;<span class="elsevierStyleGrantSponsor" id="gs1">Premio H&#46;U&#46; Marqu&#233;s de Valdecilla&#44; de investigaci&#243;n en enfermer&#237;a</span>&#8221;&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Conflicts of interest</span><p id="par0155" class="elsevierStylePara elsevierViewall">All the authors declare to have no conflicts of interest with the present manuscript&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objectives</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To evaluate head-of-bed elevation &#40;HOBE&#41; compliance in mechanically ventilated &#40;MV&#41; patients during different time periods&#44; in order to identify factors that may influence compliance and to compare direct-observation compliance with checklist-reported compliance&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Design and setting</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A prospective observational study was carried out in a polyvalent Intensive Care Unit&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Patients</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">All consecutive patients with MV and no contraindication for semi-recumbency were studied&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Intervention and variables</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">HOBE was observed during four periods of one month each for one year&#44; the first period being blinded&#46; HOBE was measured with an electronic device three times daily&#46; Main variables were HOBE&#44; type of airway device&#44; type of bed&#44; nursing shift&#44; day of the week and checklist-reported compliance&#46; No patient characteristics were collected&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Results</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">During the four periods&#44; 2639 observations were collected&#46; Global HOBE compliance was 24&#46;0&#37;&#44; and the median angle head-of-bed elevation &#40;M-HOBE&#41; was 24&#46;0&#176; &#40;IQR 18&#46;8&#8211;30&#46;0&#41;&#46; HOBE compliance and M-HOBE by periods were as follows&#58; blinded period&#58; 13&#46;8&#37; and 21&#46;1&#176; &#40;IQR 16&#46;3&#8211;24&#46;4&#41;&#59; period 1&#58; 25&#46;5&#37; and 24&#46;3&#176; &#40;IQR 18&#46;8&#8211;30&#46;2&#41;&#59; period 2&#58; 22&#46;7&#37; and 24&#46;4&#176; &#40;IQR 18&#46;9&#8211;29&#46;6&#41;&#59; and period 3&#58; 31&#46;4&#37; and 26&#46;7&#176; &#40;IQR 21&#46;3&#8211;32&#46;6&#41; &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; An overestimation of 50&#8211;60&#37; was found when comparing self-reported compliance using a checklist versus direct-observation compliance &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46;</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Multivariate logistic regression analysis found the presence of an endotracheal tube &#40;ET&#41; and bed without HOBE measuring device to be independently associated to greater compliance &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Conclusions</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Although compliance increased significantly during the study period&#44; it was still not optimal&#46; Checklist-reported compliance significantly overestimated HOBE compliance&#46; The presence of an ET and a bed without HOBE measuring device was associated to greater compliance&#46;</p></span>"
        "secciones" => array:6 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Objectives"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Design and setting"
          ]
          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Patients"
          ]
          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Intervention and variables"
          ]
          4 => array:2 [
            "identificador" => "abst0025"
            "titulo" => "Results"
          ]
          5 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "Conclusions"
          ]
        ]
      ]
      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Objetivos</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Evaluar el cumplimiento de la elevaci&#243;n de la cabecera de la cama &#40;ECC&#41; en pacientes atendidos con ventilaci&#243;n mec&#225;nica &#40;MV&#41; durante distintos periodos de tiempo con el fin de identificar los factores que pueden influir sobre el cumplimiento y comparar el cumplimiento evaluado mediante observaci&#243;n directa con el cumplimiento evaluado mediante lista de verificaci&#243;n&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Dise&#241;o y &#225;mbito</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Se llev&#243; a cabo un estudio observacional y prospectivo en una unidad de cuidados intensivos polivalente&#46;</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Pacientes</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Se estudi&#243; a todos los pacientes consecutivos atendidos con MV y en los que no estaba contraindicada la reclinaci&#243;n parcial&#46;</p></span> <span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Intervenci&#243;n y variables</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Se observ&#243; la ECC durante 4 periodos de un mes a lo largo de un a&#241;o&#44; el primero de ellos con enmascaramiento&#46; Se midi&#243; la ECC mediante un dispositivo electr&#243;nico 3 veces al d&#237;a&#46; Las variables principales fueron ECC&#44; tipo de dispositivo para las v&#237;as respiratorias&#44; tipo de cama&#44; turno de enfermer&#237;a&#44; d&#237;a de la semana y cumplimiento notificado mediante lista de verificaci&#243;n&#46; No se recopilaron las caracter&#237;sticas de los pacientes&#46;</p></span> <span id="abst0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Resultados</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Se recopilaron 2&#46;639 observaciones durante los 4 periodos&#46; La tasa global de cumplimiento con la ECC fue del 24&#46;0&#37;&#44; mientras que la mediana del &#225;ngulo de elevaci&#243;n de la cabecera de la cama &#40;M-ECC&#41; fue de 24&#46;0&#176; &#40;IQR 18&#46;8&#8211;30&#46;0&#41;&#46; El cumplimiento con la ECC y la M-ECC por cada periodo fue&#58; periodo con enmascaramiento&#58; 13&#46;8&#37; y 21&#46;1&#176; &#40;IQR 16&#46;3&#8211;24&#46;4&#41;&#59; periodo 1&#58; 25&#46;5&#37; y 24&#46;3&#176; &#40;IQR 18&#46;8&#8211;30&#46;2&#41;&#59; periodo 2&#58; 22&#46;7&#37; y 24&#46;4&#176; &#40;IQR 18&#46;9&#8211;29&#46;6&#41;&#59; y periodo 3&#58; 31&#46;4&#37; y 26&#46;7&#176; &#40;IQR 21&#46;3&#8211;32&#46;6&#41; &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; Se observ&#243; una sobreestimaci&#243;n del 50&#8211;60&#37; al comparar el cumplimiento autoevaluado por medio de una lista de verificaci&#243;n frente al cumplimiento evaluado mediante observaci&#243;n directa &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46;</p><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Un an&#225;lisis de regresi&#243;n log&#237;stica multivariante concluy&#243; que la presencia de un tubo endotraqueal &#40;TE&#41; y de una cama sin dispositivo de medici&#243;n de ECC se asociaban de manera independiente a un mayor cumplimiento &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46;</p></span> <span id="abst0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Conclusiones</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Si bien el cumplimiento aument&#243; de manera significativa durante el periodo del estudio&#44; segu&#237;a sin ser el &#243;ptimo&#46; El cumplimiento evaluado mediante lista de verificaci&#243;n sobreestim&#243; de manera significativa el cumplimiento de la ECC&#46; La presencia de un TE y una cama sin dispositivo de medici&#243;n de ECC se asociaba a un mayor cumplimiento&#46;</p></span>"
        "secciones" => array:6 [
          0 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Objetivos"
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          1 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Dise&#241;o y &#225;mbito"
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          2 => array:2 [
            "identificador" => "abst0045"
            "titulo" => "Pacientes"
          ]
          3 => array:2 [
            "identificador" => "abst0050"
            "titulo" => "Intervenci&#243;n y variables"
          ]
          4 => array:2 [
            "identificador" => "abst0055"
            "titulo" => "Resultados"
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          5 => array:2 [
            "identificador" => "abst0060"
            "titulo" => "Conclusiones"
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        "etiqueta" => "&#9674;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please see Appendix for list of the CAPCRI study investigators&#46;</p>"
        "identificador" => "fn1"
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    "apendice" => array:1 [
      0 => array:1 [
        "seccion" => array:1 [
          0 => array:4 [
            "apendice" => "<p id="par0190" class="elsevierStylePara elsevierViewall">Mireia Llaurad&#243;-Serra&#59; Rosa G&#252;ell-Bar&#243;&#59; Barbara Coloma-G&#243;mez&#59; Luz Mar&#237;a Vallejo-Henao&#59; Soledad Molina-Ramos&#59; Laura Bordonado-P&#233;rez&#59; Maria Luisa Fortes-Del Valle&#59; Margarita Peralvo-Bernat&#59; Judith Marin&#233;-Vidal&#59; Yolanda Alabart-Segura&#59; Sonia Hidalgo-Margalef&#59; Carmen Portal-Porcel&#59; Xavier Alabart-Lorenzo&#59; Ascensi&#243;n L&#243;pez-Gil&#46;</p>"
            "etiqueta" => "Appendix A"
            "titulo" => "List of the CAPCRI study investigators"
            "identificador" => "sec0045"
          ]
        ]
      ]
    ]
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          "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Device used for the measurement of the head-of-bed elevation and technique for the measurement of the backrest elevation &#40;Bosch<span class="elsevierStyleSup">&#174;</span> GLM 80&#41;&#46;</p>"
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      1 => array:7 [
        "identificador" => "fig0010"
        "etiqueta" => "Figure 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
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        "descripcion" => array:1 [
          "en" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Diagram of the study sample&#46;</p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "fig0015"
        "etiqueta" => "Figure 3"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
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        "descripcion" => array:1 [
          "en" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Head-of-bed elevation compliance according to the different variables evaluated over the periods&#46;</p>"
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      3 => array:7 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
