Feature

Head-of-Bed Elevation
in Critically Ill Patients:
A Review
Norma A. Metheny, RN, PhD
Rita A. Frantz, RN, PhD
Clinicians are confused by conflicting guidelines about the use of head-of-bed elevation to prevent aspiration and
pressure ulcers in critically ill patients. Research-based information in support of guidelines for head-of-bed elevation to prevent either condition is limited. However, positioning of the head of the bed has been studied more
extensively for the prevention of aspiration than for the prevention of pressure ulcers, especially in critically ill
patients. More research on pressure ulcers has been conducted in healthy persons or residents of nursing homes
than in critically ill patients. Thus, the optimal elevation for the head of the bed to balance the risks for aspiration and pressure ulcers in critically ill patients who are receiving mechanical ventilation and tube feedings is
unknown. Currently available information provides some indications of how to position patients; however, randomized controlled trials where both outcomes are evaluated simultaneously at various head-of-bed positions
are needed. (Critical Care Nurse. 2013;33[3]:53-67)

uidelines for head-of-bed (HOB) elevation to prevent aspiration and pressure ulcers are
in conflict. As indicated in Table 1, several expert sources recommend a 45 HOB elevation
(unless medically contraindicated) to prevent aspiration1-3 while others recommend an HOB
elevation between 30 and 45 (again, unless medically contraindicated).4-10 In contrast, pressure ulcer
guidelines call for raising the HOB no more than 30 to avoid excessive pressure on the sacral region.11-13
Although the recommendations overlap, a 45 HOB elevation is generally favored to prevent aspiration
in critically ill patients who are receiving mechanical ventilation and tube feedings.1,14 Because aspiration
is a threat to oxygenation, some authors caution that aspiration is a greater and more immediate concern
than are pressure ulcers in critically ill patients.15 Clearly, the conflicting guidelines regarding aspiration
and pressure ulcers are problematic for critical care clinicians who strive to prevent the suffering and
increased costs associated with both conditions.16

CNE Continuing Nursing Education

This article has been designated for CNE credit. A closed-book, multiple-choice examination follows this article, which
tests your knowledge of the following objectives:
1. Discuss guidelines for head-of-bed (HOB) elevation to prevent aspiration and pressure ulcers
2. Distinguish relevant studies recommending HOB elevation to prevent aspiration and aspiration-related conditions
3. Critique studies relevant to HOB elevation for pressure ulcer prevention
2013 American Association of Critical-Care Nurses doi: http://dx.doi.org/10.4037/ccn2013456

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Table 1

Summary of guidelines for head-of-bed elevation

Guidelines to prevent
pressure ulcers

Guidelines to prevent aspiration/pneumonia

Elevate head of bed to 45, unless contraindicated
Canadian clinical practice guidelines for nutrition support in mechanically ventilated, critically
ill adult patients. Journal of Parenteral and Enteral Nutrition, 20031
Prevention of ventilator-associated pneumonia: an evidence-based systematic review.
Annals of Internal Medicine, 20032
Comprehensive evidence-based clinical practice guidelines for ventilator-associated pneumonia:
diagnosis and treatment. Journal of Critical Care, 20083
Elevate head of bed from 30 to 45, unless contraindicated
Guidelines for the provision and assessment of nutrition support therapy in the adult critically
ill patient: Society of Critical Care Medicine and American Society for Parenteral and Enteral
Nutrition. Journal of Parenteral and Enteral Nutrition, 20094
Enteral nutrition practice recommendations. American Society for Parenteral & Enteral
Nutrition. Journal of Parenteral and Enteral Nutrition 20095

Raise head of bed no more than 30

(and preferably less)
Prevention and Treatment of Pressure
Ulcers: Clinical Practice Guideline.
Washington, DC: National Pressure
Ulcer Advisory Panel (NPUAP); 200911
Guideline for Prevention and Management of Pressure Ulcers. 2010 June 1.
96 p. (Wound Ostomy and Continence
Nurses Association clinical practice
guideline; no. 2)12
Guidelines for the prevention of
pressure ulcers. Wound Healing
Society, Wound Repair and Regeneration, 2008 13

North American summit on aspiration in the critically ill patient: consensus statement,
American Society for Parenteral and Enteral Nutrition. Journal of Parenteral and Enteral
Nutrition, 20026
American Gastroenterological Association technical review on tube feeding for enteral
nutrition. Gastroenterology, 19957
Guidelines for preventing health-careassociated pneumonia, 2003: recommendations of
CDC and Healthcare Infection Control Practices Advisory Committee. Morbidity and Mortality Weekly Report, 20048
Practice Alert: Ventilator-Associated Pneumonia. American Association of Critical-Care
Nurses, 20089
Practice Alert: Prevention of Aspiration. American Association of Critical-Care Nurses, 201110