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          "leyenda" => "<p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">Each symbol represents the M-HOBE of each period where significant differences were found compared to another one&#46;<span class="elsevierStyleSup">&#945;</span>vs<span class="elsevierStyleSup">&#945;&#945;</span><span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#44; <span class="elsevierStyleSup">&#945;</span>vs<span class="elsevierStyleSup">&#945;&#945;&#945;</span><span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#44; <span class="elsevierStyleSup">&#945;</span>vs<span class="elsevierStyleSup">&#945;&#945;&#945;&#945;</span><span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#44; &#42;vs&#42;&#42;&#42; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#44; &#42;&#42;vs&#42;&#42;&#42; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#47;<span class="elsevierStyleSup">&#43;</span>vs<span class="elsevierStyleSup">&#43;&#43;</span><span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#47;<span class="elsevierStyleSup">&#161;</span>vs<span class="elsevierStyleSup">&#161;&#161;</span><span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#47;<span class="elsevierStyleSup">&#191;</span>vs<span class="elsevierStyleSup">&#191;&#191;</span><span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#47;<span class="elsevierStyleSup">&#36;</span>vs<span class="elsevierStyleSup">&#36;&#36;</span><span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#47;<span class="elsevierStyleSup">&#35;</span>vs<span class="elsevierStyleSup">&#35;&#35;</span><span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#44; <span class="elsevierStyleSup">&#35;</span>vs<span class="elsevierStyleSup">&#35;&#35;&#35;</span><span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#47;<span class="elsevierStyleSup">&#64;</span>vs<span class="elsevierStyleSup">&#64;&#64;</span><span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#47;<span class="elsevierStyleSup">&#38;</span>vs<span class="elsevierStyleSup">&#38;&#38;</span><span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#47;<span class="elsevierStyleSup">&#8364;</span>vs<span class="elsevierStyleSup">&#8364;&#8364;</span><span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#46; The rest of the comparisons were not significant&#46; M-HOBE<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>median of head-of-bed elevation&#59; IQR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>interquartile range&#46;</p>"
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Baseline period &#91;median &#40;IQR 25&#8211;75&#41;&#93;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>557&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Period 1 &#91;median &#40;IQR 25&#8211;75&#41;&#93;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>773&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Period 2 &#91;median &#40;IQR 25&#8211;75&#41;&#93;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>590&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Period 3 &#91;median &#40;IQR 25&#8211;75&#41;&#93;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>719&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleItalic">Overall</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">21&#46;1&#176; &#40;16&#46;3&#8211;25&#46;4&#41;<span class="elsevierStyleSup">&#945;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">24&#46;3&#176; &#40;18&#46;8&#8211;30&#46;2&#41;<span class="elsevierStyleSup">&#945;&#945;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">24&#46;4&#176; &#40;18&#46;9&#8211;29&#46;6&#41; <span class="elsevierStyleSup">&#945;&#945;&#945;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">26&#46;7&#176; &#40;21&#46;3&#8211;32&#46;6&#41; <span class="elsevierStyleSup">&#945;&#945;&#945;&#945;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleItalic">Working shift</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Morning&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">24&#46;7 &#40;19&#46;1&#8211;30&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">27&#46;7 &#40;22&#46;4&#8211;33&#46;8&#41;<span class="elsevierStyleSup">&#38;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Evening&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">20&#46;6&#176; &#40;16&#46;8&#8211;23&#46;7&#41;&#42;&#42;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">24&#46;6 &#40;19&#46;1&#8211;30&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">26&#46;5 &#40;21&#46;4&#8211;32&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Night&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">22&#46;8 &#40;17&#46;0&#8211;30&#46;0&#41;&#42;&#42;&#42;&nbsp;\t\t\t\t\t\t\n
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          "identificador" => "bibs0005"
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            0 => array:3 [
              "identificador" => "bib0005"
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "Guidelines for the management of adults with hospital-acquired&#44; ventilator-associated&#44; and healthcare-associated pneumonia"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "American Thoracic S"
                            1 => "Infectious Diseases Society of A"
                          ]
                        ]
                      ]
                    ]
                  ]
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                    0 => array:2 [
                      "doi" => "10.1164/rccm.200405-644ST"
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                        "tituloSerie" => "Am J Respir Crit Care Med"
                        "fecha" => "2005"
                        "volumen" => "171"
                        "paginaInicial" => "388"
                        "paginaFinal" => "416"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15699079"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
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              "identificador" => "bib0010"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Evidence-based clinical practice guideline for the prevention of ventilator-associated pneumonia"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "P&#46; Dodek"
                            1 => "S&#46; Keenan"
                            2 => "D&#46; Cook"
                            3 => "D&#46; Heyland"
                            4 => "M&#46; Jacka"
                            5 => "L&#46; Hand"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Ann Intern Med"
                        "fecha" => "2004"
                        "volumen" => "141"
                        "paginaInicial" => "305"
                        "paginaFinal" => "313"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15313747"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0015"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Clinical practice guidelines for hospital-acquired pneumonia and ventilator-associated pneumonia in adults"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "C&#46; Rotstein"
                            1 => "G&#46; Evans"
                            2 => "A&#46; Born"
                            3 => "R&#46; Grossman"
                            4 => "R&#46;B&#46; Light"
                            5 => "S&#46; Magder"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Can J Infect Dis Med Microbiol"
                        "fecha" => "2008"
                        "volumen" => "19"
                        "paginaInicial" => "19"
                        "paginaFinal" => "53"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19145262"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
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              "identificador" => "bib0020"
              "etiqueta" => "4"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Indicadores de Calidad en el Enfermo Cr&#237;tico&#44; actualizaci&#243;n 2011"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "Sociedad Espa&#241;ola de Medicina Intensiva Cr&#237;tica y Unidades Coronarias"
                          ]
                        ]
                      ]
                    ]
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                    0 => array:1 [
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                        "fecha" => "2011"
                        "editorial" => "SEMICYUC"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib0025"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Guidelines for the prevention of ventilator-associated pneumonia and their implementation&#46; The Spanish &#8220;Zero-VAP&#8221; bundle"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "F&#46; &#193;lvarez Lerma"
                            1 => "M&#46; S&#225;nchez Garc&#237;a"
                            2 => "L&#46; Lorente"
                            3 => "F&#46; Gordo"
                            4 => "J&#46;M&#46; A&#241;&#243;n"
                            5 => "J&#46; &#193;lvarez"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.medin.2013.12.007"
                      "Revista" => array:6 [
                        "tituloSerie" => "Med Intensiva"
                        "fecha" => "2014"
                        "volumen" => "38"
                        "paginaInicial" => "226"
                        "paginaFinal" => "236"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24594437"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            5 => array:3 [
              "identificador" => "bib0030"
              "etiqueta" => "6"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Neumon&#237;a asociada a la ventilaci&#243;n mec&#225;nica"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "E&#46; D&#237;az"
                            1 => "L&#46; Lorente"
                            2 => "J&#46; Vall&#233;s"
                            3 => "J&#46; Rello"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.medin.2010.03.004"
                      "Revista" => array:6 [
                        "tituloSerie" => "Med Intensiva"
                        "fecha" => "2010"
                        "volumen" => "34"
                        "paginaInicial" => "318"
                        "paginaFinal" => "324"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20466456"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            6 => array:3 [
              "identificador" => "bib0035"
              "etiqueta" => "7"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Reducing the risk of ventilator-acquired pneumonia through head of bed elevation"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "L&#46; Keeley"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/j.1478-5153.2007.00247.x"
                      "Revista" => array:6 [
                        "tituloSerie" => "Nurs Crit Care"
                        "fecha" => "2007"
                        "volumen" => "12"
                        "paginaInicial" => "287"
                        "paginaFinal" => "294"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17983363"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            7 => array:3 [
              "identificador" => "bib0040"
              "etiqueta" => "8"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Ventilator-associated pneumonia&#46; A multivariate analysis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "M&#46;H&#46; Kollef"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "JAMA"
                        "fecha" => "1993"
                        "volumen" => "270"
                        "paginaInicial" => "1965"
                        "paginaFinal" => "1970"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8411554"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            8 => array:3 [
              "identificador" => "bib0045"
              "etiqueta" => "9"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Pulmonary aspiration of gastric contents in patients receiving mechanical ventilation&#58; the effect of body position"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "A&#46; Torres"
                            1 => "J&#46; Serra-Batlles"
                            2 => "E&#46; Ros"
                            3 => "C&#46; Piera"
                            4 => "J&#46; Puig de la Bellacasa"
                            5 => "A&#46; Cobos"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Ann Intern Med"
                        "fecha" => "1992"
                        "volumen" => "116"
                        "paginaInicial" => "540"
                        "paginaFinal" => "543"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/1543307"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            9 => array:3 [
              "identificador" => "bib0050"
              "etiqueta" => "10"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
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                            3 => "H&#46;C&#46; Joore"