Aspiration of gastric contents is a primary route of

bacterial entry into the lungs and is an important factor in
the development of ventilator-associated pneumonia (VAP).
VAP is the most common nosocomial infection in critically
ill patients and is an important cause of prolonged hospitalization and mortality.17 For example, a review of 89 observational and randomized trials regarding VAP showed that
VAP developed in between 10% and 20% of patients receiving
more than 48 hours of mechanical ventilation, and critically
ill patients in whom VAP develops appear to be twice as
likely to die as similar patients without VAP.18 Further,
patients in whom VAP develops may incur at least $10019
in additional hospital costs.18 Because VAP prevention is

partially predicated on the prevention of aspiration, it is

understandable why guidelines for both aspiration and
VAP include an elevated HOB position.9,10 The Centers for
Medicare and Medicaid Services (CMS) is considering
adding VAP to the list of never events; if this happens,
punitive reimbursement policies could follow.19
Pressure ulcers are also associated with adverse outcomes and increased hospital costs.20 Fatalities from septicemia associated with untreated pressure ulcers are
occasionally reported.21 However, a pressure ulcer is often
a marker for coexisting illness and other risk factors for
mortality.22 Among all hospitalized patients, prevalence
rates of acquired pressure ulcers are highest in patients in

Authors
Norma A. Metheny is a professor and Dorothy A. Votsmier Endowed Chair at Saint Louis University School of Nursing, St Louis, Missouri.
Rita A. Frantz is Kelting Dean and professor at the University of Iowa College of Nursing in Iowa City.
Corresponding author: Norma A. Metheny, RN, PhD, FAAN, Saint Louis University School of Nursing, 3525 Caroline Mall, St. Louis, MO 63104 (e-mail: methenna@slu.edu).
To purchase electronic or print reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 899-1712 or (949) 362-2050 (ext 532); fax, (949)
362-2049; e-mail, reprints@aacn.org.

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intensive care units (ICUs). In 2009, approximately 1 in

10 patients in adult ICUs in the United States had a pressure ulcer develop.23 Facility-acquired pressure ulcer rates
were 8.8% in general cardiac care units, 9.4% in medical
ICUs, 10.3% in general ICUs, and 10.4% in surgical ICUs;
about 65% to 75% of the ulcers were more severe than
stage I.23 The cost of treating pressure ulcers, especially
stage III and IV ulcers, is substantial.24 The mean cost of
care for an acute care patient with a stage III or IV pressure ulcer is reported by the CMS to be $43180.25 In 2006,
the CMS added stage III and IV pressure ulcers to the list
of never events.26 Beginning in 2008, the CMS refused
to pay for the care of a hospital-acquired pressure ulcer in
stages III and IV unless it was determined to have been
unavoidable. One component of the pressure ulcer guidelines issued by the National Pressure Ulcer Advisory Panel
is a low HOB elevation (preferably <30).11

Pathophysiology of Aspiration
Aspiration is defined as the inhalation of oropharyngeal secretions or gastric contents into the airways
beyond the vocal cords. Consequences of pulmonary aspiration depend on the volume and chemical composition
of the aspirated material as well as on the presence or
absence of infectious agents and the patients underlying
condition. The associated lung injury is characterized by
pulmonary inflammation, capillary leakage, and oxidative
damage. Variable outcomes are possible, ranging from
mild pneumonitis to acute respiratory distress and death.
Risk factors for pulmonary aspiration include conditions
that depress the level of consciousness, a decreased gag
reflex, tracheal intubation, presence of a gastric tube, and
a full stomach. Critically ill patients undergoing mechanical ventilation who are receiving tube feedings are at especially high risk for the aspiration of regurgitated gastric
contents. Reports of witnessed macroaspirations in critically ill patients range from less than 1% to 11.7%27; far
more common are clinically silent, small-volume aspirations. For example, McClave et al28 reported a 22.1% mean
frequency of clinically silent microaspirations per patient
(range, 0%-94%) in a group of 40 adult critically ill, tubefed patients receiving mechanical ventilation.

Pathophysiology of Pressure Ulcers

The National Pressure Ulcer Advisory Panel has defined
a pressure ulcer as localized injury of the skin and/or underlying tissue, usually over a bony prominence, as a result of

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pressure or pressure in combination with shearing force.11

Oxygen delivery to the skin is compromised when it is
exposed to a pressure greater than the capillary closing
pressure; if sustained, tissue necrosis results. An elevated
HOB position results in an increased interface pressure
between the sacrum and the beds surface; in addition,
potential for injury of skin in the sacral region is increased
when the HOB is elevated sufficiently to cause the patient to
slide downward. The bony prominence most affected by
pressure ulcers is the sacrum.29 For patients turned on
their sides at regular intervals, damage of skin over the
trochanters may occur (although it is unlikely when patients
are turned to an angle 30). Healing rates of pressure
ulcers vary considerably and are dependent on comorbid
conditions, clinical interventions, and severity of the ulcer.

Purpose
In this article, we review guidelines for HOB elevation
to prevent aspiration and pressure ulcers, as well as the
limited research-based information in support of the
guidelines. Table 2 lists studies relevant to HOB elevation
and aspiration30-37 (as well as aspiration-related conditions),
and Table 3 lists studies relevant to HOB elevation and
pressure ulcers.38-44

Evidence to Support HOB Elevation to

Prevent Aspiration
Much of the supportive evidence for a semirecumbent
position to prevent aspiration was gathered several decades
ago in studies with relatively small sample sizes. In randomized trials of critically ill patients, investigators compared the
effect of a
Increased compliance with keeping the HOB
supine (0
elevated 30 led to a decrease in rates of
HOB eleventilator-associated pneumonia.
vated position) versus a 45 HOB elevated position on aspiration by
adding a radioactive substance to gastric contents and
subsequently scanning bronchial secretions for radioactivity.30,31 This method for testing for aspiration is highly
reliable and demonstrates the extent to which HOB elevation is associated with aspiration. In another frequently
cited and credible study,33 researchers assessed for microbiologically confirmed pneumonia when patients were
flat in bed versus at a 45 HOB elevation. Because of ethical concerns, it would be not be possible today to assign
critically ill patients to a supine position to study aspiration.

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Table 2

Studies related to head-of-bed (HOB) elevation and aspiration or aspiration-related pneumonia

Source

Sample

Design

Outcome

Torres et al,30 Annals of

Internal Medicine, 1992

19 patients with nasogastric tubes

undergoing mechanical ventilation
Mean age, 60 y

Randomized 2-period
cross-over study

Aspiration of gastric contents

Orozco-Levi et al,31 American

Journal of Respiratory and
Critical Care Medicine, 1995

15 patients with nasogastric tubes

undergoing mechanical ventilation
Mean age, 56 y

Randomized 2-period
cross-over study

Aspiration of gastric contents

Gastroesophageal reflux (GER)

Ibanez et al,32 Journal of Parenteral and Enteral Nutrition,

1992

70 orotracheally intubated patients

50 received enteral nutrition while
gastric contents labeled with
technetium Tc 99m
20 had nasogastric tubes removed after
instillation of technetium Tc 99m

Randomized 2-group study

GER

Drakulovic et al,33 Lancet, 1999

86 critically ill patients receiving mechanical

ventilation
47 supine, 39 semirecumbent
Enteral feedings used in 56%-60% of
patients
Mean age, 65 y

Randomized 2-group study

Microbiologically confirmed
nosocomial pneumonia

Metheny et al,34 Critical Care

Medicine, 2006

360 critically ill tube-fed patients undergoing

mechanical ventilation
Mean age, 52 y

Prospective descriptive study

Aspiration of gastric contents

Pneumonia

Method

Results

Randomly assigned to supine (0) or 45 HOB elevation

during period 1 and other position during period 2
Technetium Tc 99m instilled into nasogastric tubes;
bronchial secretions collected at 0, 30, 60, 120, 180,
240, and 300 min and tested for radioactivity
(counts per minutes [cpm])
Samples of bronchial secretions, gastric juice, and
pharyngeal contents also obtained for qualitative
bacterial cultures

Mean radioactive counts higher in bronchial

samples obtained with patient supine vs
semirecumbent (4154 cpm vs 954 cpm,
respectively, P = .04).
Aspiration increased over time while patient
supine (2592 cpm at 300 min vs 298 cpm
at 30 min, P = .01)
Same microorganisms isolated from stomach,
pharynx, and bronchial samples in 68% of
studies when patients supine, as compared
with 32% when patients semirecumbent

45 HOB elevation associated with less

aspiration than supine position
Risk for aspiration increases over time
when patient is supine

Conclusions

Random assignment to supine (0) or semirecumbent

(45 HOB elevation) position
Samples of gastric, pharyngeal, and bronchial secretions
obtained at baseline and hourly for 5 hours after
nasogastric tube instillation of technetium Tc 99m
Specimens were examined for radioactivity and
microbiological cultures were obtained

Radioactivity of pharyngeal secretions higher

with patients supine from hours 1-4, P <.05;
however, no difference noted at 5 hours
Radioactivity in bronchial secretions higher
at 5 hours in supine patients compared
with baseline (P < .05) and semirecumbency
(P < .01)
Results of microbiological cultures showed
a sequence of colonization from the stomach to the pharynx in 6 patients (4 of them
supine), and from the pharynx to the
bronchi in 2 others (one supine and one
semirecumbent)

GER is a frequent feature in patients with

nasogastric tubes
GER occurs irrespective of body position
in patients undergoing mechanical ventilation
A semirecumbent position lessens aspiration, but does not completely prevent it

Patients assigned to supine (0 HOB elevation) or

semirecumbent group (45 HOB elevation)
GER assessed by scintigraphy after gastric contents
labeled with technetium Tc 99m via the nasogastric
tube

In the 50 patients with nasogastric tubes,

incidence of GER higher in supine patients
(81%, 21/26) than in semirecumbent
patients (67%, 16/24), P = .26
In the 20 patients without nasogastric tubes,
GER was also more frequent in supine
position (50%, 6/12) than in the semirecumbent position (12%, 1/8), P = .16
Overall, GER more frequent in patients with
nasogastric tubes than in those without
(74% vs 35%, P < .001)

Incidence of GER is high in patients with

orotracheal intubation and nasogastric
tubes
Semirecumbency does not prevent GER,
although GER tends to occur less often
in semirecumbent patients

Random assignment to supine (0) or semirecumbent

(45 HOB elevation) position
Correctness of assigned body position checked daily
Surveillance for clinical detection of pneumonia done
daily; samples for microbiological diagnostic tests
taken if infection clinically suspected
Standard pressure area care protocol applied in all
patients (water-filled cushion placed under sacral
region); method of monitoring for pressure ulcers
not described

Microbiologically confirmed pneumonia

occurred less often in the semirecumbent
group than in the supine group (2/39 [5%]
vs 11/47 [23%], respectively, P = .02)
Highest risk for nosocomial pneumonia
occurred in patients receiving tube feedings
in the supine position
No adverse effects of the semirecumbent
position were found; investigators emphasized use of protective measures to prevent
pressure ulcers