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                        "paginaInicial" => "396"
                        "paginaFinal" => "402"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16424720"
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "An evidence-based recommendation on bed head elevation for mechanically ventilated patients"
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                          "colaboracion" => "Bed Head Elevation Study Group"
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                        "paginaInicial" => "R111"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21481251"
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "Quality improvement in backrest elevation&#58; improving outcomes in critical care"
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                        "paginaInicial" => "133"
                        "paginaFinal" => "139"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15876880"
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                    0 => array:2 [
                      "titulo" => "Predictors of backrest elevation in critical care"
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                            3 => "B&#46; Ashtiani"
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                    0 => array:1 [
                      "Revista" => array:6 [
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                        "paginaInicial" => "68"
                        "paginaFinal" => "74"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12706732"
                            "web" => "Medline"
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                0 => array:2 [
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                            3 => "R&#46; Parke"
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                  "host" => array:1 [
                    0 => array:2 [
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                        "paginaInicial" => "e100"
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                        "link" => array:1 [
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                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21041187"
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "Effect of standardized orders and provider education on head-of-bed positioning in mechanically ventilated patients"
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                        "paginaFinal" => "2290"
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                    0 => array:2 [
                      "titulo" => "Factors associated with low adherence to head-of-bed elevation during mechanical ventilation in Chinese intensive care units"
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                            5 => "S&#46;H&#46; Lin"
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                    0 => array:2 [
                      "titulo" => "Effects of staff training on the care of mechanically ventilated patients&#58; a prospective cohort study"
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                        "tituloSerie" => "Br J Anaesth"
                        "fecha" => "2009"
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                        "paginaInicial" => "232"
                        "paginaFinal" => "237"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19457893"
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "A novel method of continuous measurement of head of bed elevation in ventilated patients"
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                        "tituloSerie" => "Intensive Care Med"
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                        "paginaFinal" => "1054"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17393138"
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                    0 => array:2 [
                      "titulo" => "A nursing clinical decision support system and potential predictors of head-of-bed position for patients receiving mechanical ventilation"
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                        "tituloSerie" => "Am J Crit Care"
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                        "paginaInicial" => "39"
                        "paginaFinal" => "47"
                        "link" => array:1 [
                          0 => array:2 [
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                    0 => array:2 [
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                        "link" => array:1 [
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                      "titulo" => "A care bundle approach for prevention of ventilator-associated pneumonia"
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                0 => array:2 [
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                        "paginaFinal" => "686"
                        "link" => array:1 [
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                0 => array:2 [
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                0 => array:2 [
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Original
Evaluation of head-of-bed elevation compliance in critically ill patients under mechanical ventilation in a polyvalent intensive care unit
Evaluación del cumplimiento de la elevación de la cabecera de la cama en pacientes críticamente enfermos sometidos a ventilación mecánica en una unidad de cuidados intensivos polivalente
M. Llaurado-Serraa,b,c,
Autor para correspondencia
mireiallaurado@gmail.com

Corresponding author.
, M. Ulldemolinsd,e, R. Güell-Barób, B. Coloma-Gómezb,c, X. Alabart-Lorenzob, A. López-Gilb, M. Bodía,b,f, A. Rodrigueza,b,f, M.F. Jiménez-Herrerac, on behalf of the CAPCRI Study Investigators
a Institut d’investigació Sanitària Pere Virgili, Spain
b Intensive Care Unit, University Hospital Joan XXIII, Tarragona, Spain
c Nursing Department, Universitat Rovira i Virgili, Tarragona, Spain
d Critical Care Department, Sabadell Hospital, University Institute Parc Taulí – Universitat Autònoma de Barcelona (UAB), Sabadell Spain
e Fundació Clínic per la Recerca Biomèdica – Universitat de Barcelona (UB), Barcelona, Spain
f Medical school, Universitat Rovira i Virgili, Tarragona, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Background</span><p id="par0005" class="elsevierStylePara elsevierViewall">Semi-recumbent position is defined as head-of-bed elevation &#40;HOBE&#41; from 30 to 45&#176;&#44; and is recommended for the prevention of Ventilator-Associated Pneumonia &#40;VAP&#41; in all international guidelines&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;6</span></a> However&#44; despite the broad recommendation of the use of HOBE for the prevention of VAP&#44; evidence supporting this measure is limited&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#8211;10</span></a></p><p id="par0195" class="elsevierStylePara elsevierViewall">The first study supporting HOBE was published in 1992 by Torres et al&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> and reported that 45&#176; HOBE significantly decreased the incidence of broncoaspiration when compared to supine position at 0&#176;&#46; Later&#44; a randomized controlled trial comparing backrest patients positioned at 45&#176; with patients positioned at 0&#176; found a 76&#37; decrease in VAP incidence in the 45&#176; group&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> On the one hand&#44; only these two randomized trials have prospectively demonstrated the effectiveness of HOBE at 45&#176; for VAP prevention&#46; On the other hand&#44; other studies with more realistic control groups&#44; such as HOBE of 25&#176; or 10&#176;&#44; did not find any significant differences in VAP incidence compared to the 45&#176; group&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;11</span></a> Regarding observational studies&#44; a multivariate logistic regression analysis showed that keeping patients on at least 30&#176; during the first 24<span class="elsevierStyleHsp" style=""></span>h of mechanical ventilation &#40;MV&#41; was independently associated with lower VAP incidence and mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Due to lack of conclusive evidence supporting HOBE&#44; the European Society of Intensive Care Medicine &#40;ESICM&#41; recommends elevating the head-of-bed from 20 to 45&#176;&#44; preferably &#62;30&#176;&#44; unless it interferes with patient care or wishes&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p><p id="par0200" class="elsevierStylePara elsevierViewall">However&#44; compliance is a factor that may limit the effectiveness of this recommendation&#46; In fact&#44; a common issue in all of the previously mentioned studies is low compliance<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;11</span></a> or even non-report of compliance&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#8211;9</span></a> For instance&#44; in the study performed by Van Nieuwenhoven et al&#46;&#44; the patients were positioned to 45&#176; or 10&#176; and compliance was monitored continuously&#46; The investigators found that the group at 45&#176; did not achieve this position for 85&#37; of the time&#44; being the median HOBE &#40;M-HOBE&#41; 28&#176;&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> Studies particularly focusing on compliance have found that M-HOBE ranges from 19&#46;2&#176; to 28&#176;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#8211;15</span></a> and that HOBE compliance is below the optimal value&#44; from 22&#46;3&#37; to 40&#46;9&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15&#8211;18</span></a></p><p id="par0205" class="elsevierStylePara elsevierViewall">Many strategies have been described that aim to increase compliance to HOBE&#44; such as training sessions&#44;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#44;19</span></a> devices to remind staff of the importance of the HOBE<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> and even considering HOBE a clinical monitoring parameter&#46;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21&#44;22</span></a> However&#44; maintaining patients positioned at 30&#8211;45&#176; still seems challenging&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">Some studies evaluated the main factors associated with low compliance and concluded that airway device type&#44; nursing shift&#44; nursing experience&#44; enteral nutrition&#44; weaning and haemodynamic status of the patients were factors associated with low compliance&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14&#44;15&#44;17&#44;18</span></a></p><p id="par0215" class="elsevierStylePara elsevierViewall">Most of the studies that evaluated HOBE compliance were performed during a 7-days period&#44; regardless of whether they evaluated or not the relationship between HOBE and VAP&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#44;13&#44;15&#44;18&#44;23</span></a> For the assessment of compliance during longer periods of time&#44; self-reported checklists may be regarded as an alternative as they might be easier to implement compared to direct observation&#46; Checklists have been demonstrated to be useful in improving adherence to patient&#39;s care<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> and might have an impact in patient outcomes&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> However&#44; the effectiveness of this measuring technique has not been yet evaluated for HOBE compliance&#46; The aim of the present study was to assess the real HOBE compliance in a 14-bed Intensive Care Unit &#40;ICU&#41;&#44; to compare direct-observation with self-reported compliance using a daily checklist &#40;checklist-reported&#41; and to identify the factors that might influence HOBE compliance&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Patients