45 HOB elevation reduces frequency of

pneumonia, especially in tube-fed
patients

Observed 16 hours per day for 3 days; HOB elevation

recorded hourly; other risk factors for aspiration also
recorded
Tracheal secretions assayed for pepsin (proxy for aspiration of gastric contents)
Pneumonia assessed by Simplified Clinical Pulmonary
Infection Score on day 4
Mean HOB angle compared with percentage of aspiration and incidence of pneumonia

At least 1 aspiration event identified in 89%

of participants
Patients with mean HOB elevation <30
(n = 226) had higher percentage of aspiration than did the 134 patients with mean
HOB 30 (35% vs 25%, P < .001)
Mean HOB elevation <30 found significantly
more often in patients with pneumonia
than in those without (P = .02)
Higher percentage of pepsin-positive secretions found in patients with pneumonia than
in those without (42% vs 21%, P < .001)
Other significant risk factors were decreased
level of consciousness, vomiting, and GER

Microaspiration common in critically ill,

tube-fed patients receiving mechanical
ventilation
Frequent aspiration significantly increases
risk for pneumonia
HOB elevation <30 is a significant risk
factor for aspiration and pneumonia

Continued

Table 2
Source

Continued

Sample

Design

Outcome

Metheny et al,35 Nursing

Research, 2010

474 critically ill, tube-fed patients receiving

mechanical ventilation
Intervention group, 145; usual care
group, 329
Mean age, 49-53 y

Two-group quasi-experimental
study

Aspiration of gastric contents

Pneumonia

van Nieuwenhoven et al,36

Critical Care Medicine, 2006

221 critically ill patients receiving mechanical ventilation

Standard care group, 109; semirecumbent group, 112
(Mean ages 63-65 y)

Prospective multicenter
randomized 2-group trial

Ventilator-associated pneumonia
(VAP)
Pressure ulcers

Keeley,37 Nursing in Critical

Care, 2007

30 critically ill patients receiving mechanical

ventilation completed the study
Treatment group, 17; control group, 13
Mean ages, 64-68 y

Randomized controlled trial

VAP

Nonetheless, results from these studies are helpful in current practice because they clearly show that a 45 HOB elevation is superior to a flat in bed position in preventing
aspiration. Recommendations in guidelines to prevent
aspiration are largely based on these trials.
No randomized controlled trials were identified that
compare aspiration while patients are at a 30 HOB elevation versus a 0 elevation, or a 30 elevation versus a 45
elevation. Thus, although a 30 HOB elevation is commonly recommended in practice settings, there is no direct

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evidence that it is as effective as a 45 elevation in reducing

aspiration. However, as indicated in Table 2, several
descriptive studies34,35 suggest that an HOB elevation of 30
or greater is associated with fewer adverse outcomes (aspiration and pneumonia) than is a lower HOB elevation. It
must be noted that evidence garnered from descriptive
studies is not as strong as evidence obtained from a controlled trial where patients are randomly assigned to differing HOB elevations. Further, the descriptive studies34-37
described in Table 2 have typically included HOB elevation

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Method

Results

Conclusions

Intervention group compared with usual-care group

for 3 days for percentage of aspiration and incidence
of pneumonia (assessed by the Simplified Clinical
Pulmonary Infection Score)
Intervention consisted of encouraging HOB elevation
to 30 or greater and insertion of feeding tubes into
small bowel

Mean HOB elevation 30 found in 90% of

intervention group, as compared with 38%
of the usual-care group, P < .001
Small-bowel tube placements more frequent
in intervention group than in the usual care
group (75% vs 50%, respectively, P < .001)
Aspiration (defined as at least 1 pepsinpositive tracheal secretion) lower in the
intervention group than in the usual-care
group (39% vs 88%, P < .001)
Pneumonia lower in the intervention group
than in the usual care group (19% vs 48%,
respectively, P < .001)

Combination of HOB position elevated to

30 and use of small-bowel feeding
site can significantly reduce the incidence
of aspiration and aspiration-related
pneumonia in critically ill, tube-fed
patients receiving mechanical ventilation

109 patients randomly assigned to standard-care group

(10 HOB elevation) and 112 randomly assigned to
semirecumbent group (45 HOB elevation)
HOB angle measured continuously in 174 patients by
a monitor-linked device during the first week of
mechanical ventilation
VAP diagnosed by quantitative cultures of samples
obtained by bronchoscopic techniques
Pressure ulcer development staged daily by research
nurses

HOB elevation to 45 achieved only 15% of

study time in the semirecumbent group
Average HOB elevations were 9.8 and 16.1
at day 1 and day 7 for supine group and
28.1 and 22.6 at day 1 and day 7 for the
semirecumbent group (P < .001)
Microbiologically confirmed VAP was diagnosed in 8/109 patients (7.3%) in the supine
group and in 13/112 patients (11.6%) in
the semirecumbent group (difference not
significant)
Pressure ulcers developed in 30% of the
patients assigned to the supine group and
in 28% of the patients assigned to the
semirecumbent group

Investigators concluded that a 45 HOB

elevation is not feasible in critically ill
patients receiving mechanical ventilation
Mean HOB <30 in all patients
Could not compare VAP at the assigned
HOB elevations (10 vs 45) because
only a small number of patients were
positioned at 45
Also could not compare pressure ulcer
development at the assigned positions

Patients randomized to treatment (45 HOB elevation)

or standard-care group (25 HOB elevation)
Study continued until 1 of the following conditions
occurred: extubation, death, successful weaning,
withdrawal at request of patient or next of kin, change
in patients position that lasted more than 6 of 24
hours, transfer to another department, or need for
prone positioning
In surviving patients, follow-up continued for 72 hours
after a study end point had been reached
Pneumonia diagnosed as either clinically suspected or
microbiologically confirmed.
HOB angle measured on a random selection of patients,
by using a protractor and plumb line
Patients repositioned every 2-4 hours, either side lying
or supine while the required HOB angle was maintained

5 of 17 patients (29%) in treatment group

contracted VAP, compared with 7 of 13
(56%) in the control group, P = .18
9 patients who expressed discomfort or who
wished to be cared for in positions other
than those to which they had been randomized were withdrawn
Incidence of pressure ulcers not described

Trend toward a reduction in VAP found in

patients nursed at 45; however,
statistical significance was not achieved
Elevation of HOB to 45 may be poorly
accepted by patients who are not heavily
sedated

in context with multiple other variables, thus making it

difficult to determine the singular effect of HOB elevation on outcomes.
Following a systematic review of 3 of the trials33,36,37
described in Table 2, a European panel concluded that it
is uncertain whether a 45 HOB elevation is effective or
harmful in regard to pneumonia and pressure ulcers.45
One aspect considered in the panels deliberations was the
paucity of data to support the use of a 45 HOB elevation
for a sustained period.45 The authors questioned whether

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a 45 HOB elevation for 24 hours a day might increase

the risk for thromboembolism, hemodynamic instability,
and pressure ulcers. Although these are reasonable concerns, the 3 studies reviewed by the panel did not assess
for thromboembolism and hemodynamic instability and
only 1 referred to pressure ulcers as an outcome (noting
no difference at the end of 1 week between groups with
mean HOB elevations of 16 and 23). Based on their
deliberations, the panel recommended an HOB elevation
of 20 to 45 for patients receiving mechanical ventilation

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Table 3
Source

Studies related to head-of-bed (HOB) elevation and pressure ulcers

Sample

Design

Outcome

Peterson et al, Critical Care

Medicine, 2008

15 healthy adults
Age range, 23-54 y

Descriptive observational study Peak sacral interface pressures

Harada et al,39 Journal of

Wound Ostomy Continence
Nursing, 2002

10 healthy Japanese women

Age range, 18-25 y

Comparative, quasiexperimental study with

repeated measures

Peterson et al,40 Journal of

Advanced Nursing, 2010

15 healthy adults
Age range, 23-54 y

Descriptive observational study Interface pressures in the sacral,

trochanteric, and buttock regions
Effectiveness of turning in unloading pressure on at-risk tissues

Gray-Siracusa and Schrier,41

Journal of Nursing Care
Quality, 2011

Total 1199 critically ill patients (554 in

before group and 645 in after group)

Two-group (before-after)
comparison study

Rate of hospital-acquired pressure

ulcers

Nanjo et al,42 Journal of

Wound Ostomy Continence
Nursing, 2011

30 adult critically ill patients

Mean age, 68 y

Qualitative exploratory study

Relationships among etiologic

factors, characteristics of pressure ulcers, and interventional
nursing care

38

Body displacement
Sacral interface pressure

Method

Results

Conclusions

Interface pressure profiles of the sacral area obtained

for the 0, 10, 20, 30, 45, 60, and 75 HOB
elevated positions
Measurements obtained using a thin pressure-sensing
pad placed under the sacral region

After repeated-measures analysis of variance, the HOB positions of 45, 60, and
75 all caused statistically significant
increases in affected areas compared with
the supine measurement (P < .001)
With the same statistical test, the areas with
>32 mm Hg interface pressure at the HOB
positions of 45, 60, and 75 were all
significantly different from all other HOB
positions
The 30 HOB elevation was different from
the 10 and the 20 HOB elevation positions (P < .02)

Raising the HOB to 30 significantly

increases the skinsupport surface
interface pressure, and a 45 HOB
elevation significantly increases the
area of skin exposed to a pressure
>32 mm Hg

Subjects placed supine on standard hospital bed;

HOB then raised to 30 according to 2 protocols:
(1) supine for 10 minutes without leg elevation
alternating with 10 minutes of side-lying, or (2)
supine for 10 minutes with leg elevation at 10
alternating with side-lying every 10 minutes
Difference over time between the top edge of the
mattress and subjects acromion measured every
10 minutes
Sacral interface pressure measured every 10 minutes
using a pneumatic pressure sensor
Body displacement and mean sacral interface pressures
in both protocols compared by using repeatedmeasures analysis of variance

Mean body displacement in 30 elevated

HOB position without leg elevation at the
end of 2 hours was 29 cm, whereas with
leg elevation it was 18 cm (P < .001)
No significant differences in sacral interface
pressures with or without leg elevation at
baseline (7.3 mm Hg and 11.9 mm Hg,
respectively)

Leg elevation at 10 in the 30 HOB elevated position is effective for reducing

body displacement; it is not effective
for reducing sacral interface pressures

Interface pressure profiles obtained from sacral,

trochanteric, and buttock regions while patients were
supine, followed by lateral turning with pillow or
wedge support and subsequent HOB elevation to 30
Turning performed by an experienced intensive care
unit nurse