and methods</span><p id="par0035" class="elsevierStylePara elsevierViewall">A prospective&#44; observational study was performed in a 14-bed polyvalent ICU&#44; in a tertiary hospital&#46; Study was undertaken from January 2012 to March 2013&#44; during four time periods of one month in length each&#46; HOBE was recorded from all patients requiring MV with no absolute contraindications for HOBE&#46; Absolute contraindications for HOBE were pelvic fracture&#44; suspected or confirmed spinal injury and anti-Trendelemburg and prone positioning&#46; Study investigators registered HOBE three times daily &#40;once per nursing shift&#41;&#44; when the nurse was not in the patient room&#46; For each nursing shift there were two study investigators responsible for data collection&#46; The first evaluation period was over January 2012 &#91;&#40;Blinded period &#40;BP&#41;&#93;&#44; where HOBE was audited without the awareness of the nursing staff in order to minimize the Hawthorne effect&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> To achieve this blinding&#44; data were collected during the nurses&#8217; break time&#46; At the end of the BP&#44; an intervention was implemented to all the health care workers&#46; It consisted of presenting &#40;1&#41; the results of the BP evaluation&#44; mainly median-HOBE &#40;M-HOBE&#44; &#40;&#176;&#41; and HOBE compliance &#40;&#37;&#41;&#44; and &#40;2&#41; the research project and the rationale for implementing HOBE&#46; Afterwards&#44; HOBE evaluation was continued using the methodology described above for another month &#91;period 1 &#40;P1&#41;&#93;&#46; The follow-up observations were performed six and 12 months after BP&#44; corresponding to P2 and P3 respectively&#46;</p><p id="par0220" class="elsevierStylePara elsevierViewall">Variables recorded for each measurement were&#58; degrees of HOBE&#44; airway device type &#40;endotracheal tube &#40;ET&#41; or tracheostomy&#41;&#44; type of bed &#40;with or without HOBE measuring device&#41;&#44; day of the week &#40;weekday or weekend&#41;&#44; nursing shift &#40;day&#44; evening or night&#41; and checklist-reported compliance&#46; The ICU has two types of beds&#44; 7 beds with HOBE measuring device &#40;Hill-Room Total Care<span class="elsevierStyleSup">&#174;</span>&#41; and 7 beds without the device&#46; The device available to measure the HOBE consists of a protractor with a small sphere inside&#46; This bed has no alarm but the angle of elevation can be monitored continuously in an approximate manner&#46;</p><p id="par0225" class="elsevierStylePara elsevierViewall">Direct-observation compliance was defined as HOBE between 30&#46;0&#176; and 45&#46;0&#176;&#46; Data were collected as observations rather than as individual patients&#46;</p><p id="par0230" class="elsevierStylePara elsevierViewall">The study investigators measured HOBE when patients were not undergoing clinical procedures in order to avoid position changes that may affect reliability of the data&#46; HOBE was assessed at the mattress&#8217; base of the bed&#44; always using the same device &#40;BOSCH GLM80<span class="elsevierStyleSup">&#174;</span>&#41; regardless of bed type &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; All the study investigators were properly trained by the principal investigator&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0235" class="elsevierStylePara elsevierViewall">For comparing direct-observation with self-reported compliance&#44; a checklist that included several VAP preventive measures was used&#44; including HOBE between 30&#46;0&#176; and 45&#46;0&#176;&#46; In the study unit&#44; this checklist has been used routinely during three years before the onset of the study&#44; and consists of 5 evidence-based interventions for VAP prevention&#44; including HOBE&#46; This checklist was completed at the end of every working shift&#46; For each marked item&#44; it was assumed that the intervention had been performed during the whole time period&#46; In the present study&#44; checklist-reported compliance was defined as whether or not the nurse marked in the checklist the accomplishment of HOBE recommendation during her working shift&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Ethical considerations</span><p id="par0060" class="elsevierStylePara elsevierViewall">The study was designed according to the ethical standards stated in the Helsinki Declaration and following the good clinical practices and it was approved by the local ethics committee&#46; The informed consent was waived for all study subjects&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Data analysis</span><p id="par0065" class="elsevierStylePara elsevierViewall">Statistical analysis was performed using SPSS v15 for Windows &#40;SPSS Inc&#46;&#44; Chicago&#44; USA&#41;&#46; Results are expressed as absolute and relative frequencies for categorical variables and as medians with percentiles 25&#8211;75 &#40;IQR 25&#8211;75&#41; for continuous variables&#46; U-Mann Whitney test was used for non-normally distributed variables&#44; and Chi-square test was used for categorical variables&#46; ANOVA analysis was performed to compare HOBE compliance across the four periods&#46; A multivariate logistic regression model was developed in order to identify the factors independently associated with HOBE compliance&#46; The variables were included in the multivariate analysis if they were significant in the univariate analysis &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46; The logistic regression models were assessed for goodness of fit using the method of Hosmer and Lemeshow&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> The significance level for all the analyses was defined as <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#46;</p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Results</span><p id="par0070" class="elsevierStylePara elsevierViewall">From a total of 3254 possible observations&#44; 2639 observations were obtained &#40;81&#46;1&#37;&#41;&#46; Of these&#44; 557 were obtained during BP&#44; 773 during P1&#44; 590 during P2 and 719 during P3 &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; The remaining 18&#46;9&#37; observations were not obtained due to absence of study investigators or too high workload during some shifts&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0240" class="elsevierStylePara elsevierViewall">Overall compliance was 24&#46;0&#37; with a M-HOBE of 24&#46;0&#176; &#40;IQR 18&#46;8&#8211;30&#46;0&#41;&#46; During the BP&#44; M-HOBE was 21&#46;1&#176; &#40;IQR 16&#46;3&#176;&#8211;25&#46;4&#176;&#41; with a compliance of 13&#46;8&#37;&#46; During P1 M-HOBE increased to 24&#46;3&#176; &#40;IQR 18&#46;8&#176;&#8211;30&#46;2&#176;&#41; &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#44; with a compliance of 25&#46;5&#37; &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; During P2 M-HOBE was 24&#46;4&#176; &#40;IQR 18&#46;9&#176;&#8211;29&#46;6&#176;&#41; and compliance was 22&#46;7&#37;&#46; Finally&#44; during P3 M-HOBE was 26&#46;7&#176; &#40;IQR 21&#46;3&#176;&#8211;32&#46;6&#176;&#41; with a compliance of 31&#46;4&#37;&#46;</p><p id="par0245" class="elsevierStylePara elsevierViewall">When comparing BP&#44; P1&#44; P2 and P3&#44; significant differences were found among periods for M-HOBE and HOBE compliance&#44; except for P1 versus P2&#46; ANOVA showed statistical significance when comparing M-HOBE across the study periods &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> and <a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0250" class="elsevierStylePara elsevierViewall">When comparing HOBE compliance by direct-observation with self-reported compliance using the checklist&#44; 50&#8211;60&#37; differences were observed&#46; Checklist-reported compliance was 89&#46;2&#37; &#40;BP&#41;&#44; 86&#46;0&#37; &#40;P1&#41;&#44; 86&#46;4&#37; &#40;P2&#41; and 90&#46;7&#37; &#40;P3&#41; while direct-observation compliance was 13&#46;8&#37;&#44; 25&#46;5&#37;&#44; 22&#46;7&#37; and 31&#46;4&#37; respectively &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46;</p><p id="par0255" class="elsevierStylePara elsevierViewall">Factors associated with an increased HOBE compliance differed depending on the periods in the bivariate analysis&#46; During BP only the shift had an influence on HOBE compliance&#44; being higher during night shift &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; During P2&#44; morning shift and presence of ET were associated with higher HOBE compliance &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46; During P3&#44; morning shift and bed without HOBE measuring device were associated with an increased HOBE compliance &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05 and <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001 respectively&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; When considering data as a whole&#44; bivariate analysis found that morning shift&#44; presence of ET and bed without HOBE measuring device were associated with an increased HOBE compliance &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46;</p><p id="par0260" class="elsevierStylePara elsevierViewall">Factors associated with an increase of M-HOBE also differed according to the different study periods&#46; Nursing shift was associated with increased M-HOBE&#44; although it changed through study periods &#40;night shift in BP&#44; and morning shift in P2 and P3&#41; &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#59; the presence of ET was associated with higher M-HOBE in all periods except P3 &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#59; the presence of bed without HOBE measuring device was associated with a higher M-HOBE in all periods except P2 &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; When considering data as a whole&#44; morning shift&#44; presence of ET and bed without HOBE measuring device were associated with higher M-HOBE &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46;</p><p id="par0265" class="elsevierStylePara elsevierViewall">The multivariate logistic regression model identified presence of tracheostomy &#40;OR 0&#46;69&#44; IC95&#37; &#40;0&#46;57&#8211;0&#46;85&#41; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#44; afternoon shift &#40;OR 0&#46;77 IC95&#37; &#40;0&#46;63&#8211;0&#46;94&#41; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;01&#41; and the presence of HOBE measuring device &#40;OR 0&#46;78 IC95&#37; &#40;0&#46;67&#8211;0&#46;94&#41; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;01&#41; as the factors independently associated with lower HOBE compliance &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Discussion</span><p id="par0105" class="elsevierStylePara elsevierViewall">The present study reports the evaluation of M-HOBE and HOBE compliance during the longest follow-up period in the literature&#46; Moreover&#44; it is the first study that compares direct-observation compliance with checklist-reported compliance&#46; As a summary&#44; compliance lower than 35&#37; was found during the study period&#44; as well as a very significant gap between checklist-reported and direct observation compliance&#46; Moreover&#44; the presence of beds with a HOBE measuring device was not associated to higher compliances&#46;</p><p id="par0270" class="elsevierStylePara elsevierViewall">Our results are in accordance with others reported in the literature that have found a range of M-HOBE of 19&#46;2&#176;&#8211;28&#176;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#8211;15</span></a> as well as low compliances &#40;&#60;40&#37;&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15&#8211;18</span></a> Importantly&#44; we found an improvement of HOBE compliance and M-HOBE after an educational intervention&#44; which was statistically significant and was maintained over time&#46; Similar improvements have been reported in other studies with shorter follow-up times&#46; However&#44; in most of them results were not sustained over time&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#44;19&#44;22&#44;23</span></a></p><p id="par0275" class="elsevierStylePara elsevierViewall">Regarding checklist-reported and direct-observation compliance&#44; we found a 50&#8211;60&#37; difference&#44; which was an unexpected finding&#46; Since HOBE compliance was introduced as a part of the checklist 3 years before the study was performed&#44; this self-reporting tool had been routinely used in every shift by the nursing staff of the study unit&#46; Checklists implementation has been proven to be useful for avoiding human errors and improving patients&#8217; outcomes and safety&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">25&#44;28</span></a> However&#44; checklists used for prolonged periods of time may turn them into a routine tool&#44; failing in its intended purpose&#46; Investigators hypothesize that this may have happened in this study&#46; Published findings regarding hand hygiene compliance found similar results when comparing compliance estimation methods&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> They reported that self-reported compliance and self-administered checklists importantly overestimated hand hygiene compliance&#44; which also happened in our study&#46; For this reason&#44; we believe that checklists are not the optimal method for improving compliance of measures that have to be implemented continuously such as HOBE&#44; and we would recommend complementing them with random audits and feedback of the results to the clinical staff in order to encourage compliance optimization&#46;</p><p id="par0280" class="elsevierStylePara elsevierViewall">When analysing HOBE compliance and M-HOBE&#44; we found that the presence of ET was associated with an increase in M-HOBE and HOBE compliance&#44; which is in accordance with other studies&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> Variations in sickness severity along ICU stay may explain this finding&#46; Tracheostomy is normally performed after a prolonged period of MV&#44; once vital signs are stable&#46; Stabilization may lead to prioritization of nursing attention to other areas of patient care other than backrest position measurement&#44; such as patient&#39;s comfort or weaning&#46;</p><p id="par0285" class="elsevierStylePara elsevierViewall">We also found an influence of nursing shifts in M-HOBE and HOBE compliance&#44; although it differed from period to period&#46; During BP and P1&#44; the night shift exhibited the highest M-HOBE&#44; while morning shift was the highest during P2 and P3&#46; We attribute this finding to a new protocol that has been implemented in our unit for improving patient&#39;s safety that includes HOBE compliance evaluation&#46; The protocol is only performed during the morning shift and started after P1&#59; hence we believe that this might have influenced the increase in HOBE compliance and M-HOBE during morning shifts observed in P2 and P3&#46;</p><p id="par0290" class="elsevierStylePara elsevierViewall">Surprisingly&#44; and contrary to the existing evidence&#44;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">23&#44;30</span></a> we found that patients in beds without a HOBE measuring device had higher backrest elevation than the ones lying on beds with HOBE measuring device&#46; Moreover&#44; absence of HOBE measuring device was independently associated with HOBE compliance in the multivariate logistic regression analysis&#46; When confronted with these results&#44; staff nurses pointed out that visual perception of the beds with the device was somehow higher compared to the ones without it&#46; Multiple explanations might have contributed to this observation bias&#44; such as the pillow&#44; the mattress type&#44; obesity or abdominal perimeter&#59; however&#44; most of them are beyond the investigators control&#46;</p><p id="par0295" class="elsevierStylePara elsevierViewall">We expected to find lower HOBE compliance during weekends compared to weekdays&#46; Frequently&#44; higher percentages of unexperienced nurses work during weekends&#44; and Vinagre et al&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> reported that experience has an impact on HOBE compliance&#46; However&#44; we did not find significant differences in HOBE compliance between weekdays and weekends&#44; but it is unknown whether differences in experience were present across these two periods&#44; as experience was not recorded during the present study&#46;</p><p id="par0300" class="elsevierStylePara elsevierViewall">We acknowledge that our study has several limitations&#46; We included observations rather than patients&#59; therefore we could not assess the impact of HOBE in VAP prevention&#46; The compliance of the HOBE could be overestimated due to the punctual observation of the HOBE as has been demonstrated by Wolken et al&#46; rather than continuous evaluation&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> Moreover&#44; the number of variables studied was limited&#44; and 18&#46;9&#37; of the measures could not be recorded unfortunately due to the lack&#47;unavailability of study investigators during certain periods&#46; Variables related to the nurse responsible for the patient&#44; such as reasons for not following HOBE recommendations&#44; could not be obtained due to the blinded fashion of the study&#46; The blinded fashion also limited very importantly the number of variables that could be evaluated&#44; as data collection was quick for not raising nurse&#39;s awareness&#46; Moreover&#44; this study is a single centre study&#44; what limits the representativeness of the results&#46; However&#44; among our strengths we include the blinded observation to clinical staff&#44; the comparison between checklist-reported compliance and direct-observation compliance and the one-year period follow-up&#46;</p><p id="par0305" class="elsevierStylePara elsevierViewall">According to our results&#44; HOBE compliance is below optimal values and the use of checklist does not reflect the reality&#46; Regarding risk factors for non-compliance&#44; extra efforts are required in the nursing management of tracheostomized patients and in the correct HOBE visual perception by the nurse&#46; The nursing shift should be also considered as an influencing factor and further analyzed to avoid differences in HOBE compliance&#46;</p><p id="par0310" class="elsevierStylePara elsevierViewall">In conclusion&#44; we found an increase in M-HOBE and HOBE compliance after a formative session that remained for a year of follow-up&#46; Checklist-reported compliance is not a good indicator for the evaluation of the HOBE compliance and is associated with important overestimation&#46; Patients with ET had higher backrest elevation and HOBE compliance&#46; The presence of beds with a HOBE measuring device was associated with neither an increased compliance nor M-HOBE&#46; Nursing shift also had an influence in the HOBE compliance and M-HOBE but it changed over the time&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Authorship</span><p id="par0315" class="elsevierStylePara elsevierViewall">All the authors have contributed actively in the data collection and have critically reviewed and approved the manuscript&#44; Maria Jim&#233;nez and Alejandro Rodriguez have contributed to the data analysis&#44; and Mireia Llaurado has participated in all the procedures&#44; analysis and manuscript writing&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Financial support and previous diffusion of the results</span><p id="par0320" class="elsevierStylePara elsevierViewall">Presented partially in the &#8220;Annual National Congress of the Spanish Society of Intensive and Critical Care Nursing&#8221;&#44; 2013 and &#8220;Annual Congress of the European Society of Intensive Care Medicine&#8221;&#44; 2013&#46;</p><p id="par0325" class="elsevierStylePara elsevierViewall">Partially funded by the Research grant &#8220;<span class="elsevierStyleGrantSponsor" id="gs1">Premio H&#46;U&#46; Marqu&#233;s de Valdecilla&#44; de investigaci&#243;n en enfermer&#237;a</span>&#8221;&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Conflicts of interest</span><p id="par0155" class="elsevierStylePara elsevierViewall">All the authors declare to have no conflicts of interest with the present manuscript&#46;</p></span></span>"
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              "titulo" => "Patients"
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              "identificador" => "abst0020"
              "titulo" => "Intervention and variables"
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            4 => array:2 [
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              "titulo" => "Results"
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        1 => array:2 [
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          "titulo" => "Keywords"
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          "titulo" => "Resumen"
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              "titulo" => "Dise&#241;o y &#225;mbito"
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              "titulo" => "Pacientes"
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              "titulo" => "Intervenci&#243;n y variables"
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          "titulo" => "Palabras clave"
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          "titulo" => "Background"
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          "identificador" => "sec0010"
          "titulo" => "Patients and methods"
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            0 => array:2 [
              "identificador" => "sec0015"
              "titulo" => "Ethical considerations"
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              "titulo" => "Data analysis"
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          "titulo" => "Authorship"
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          "identificador" => "sec0055"
          "titulo" => "Financial support and previous diffusion of the results"
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          "titulo" => "Conflicts of interest"
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          "identificador" => "xack181481"
          "titulo" => "Acknowledgements"
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        12 => array:1 [
          "titulo" => "References"
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    "pdfFichero" => "main.pdf"
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    "fechaRecibido" => "2014-06-01"
    "fechaAceptado" => "2014-07-28"
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          "clase" => "keyword"
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          "palabras" => array:3 [
            0 => "Patient positioning"
            1 => "Head-of-bed elevation"
            2 => "Clinical practice based evidence"
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        0 => array:4 [
          "clase" => "keyword"
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          "palabras" => array:3 [
            0 => "Colocaci&#243;n del paciente"
            1 => "Elevaci&#243;n del cabezal de la cama"
            2 => "Pr&#225;ctica cl&#237;nica basada en la evidencia"
          ]
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    "resumen" => array:2 [