Peak perisacral area interface pressures not

significantly affected by lateral turning, but
demonstrated a significant increase upon
elevating the HOB to 30 (P < .05)
93% of participants had skin areas with
interface pressures 32 mm Hg throughout all positions (mean [SD], 60 [54] cm2),
termed triple jeopardy area
The triple jeopardy area increased significantly with wedges as compared with
pillows (mean [SD], 153 [99] cm2 vs 48
[47] cm2, P < .05)

Standard turning by experienced intensive care unit nurses does not reliably
unload all areas of high skin-bed interface pressures
Support materials for maintaining lateral
turned positions can influence tissue
unloading and triple jeopardy areas,
and need to be further evaluated to
improve care
Further study is needed to establish how
to achieve optimal positioning to eliminate areas that remain at risk

Determined rate of hospital-acquired pressure ulcers during year before implementation of bundle intervention
Implemented 7-item pressure ulcer bundle; portions
pertaining to HOB elevation included (1) elevating
HOB to 45 for all patients receiving mechanical ventilation, and (2) maintaining HOB at 30 or less for
patients who are not receiving mechanical ventilation, who are at lower risk
Determined rate of hospital-acquired pressure ulcers
during year following implementation of pressure
ulcer bundle

Analysis of quarterly hospital-acquired pressure ulcers rates before and after shows
no significant difference (P = .11)
Before pressure ulcer bundle, quarterly
survey results for hospital-acquired pressure ulcer rates were as follows: quarter
1 = 5.7%; quarter 2 = 0%; quarter 3 = 5.2%,
and quarter 4 = 0%
After implementation of pressure ulcer bundle,
quarterly hospital-acquired pressure ulcer
rates remained <1% through the year

Pressure ulcer bundle reduced the incidence of pressure ulcers but difference
was not statistically significant

Details of 30 individual pressure ulcers described by

sketching pressure ulcer photographs
Characteristics of pressure ulcers divided into 4
categories: (1) location, (2) shape, (3) type of skin
lesion, and (4) periwound skin
After identification of pressure ulcer characteristics,
in-depth review of medical records to evaluate the
pressure ulcers development process
Semistructured interviews with 5 nurses who cared
for patients in study; topics included position and
positioning methods, criteria for deciding how to
position a particular patient, and typical interventions
to prevent pressure ulcers

Pressure ulcer sites:

Upper sacrum (n = 5)
Lower sacrum (n = 14)
Coccyx (n = 8)
Ischium (n = 1)
Heel/ankle (n = 2)
Possible etiological factors for specific
pressure ulcer divided into 4 categories:
(1) occurrence of pressure ulcer risk
episodes, (2) failure of peripheral circulation, (3) periods of critical immobility, and
(4) position change techniques inducing
skin deformation

Frequently repeated position changes,

such as lateral tilt and repeated HOB
elevation, may cause deformation of
the sacral skin and possibly play a role
in development of pressure ulcers

Continued

Table 3
Source

Continued

Sample

Design

Outcome

Sideranko et al,43 Research in

Nursing and Health, 1992

57 patients in a surgical intensive care unit

Repeated measures study

Sacral and heel pressures

Development of pressure ulcers

Sanada et al,44 Journal of Tissue Viability, 2003

82 patients from general care area in hospital

Mean age range, 69.5-73.9 y

Randomized controlled trial

Development of pressure ulcers

(preferably 30) as long as it does not conflict with

medical interventions, patients wishes, or nursing tasks.

benefit of pressure-relieving surfaces in preventing pressure ulcers.43,44

Evidence to Support a Low HOB

Elevation to Prevent Pressure Ulcers

Compliance With Guidelines

in Critical Care Settings

Overall, less research is available about the effect of

HOB elevation on pressure ulcer development than on
aspiration; further, relatively few studies have been conducted in a critical care setting. Three of the studies38-40
described in Table 3 were conducted with healthy persons
and show that interface pressure between the skin and
bed surface is increased as the HOB angle is increased.
One of the
Using a lift sheet to reposition patients
studies39 also
reduces shear pressure and lowers risk for
suggests that
pressure ulcers.
sliding down
in bed is more likely at a 30 HOB angle than when the
bed is flat. No randomized controlled trials were identified that compared the effect of various HOB elevations
on development of pressure ulcers. However, 1 group of
investigators41 compared pressure ulcer outcomes before
and after the implementation of a pressure ulcer bundle
(1 component of which was manipulation of the HOB
angle) in a critical care setting. A trend toward reduction
in pressure ulcer rates was noted, although statistical
significance was not achieved. Two other studies described
in Table 3 are examples of projects that demonstrate the

62

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Aspiration Guidelines
Among contraindications to an elevated HOB position are recent lumbar spine injury, hemodynamic instability, trauma of the pelvic region, and severe sacral
pressure ulcers. Even when there are no contraindications to an elevated HOB position, it is not consistently
applied. (See the study by van Nieuwenhoven et al36 in
Table 2.) A variety of strategies have been studied in
regard to increasing use of an elevated HOB position.
For example, Helman et al46 implemented a standardized
order for placing patients in a 45 HOB elevated position, along with an educational program for nurses and
physicians; however, compliance with the order was
achieved in less than one-third of the observations.
Nurses who participated in that study reported the following concerns:
Increased probability of patient sliding down in bed
More difficulty in turning patient from side to side
Greater pressure exerted on patients sacral area
Greater discomfort and interference with sleep
Even a 30 HOB-elevated position is not consistently
used in some critical care settings.15,47,48 In 2003, Grap et al47

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Method

Results

Conclusions

Subjects divided into 3 groups according to type of

pressure-relieving surface: (1) alternating air (n = 20);
(2) static air (n = 20); and (3) water mattress (n = 17)
Pressures recorded from sacrum and heel in the dorsal recumbent position; same measurements made
while patient positioned at a 45 HOB elevation
Sacral and heel pressures tested for each surface, at
each HOB position, using a repeated-measures design

Mean pressure with alternating air mattress

was 30 mm Hg; it was 23.3 mm Hg with
the water mattress and 25 mm Hg with
the static air mattress (P < .01)
The 45 HOB elevated position (regardless
of pressure-relieving surface) produced
significantly more sacral pressure at an
average of 32.9 mm Hg, as compared with
recumbent position average (25.1 mm Hg;
P < .01)
Heel pressures showed no differences
across mattress type and position
Pressure ulcers developed in 8 patients (5 on
alternating air, 2 on water, and 1 on static
air surface); 2 analysis not significant

Findings suggest that alternating air

overlays should be avoided
Investigators emphasized importance of
periodically repositioning patients who
require a prolonged HOB elevation to
reduce the incidence of sacral pressure
ulcers

Participants were patients who had Braden scale

scores 16 and required a HOB elevation 45
Assigned to 1 of 3 support surfaces: (1) double-layer
air-cell overlay, (2) single-layer air-cell overlay, or
(3) standard hospital mattress

Incidence of pressure ulcers according to

support surface were as follows:
Double-layer air-cell overlay, 3.4%
Single-layer air-cell overall, 19.2%
Standard mattress, 37%

Standard mattress associated with a

much higher incidence of pressure
ulcers than pressure-relieving surfaces
in a population of patients who
required a 45 HOB elevated position

reported that the mean backrest elevation in a population

of 170 critically patients was 19.2. Although an elevated
HOB position is especially warranted in tube-fed patients,
there was no difference in backrest elevation between
patients being fed and not being fed. In a 2005 study15 of
66 critically ill patients monitored during 275 patient
days, investigators found that backrest elevations were
less than 30 72% of the time. More encouraging findings
were reported in a later study49 conducted in a thoracic
ICU; mean compliance with an HOB elevated position
greater than 30 changed from 65% in 2007 to 99% in
2009; associated with this increased compliance was a
significant decrease in the incidence of VAP.
HOB elevation is related to acuity level. For example,
Evans48 found a significant negative correlation (r2 =-0.17)
between scores on the Acute Physiology and Chronic
Health Evaluation II and HOB elevation in 113 critically ill
patients. Evans48 also reported that patients receiving
mechanical ventilation had a lower mean HOB elevation
than did self-ventilating patients (19 vs 32). In a study50 of
100 patients in a thoracic cardiovascular ICU, investigators
found that patients with a mean arterial blood pressure
of 64 mm Hg or less had a lower mean backrest elevation
(17) than did patients with a higher arterial pressure
(24). In a study of 438 patients, investigators51 reported
that mean HOB elevations were lower in intubated
patients (23) than in nonintubated patients (33, P<.001).

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Delivery of standard nursing care often calls for temporary lowering of the HOB elevation. For example,
because it is difficult to turn patients when the beds
backrest is elevated, nurses usually lower the bed to 0
(in some instances,
Elevating the HOB decreases risk
they may even put
for aspiration but increases risk for
the bed in reverse
pressure ulcers.
Trendelenberg position while turning patients and pulling them up in bed).
There are reports of nurses forgetting to elevate the backrest after completing the turning procedure (sometimes
for a period up to 1 hour).52,53 Medical procedures (such
as insertions of central catheters) can cause temporary
interruptions in the desired HOB elevation. Transitory
physiological conditions such as hemodynamic instability or low cerebral perfusion pressure also may mandate
lowering of the HOB elevation.
Another possible reason for noncompliance with an
elevated HOB position is difficulty in making accurate
visual estimates of an HOB angle. For example, Hiner et
al54 asked 175 clinicians to estimate a simulated HOB
angle of 30; the angle was perceived accurately by 50%
of 89 nurses and 53% of 39 physicians; a higher percentage (86%) of 21 respiratory therapists identified the
angle accurately. These findings are significant because
some hospital beds do not have built-in electronic
devices to determine the beds angle.
CriticalCareNurse

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63

Pressure Ulcer Guidelines

No studies were located that measured adherence to
a low (30) HOB elevation to prevent pressure ulcers in
critically ill patients. However, in a study55 involving 362
long-term care facilities in Missouri, researchers found
that minimizing the HOB elevation to less than 30 was
done by fewer than 20% of the facilities.