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objectives</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To evaluate head-of-bed elevation &#40;HOBE&#41; compliance in mechanically ventilated &#40;MV&#41; patients during different time periods&#44; in order to identify factors that may influence compliance and to compare direct-observation compliance with checklist-reported compliance&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Design and setting</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A prospective observational study was carried out in a polyvalent Intensive Care Unit&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Patients</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">All consecutive patients with MV and no contraindication for semi-recumbency were studied&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Intervention and variables</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">HOBE was observed during four periods of one month each for one year&#44; the first period being blinded&#46; HOBE was measured with an electronic device three times daily&#46; Main variables were HOBE&#44; type of airway device&#44; type of bed&#44; nursing shift&#44; day of the week and checklist-reported compliance&#46; No patient characteristics were collected&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Results</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">During the four periods&#44; 2639 observations were collected&#46; Global HOBE compliance was 24&#46;0&#37;&#44; and the median angle head-of-bed elevation &#40;M-HOBE&#41; was 24&#46;0&#176; &#40;IQR 18&#46;8&#8211;30&#46;0&#41;&#46; HOBE compliance and M-HOBE by periods were as follows&#58; blinded period&#58; 13&#46;8&#37; and 21&#46;1&#176; &#40;IQR 16&#46;3&#8211;24&#46;4&#41;&#59; period 1&#58; 25&#46;5&#37; and 24&#46;3&#176; &#40;IQR 18&#46;8&#8211;30&#46;2&#41;&#59; period 2&#58; 22&#46;7&#37; and 24&#46;4&#176; &#40;IQR 18&#46;9&#8211;29&#46;6&#41;&#59; and period 3&#58; 31&#46;4&#37; and 26&#46;7&#176; &#40;IQR 21&#46;3&#8211;32&#46;6&#41; &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; An overestimation of 50&#8211;60&#37; was found when comparing self-reported compliance using a checklist versus direct-observation compliance &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46;</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Multivariate logistic regression analysis found the presence of an endotracheal tube &#40;ET&#41; and bed without HOBE measuring device to be independently associated to greater compliance &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Conclusions</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Although compliance increased significantly during the study period&#44; it was still not optimal&#46; Checklist-reported compliance significantly overestimated HOBE compliance&#46; The presence of an ET and a bed without HOBE measuring device was associated to greater compliance&#46;</p></span>"
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            "identificador" => "abst0005"
            "titulo" => "Objectives"
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        "resumen" => "<span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Objetivos</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Evaluar el cumplimiento de la elevaci&#243;n de la cabecera de la cama &#40;ECC&#41; en pacientes atendidos con ventilaci&#243;n mec&#225;nica &#40;MV&#41; durante distintos periodos de tiempo con el fin de identificar los factores que pueden influir sobre el cumplimiento y comparar el cumplimiento evaluado mediante observaci&#243;n directa con el cumplimiento evaluado mediante lista de verificaci&#243;n&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Dise&#241;o y &#225;mbito</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Se llev&#243; a cabo un estudio observacional y prospectivo en una unidad de cuidados intensivos polivalente&#46;</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Pacientes</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Se estudi&#243; a todos los pacientes consecutivos atendidos con MV y en los que no estaba contraindicada la reclinaci&#243;n parcial&#46;</p></span> <span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Intervenci&#243;n y variables</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Se observ&#243; la ECC durante 4 periodos de un mes a lo largo de un a&#241;o&#44; el primero de ellos con enmascaramiento&#46; Se midi&#243; la ECC mediante un dispositivo electr&#243;nico 3 veces al d&#237;a&#46; Las variables principales fueron ECC&#44; tipo de dispositivo para las v&#237;as respiratorias&#44; tipo de cama&#44; turno de enfermer&#237;a&#44; d&#237;a de la semana y cumplimiento notificado mediante lista de verificaci&#243;n&#46; No se recopilaron las caracter&#237;sticas de los pacientes&#46;</p></span> <span id="abst0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Resultados</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Se recopilaron 2&#46;639 observaciones durante los 4 periodos&#46; La tasa global de cumplimiento con la ECC fue del 24&#46;0&#37;&#44; mientras que la mediana del &#225;ngulo de elevaci&#243;n de la cabecera de la cama &#40;M-ECC&#41; fue de 24&#46;0&#176; &#40;IQR 18&#46;8&#8211;30&#46;0&#41;&#46; El cumplimiento con la ECC y la M-ECC por cada periodo fue&#58; periodo con enmascaramiento&#58; 13&#46;8&#37; y 21&#46;1&#176; &#40;IQR 16&#46;3&#8211;24&#46;4&#41;&#59; periodo 1&#58; 25&#46;5&#37; y 24&#46;3&#176; &#40;IQR 18&#46;8&#8211;30&#46;2&#41;&#59; periodo 2&#58; 22&#46;7&#37; y 24&#46;4&#176; &#40;IQR 18&#46;9&#8211;29&#46;6&#41;&#59; y periodo 3&#58; 31&#46;4&#37; y 26&#46;7&#176; &#40;IQR 21&#46;3&#8211;32&#46;6&#41; &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; Se observ&#243; una sobreestimaci&#243;n del 50&#8211;60&#37; al comparar el cumplimiento autoevaluado por medio de una lista de verificaci&#243;n frente al cumplimiento evaluado mediante observaci&#243;n directa &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46;</p><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Un an&#225;lisis de regresi&#243;n log&#237;stica multivariante concluy&#243; que la presencia de un tubo endotraqueal &#40;TE&#41; y de una cama sin dispositivo de medici&#243;n de ECC se asociaban de manera independiente a un mayor cumplimiento &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46;</p></span> <span id="abst0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Conclusiones</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Si bien el cumplimiento aument&#243; de manera significativa durante el periodo del estudio&#44; segu&#237;a sin ser el &#243;ptimo&#46; El cumplimiento evaluado mediante lista de verificaci&#243;n sobreestim&#243; de manera significativa el cumplimiento de la ECC&#46; La presencia de un TE y una cama sin dispositivo de medici&#243;n de ECC se asociaba a un mayor cumplimiento&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please see Appendix for list of the CAPCRI study investigators&#46;</p>"
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            "apendice" => "<p id="par0190" class="elsevierStylePara elsevierViewall">Mireia Llaurad&#243;-Serra&#59; Rosa G&#252;ell-Bar&#243;&#59; Barbara Coloma-G&#243;mez&#59; Luz Mar&#237;a Vallejo-Henao&#59; Soledad Molina-Ramos&#59; Laura Bordonado-P&#233;rez&#59; Maria Luisa Fortes-Del Valle&#59; Margarita Peralvo-Bernat&#59; Judith Marin&#233;-Vidal&#59; Yolanda Alabart-Segura&#59; Sonia Hidalgo-Margalef&#59; Carmen Portal-Porcel&#59; Xavier Alabart-Lorenzo&#59; Ascensi&#243;n L&#243;pez-Gil&#46;</p>"
            "etiqueta" => "Appendix A"
            "titulo" => "List of the CAPCRI study investigators"
            "identificador" => "sec0045"
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        ]
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          "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Device used for the measurement of the head-of-bed elevation and technique for the measurement of the backrest elevation &#40;Bosch<span class="elsevierStyleSup">&#174;</span> GLM 80&#41;&#46;</p>"
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          "en" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Diagram of the study sample&#46;</p>"
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        "etiqueta" => "Figure 3"
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          "en" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Head-of-bed elevation compliance according to the different variables evaluated over the periods&#46;</p>"
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          "leyenda" => "<p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">Each symbol represents the M-HOBE of each period where significant differences were found compared to another one&#46;<span class="elsevierStyleSup">&#945;</span>vs<span class="elsevierStyleSup">&#945;&#945;</span><span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#44; <span class="elsevierStyleSup">&#945;</span>vs<span class="elsevierStyleSup">&#945;&#945;&#945;</span><span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#44; <span class="elsevierStyleSup">&#945;</span>vs<span class="elsevierStyleSup">&#945;&#945;&#945;&#945;</span><span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#44; &#42;vs&#42;&#42;&#42; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#44; &#42;&#42;vs&#42;&#42;&#42; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#47;<span class="elsevierStyleSup">&#43;</span>vs<span class="elsevierStyleSup">&#43;&#43;</span><span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#47;<span class="elsevierStyleSup">&#161;</span>vs<span class="elsevierStyleSup">&#161;&#161;</span><span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#47;<span class="elsevierStyleSup">&#191;</span>vs<span class="elsevierStyleSup">&#191;&#191;</span><span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#47;<span class="elsevierStyleSup">&#36;</span>vs<span class="elsevierStyleSup">&#36;&#36;</span><span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#47;<span class="elsevierStyleSup">&#35;</span>vs<span class="elsevierStyleSup">&#35;&#35;</span><span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#44; <span class="elsevierStyleSup">&#35;</span>vs<span class="elsevierStyleSup">&#35;&#35;&#35;</span><span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#47;<span class="elsevierStyleSup">&#64;</span>vs<span class="elsevierStyleSup">&#64;&#64;</span><span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#47;<span class="elsevierStyleSup">&#38;</span>vs<span class="elsevierStyleSup">&#38;&#38;</span><span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#47;<span class="elsevierStyleSup">&#8364;</span>vs<span class="elsevierStyleSup">&#8364;&#8364;</span><span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#46; The rest of the comparisons were not significant&#46; M-HOBE<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>median of head-of-bed elevation&#59; IQR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>interquartile range&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
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                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Baseline period &#91;median &#40;IQR 25&#8211;75&#41;&#93;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>557&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Period 1 &#91;median &#40;IQR 25&#8211;75&#41;&#93;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>773&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Period 2 &#91;median &#40;IQR 25&#8211;75&#41;&#93;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>590&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Period 3 &#91;median &#40;IQR 25&#8211;75&#41;&#93;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>719&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleItalic">Overall</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">21&#46;1&#176; &#40;16&#46;3&#8211;25&#46;4&#41;<span class="elsevierStyleSup">&#945;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">24&#46;3&#176; &#40;18&#46;8&#8211;30&#46;2&#41;<span class="elsevierStyleSup">&#945;&#945;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">24&#46;4&#176; &#40;18&#46;9&#8211;29&#46;6&#41; <span class="elsevierStyleSup">&#945;&#945;&#945;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">26&#46;7&#176; &#40;21&#46;3&#8211;32&#46;6&#41; <span class="elsevierStyleSup">&#945;&#945;&#945;&#945;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleItalic">Working shift</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Morning&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">20&#46;3&#176; &#40;15&#46;3&#8211;24&#46;4&#41;&#42;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">24&#46;7 &#40;19&#46;1&#8211;30&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">26&#46;6 &#40;21&#46;3&#8211;30&#46;6&#41;<span class="elsevierStyleSup">&#35;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">27&#46;7 &#40;22&#46;4&#8211;33&#46;8&#41;<span class="elsevierStyleSup">&#38;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">20&#46;6&#176; &#40;16&#46;8&#8211;23&#46;7&#41;&#42;&#42;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">24&#46;6 &#40;19&#46;1&#8211;30&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">23&#46;2 &#40;18&#46;4&#8211;28&#46;8&#41;<span class="elsevierStyleSup">&#35;&#35;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">26&#46;5 &#40;21&#46;4&#8211;32&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">22&#46;8 &#40;17&#46;0&#8211;30&#46;0&#41;&#42;&#42;&#42;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">23&#46;5 &#40;18&#46;6&#8211;30&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">23&#46;0 &#40;17&#46;5&#8211;28&#46;3&#41;<span class="elsevierStyleSup">&#35;&#35;&#35;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">25&#46;3 &#40;20&#46;1&#8211;31&#46;5&#41;<span class="elsevierStyleSup">&#38;&#38;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleItalic">Day of the week</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Weekday&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">24&#46;4 &#40;18&#46;8&#8211;30&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">24&#46;4 &#40;18&#46;9&#8211;29&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">24&#46;0 &#40;19&#46;7&#8211;30&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">24&#46;7 &#40;19&#46;1&#8211;30&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">26&#46;0 &#40;21&#46;3&#8211;32&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleItalic">Airway device type</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Endotracheal tube&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">21&#46;6 &#40;17&#46;5&#8211;26&#46;8&#41;<span class="elsevierStyleSup">&#43;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">24&#46;8 &#40;19&#46;1&#8211;31&#46;0&#41;<span class="elsevierStyleSup">&#191;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">25&#46;6 &#40;20&#46;3&#8211;30&#46;2&#41;<span class="elsevierStyleSup">&#64;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">26&#46;8 &#40;21&#46;2&#8211;32&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Tracheostomy&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">26&#46;4 &#40;21&#46;5&#8211;32&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleItalic">Type of bed</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Without HOBE measurement device&nbsp;\t\t\t\t\t\t\n
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                    0 => array:2 [
                      "titulo" => "Guidelines for the management of adults with hospital-acquired&#44; ventilator-associated&#44; and healthcare-associated pneumonia"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
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                            "web" => "Medline"
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                      "titulo" => "Evidence-based clinical practice guideline for the prevention of ventilator-associated pneumonia"
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                          "autores" => array:6 [
                            0 => "P&#46; Dodek"
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                            2 => "D&#46; Cook"
                            3 => "D&#46; Heyland"
                            4 => "M&#46; Jacka"
                            5 => "L&#46; Hand"
                          ]
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                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
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                      "titulo" => "Clinical practice guidelines for hospital-acquired pneumonia and ventilator-associated pneumonia in adults"
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                            5 => "S&#46; Magder"
                          ]
                        ]
                      ]
                    ]
                  ]
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                            "web" => "Medline"
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                      "titulo" => "Indicadores de Calidad en el Enfermo Cr&#237;tico&#44; actualizaci&#243;n 2011"
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                      "titulo" => "Guidelines for the prevention of ventilator-associated pneumonia and their implementation&#46; The Spanish &#8220;Zero-VAP&#8221; bundle"
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                          "etal" => true
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                            2 => "J&#46; Vall&#233;s"
                            3 => "J&#46; Rello"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.medin.2010.03.004"
                      "Revista" => array:6 [
                        "tituloSerie" => "Med Intensiva"
                        "fecha" => "2010"
                        "volumen" => "34"
                        "paginaInicial" => "318"
                        "paginaFinal" => "324"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20466456"
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                0 => array:2 [
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                      "titulo" => "Reducing the risk of ventilator-acquired pneumonia through head of bed elevation"
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                          "etal" => false
                          "autores" => array:1 [
                            0 => "L&#46; Keeley"
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                      "doi" => "10.1111/j.1478-5153.2007.00247.x"
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                        "tituloSerie" => "Nurs Crit Care"
                        "fecha" => "2007"
                        "volumen" => "12"
                        "paginaInicial" => "287"
                        "paginaFinal" => "294"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17983363"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            7 => array:3 [
              "identificador" => "bib0040"
              "etiqueta" => "8"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Ventilator-associated pneumonia&#46; A multivariate analysis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "M&#46;H&#46; Kollef"
                          ]
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                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
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                        "tituloSerie" => "JAMA"
                        "fecha" => "1993"
                        "volumen" => "270"
                        "paginaInicial" => "1965"
                        "paginaFinal" => "1970"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8411554"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            8 => array:3 [
              "identificador" => "bib0045"
              "etiqueta" => "9"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Pulmonary aspiration of gastric contents in patients receiving mechanical ventilation&#58; the effect of body position"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "A&#46; Torres"
                            1 => "J&#46; Serra-Batlles"
                            2 => "E&#46; Ros"
                            3 => "C&#46; Piera"
                            4 => "J&#46; Puig de la Bellacasa"
                            5 => "A&#46; Cobos"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Ann Intern Med"
                        "fecha" => "1992"
                        "volumen" => "116"
                        "paginaInicial" => "540"
                        "paginaFinal" => "543"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/1543307"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            9 => array:3 [
              "identificador" => "bib0050"
              "etiqueta" => "10"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Supine body position as a risk factor for nosocomial pneumonia in mechanically ventilated patients&#58; a randomised trial"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "M&#46;B&#46; Drakulovic"
                            1 => "A&#46; Torres"
                            2 => "T&#46;T&#46; Bauer"
                            3 => "J&#46;M&#46; Nicolas"
                            4 => "S&#46; Nogue"
                            5 => "M&#46; Ferrer"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/S0140-6736(98)12251-1"
                      "Revista" => array:6 [
                        "tituloSerie" => "Lancet"
                        "fecha" => "1999"
                        "volumen" => "354"
                        "paginaInicial" => "1851"
                        "paginaFinal" => "1858"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10584721"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            10 => array:3 [
              "identificador" => "bib0055"
              "etiqueta" => "11"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Feasibility and effects of the semirecumbent position to prevent ventilator-associated pneumonia&#58; a randomized study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "C&#46;A&#46; van Nieuwenhoven"
                            1 => "C&#46; Vandenbroucke-Grauls"
                            2 => "F&#46;H&#46; van Tiel"
                            3 => "H&#46;C&#46; Joore"
                            4 => "R&#46;J&#46; van Schijndel"
                            5 => "I&#46; van der Tweel"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Crit Care Med"
                        "fecha" => "2006"
                        "volumen" => "34"
                        "paginaInicial" => "396"
                        "paginaFinal" => "402"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16424720"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            11 => array:3 [
              "identificador" => "bib0060"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "An evidence-based recommendation on bed head elevation for mechanically ventilated patients"
                      "autores" => array:1 [
                        0 => array:3 [
                          "colaboracion" => "Bed Head Elevation Study Group"
                          "etal" => false
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                            0 => "B&#46;S&#46; Ni&#235;l-Weise"
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                            2 => "A&#46; Kola"
                            3 => "R&#46;P&#46; Vonberg"
                            4 => "J&#46;C&#46; Wille"
                            5 => "P&#46;J&#46; van den Broek"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1186/cc10135"
                      "Revista" => array:5 [
                        "tituloSerie" => "Crit Care"
                        "fecha" => "2011"
                        "volumen" => "15"
                        "paginaInicial" => "R111"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21481251"
                            "web" => "Medline"
                          ]
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                      ]
                    ]
                  ]
                ]
              ]
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              "identificador" => "bib0065"
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "Quality improvement in backrest elevation&#58; improving outcomes in critical care"
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                          "etal" => false
                          "autores" => array:2 [
                            0 => "M&#46;J&#46; Grap"
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                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "AACN Clin Issues"
                        "fecha" => "2005"
                        "volumen" => "16"
                        "paginaInicial" => "133"
                        "paginaFinal" => "139"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15876880"
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                          ]
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                  ]
                ]
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              "identificador" => "bib0070"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Predictors of backrest elevation in critical care"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "M&#46;J&#46; Grap"
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                            2 => "S&#46; Bryant"
                            3 => "B&#46; Ashtiani"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Intensive Crit Care Nurs"
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                        "volumen" => "19"
                        "paginaInicial" => "68"
                        "paginaFinal" => "74"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12706732"
                            "web" => "Medline"
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                    ]
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                ]
              ]
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              "identificador" => "bib0075"
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                0 => array:2 [
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                            3 => "R&#46; Parke"
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                  "host" => array:1 [
                    0 => array:2 [
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                        "paginaInicial" => "e100"
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                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21041187"
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "Effect of standardized orders and provider education on head-of-bed positioning in mechanically ventilated patients"
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                            3 => "M&#46;E&#46; Callender"
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                        "paginaFinal" => "2290"
                        "link" => array:1 [
                          0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "Factors associated with low adherence to head-of-bed elevation during mechanical ventilation in Chinese intensive care units"
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                      "titulo" => "Evaluaci&#243;n del cumplimiento de cabeceros elevados entre 30-45 en pacientes intubados"
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                    0 => array:2 [
                      "titulo" => "Effects of staff training on the care of mechanically ventilated patients&#58; a prospective cohort study"
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                            4 => "D&#46; Geil"
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                        "tituloSerie" => "Br J Anaesth"
                        "fecha" => "2009"
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                        "paginaInicial" => "232"
                        "paginaFinal" => "237"
                        "link" => array:1 [
                          0 => array:2 [
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "A novel method of continuous measurement of head of bed elevation in ventilated patients"
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                        "paginaFinal" => "1054"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17393138"
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                      "titulo" => "A nursing clinical decision support system and potential predictors of head-of-bed position for patients receiving mechanical ventilation"
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                        "tituloSerie" => "Am J Crit Care"
                        "fecha" => "2010"
                        "volumen" => "19"
                        "paginaInicial" => "39"
                        "paginaFinal" => "47"
                        "link" => array:1 [
                          0 => array:2 [
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                    0 => array:2 [
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                    ]
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                    0 => array:2 [
                      "doi" => "10.1111/j.1469-0691.2012.03808.x"
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                        "tituloSerie" => "Clin Microbiol Infect"
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                      "titulo" => "Prompting physicians to address a daily checklist and process of care and clinical outcomes&#58; a single-site study"
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                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "C&#46;H&#46; Weiss"
                            1 => "F&#46; Moazed"
                            2 => "C&#46;A&#46; McEvoy"
                            3 => "B&#46;D&#46; Singer"
                            4 => "I&#46; Szleifer"
                            5 => "L&#46;A&#46; Amaral"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1164/rccm.201101-0037OC"
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                        "tituloSerie" => "Am J Respir Crit Care Med"
                        "fecha" => "2011"
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                        "paginaInicial" => "680"
                        "paginaFinal" => "686"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21616996"
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                  ]
                ]
              ]
            ]
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              "etiqueta" => "26"
              "referencia" => array:1 [
                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "Compliance with antiseptic hand rub use in intensive care units&#58; the Hawthorne effect"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
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                            1 => "J&#46; Bessert"
                            2 => "M&#46; Behnke"
                            3 => "P&#46; Gastmeier"
                            4 => "H&#46; Ruden"
                          ]
                        ]
                      ]
                    ]
                  ]
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                    0 => array:2 [
                      "doi" => "10.1086/507294"
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                        "tituloSerie" => "Infect Control Hosp Epidemiol"
                        "fecha" => "2006"
                        "volumen" => "27"
                        "paginaInicial" => "931"
                        "paginaFinal" => "934"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16941318"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
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              "identificador" => "bib0135"
              "etiqueta" => "27"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Applied logistic regression"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "D&#46; Hosmer"
                            1 => "S&#46; Lemeshow"
                          ]
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                      ]
                    ]
                  ]
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                    0 => array:1 [
                      "Libro" => array:4 [
                        "edicion" => "2nd ed&#46;"
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                        "editorialLocalizacion" => "New York"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            27 => array:3 [
              "identificador" => "bib0140"
              "etiqueta" => "28"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Systematic review of safety checklists for use by medical care teams in acute hospital settings &#8211; limited evidence of effectiveness"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "H&#46;C&#46; Ko"
                            1 => "T&#46;J&#46; Turner"
                            2 => "M&#46;A&#46; Finnigan"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1186/1472-6963-11-211"
                      "Revista" => array:5 [
                        "tituloSerie" => "BMC Health Serv Res"
                        "fecha" => "2011"
                        "volumen" => "11"
                        "paginaInicial" => "211"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21884618"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            28 => array:3 [
              "identificador" => "bib0145"
              "etiqueta" => "29"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Assessing nurses&#8217; hand hygiene practices by direct observation or self-report"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "E&#46;L&#46; Larson"
                            1 => "A&#46;E&#46; Aiello"
                            2 => "J&#46;P&#46; Cimiotti"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "J Nurs Meas"
                        "fecha" => "2004"
                        "volumen" => "12"
                        "paginaInicial" => "77"
                        "paginaFinal" => "85"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15916321"
                            "web" => "Medline"
                          ]
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                      ]
                    ]
                  ]
                ]
              ]
            ]
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              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "A bedside placard significantly increases compliance with head of the bed elevation in the intensive care unit&#58; a pilot study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "Y&#46; Sasabuchi"
                            1 => "M&#46; Sanui"
                            2 => "T&#46; Onuma"
                            3 => "T&#46; Shimozono"
                            4 => "A&#46;T&#46; Lefor"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Anaesth Intensive Care"
                        "fecha" => "2012"
                        "volumen" => "40"
                        "paginaInicial" => "731"
                        "paginaFinal" => "732"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22813518"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
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        "texto" => "<p id="par0185" class="elsevierStylePara elsevierViewall">We want to thank all the nurses from the ICU for their collaboration in the study&#44; and especially Dr Alberto Sandiumenge&#44; Dr Christer Axelsson and Ms Elsa Afonso for their help in the critical review of the manuscript and English improvement&#46;</p>"
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