Conclusions
The optimal HOB elevation to balance the risks for
aspiration and pressure ulcers is unknown.15,39,56-58 Thus, a
need exists for randomized controlled trials where both
outcomes (aspiration and pressure ulcers) are evaluated
simultaneously at various HOB elevated positions, especially in a population of critically ill, tube-fed patients
receiving mechanical ventilation. Some authors suggest
that studies be conducted to compare the commonly
recommended 30 to 45 HOB elevations to lower and
more achievable levels (such as 10 to 30).59
Until more research-based evidence is available,
caregivers should consider guidelines from expert panels
and ultimately make decisions about HOB elevation in
the context of the patients overall condition. Given current information, the following recommendations may
be helpful to critical care clinicians:
Unless medically contraindicated, maintain an
HOB elevation of 45 in patients who are receiving mechanical ventilation and tube feedings. If
necessary for comfort, lower the HOB elevation
to 30 periodically.
For critically ill patients at less risk for aspiration
(eg, patients who are not receiving mechanical
ventilation), maintain an HOB elevation of at
least 30 unless medically contraindicated.
Use a pressure-relieving surface for all critically
ill patients to reduce the skin-bed interface pressure associated with an elevated HOB position.
Routinely assess the patients skin for signs of a
developing pressure ulcer.
To minimize shear pressure, use a lift sheet to
reposition patients (instead of sliding the patient
up in bed). CCN
Financial Disclosures
None reported.

64

CriticalCareNurse

Vol 33, No. 3, JUNE 2013

Now that youve read the article, create or contribute to an online discussion
about this topic using eLetters. Just visit www.ccnonline.org and click Submit a
response in either the full-text or PDF view of the article.

To learn more about head-of-bed elevation in the critical care

setting, read Clinicians Perception of Head-of-Bed Elevation
by Hiner et al in the American Journal of Critical Care, March
2010;19:164-167. Available at www.ajcconline.org.

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355-373.
2. Collard HR, Saint S, Matthay MA. Prevention of ventilator-associated
pneumonia: an evidence-based systematic review [see comment]. Ann
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3. Muscedere J, Dodek P, Keenan S, et al. Comprehensive evidence-based
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4. McClave SA, Martindale RG, Vanek VW, et al. Guidelines for the provision and assessment of nutrition support therapy in the adult critically
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5. Bankhead R, Boullata J, Brantley S, et al. Enteral nutrition practice recommendations. JPEN J Parenter Enteral Nutr. 2009;33(2):122-167.
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27. Miller CD, Rebuck JA, Ahern JW, Rogers FB. Daily evaluation of macroaspiration in the critically ill post-trauma patient. Curr Surg. 2005;62(5):
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28. McClave SA, Lukan JK, Stefater JA, et al. Poor validity of residual volumes
as a marker for risk of aspiration in critically ill patients [comment].
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29. Barczak CA, Barnett RI, Childs EJ, Bosley LM. Fourth national pressure
ulcer prevalence survey. Adv Wound Care. 1997;10(4):18-26.
30. Torres A, Serra-Batlles J, Ros E, et al. Pulmonary aspiration of gastric
contents in patients receiving mechanical ventilation: the effect of body
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31. Orozco-Levi M, Torres A, Ferrer M, et al. Semirecumbent position protects from pulmonary aspiration but not completely from gastroesophageal reflux in mechanically ventilated patients. Am J Respir Crit
Care Med. 1995;152(4 pt 1):1387-1390.
32. Ibanez J, Penafiel A, Raurich JM, Marse P, Jorda R, Mata F. Gastroesophageal reflux in intubated patients receiving enteral nutrition: effect
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33. Drakulovic MB, Torres A, Bauer TT, Nicolas JM, Nogue S, Ferrer M.
Supine body position as a risk factor for nosocomial pneumonia in
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34. Metheny NA, Clouse RE, Chang YH, Stewart BJ, Oliver DA, Kollef MH.
Tracheobronchial aspiration of gastric contents in critically ill tube-fed
patients: frequency, outcomes, and risk factors. Crit Care Med. 2006;
34(4):1-9.
35. Metheny NA, Davis-Jackson J, Stewart BJ. Effectiveness of an aspiration
risk-reduction protocol. Nurs Res. 2010;59(1):18-25.
36. van Nieuwenhoven CA, Vandenbroucke-Grauls C, van Tiel FH, et al.
Feasibility and effects of the semirecumbent position to prevent ventilatorassociated pneumonia: a randomized study [see comment]. Crit Care
Med. 2006;34(2):396-402.
37. Keeley L. Reducing the risk of ventilator-acquired pneumonia through
head of bed elevation. Nurs Crit Care. 2007;12(6):287-294.
38. Peterson M, Schwab W, McCutcheon K, van Oostrom JH, Gravenstein N,
Caruso L. Effects of elevating the head of bed on interface pressure in
volunteers. Crit Care Med. 2008;36(11):3038-3042.
39. Harada C, Shigematsu T, Hagisawa S. The effect of 10-degree leg elevation
and 30-degree head elevation on body displacement and sacral interface
pressures over a 2-hour period. J Wound Ostomy Continence Nurs. 2002;
29(3):143-148.
40. Peterson MJ, Schwab W, van Oostrom JH, Gravenstein N, Caruso LJ.
Effects of turning on skin-bed interface pressures in healthy adults. J Adv
Nurs. 2010;66(7):1556-1564.
41. Gray-Siracusa K, Schrier L. Use of an intervention bundle to eliminate
pressure ulcers in critical care. J Nurs Care Qual. 2011;26(3):216-225.
42. Nanjo Y, Nakagami G, Kaitani T, et al. Relationship between morphological characteristics and etiology of pressure ulcers in intensive care
unit patients. J Wound Ostomy Continence Nurs. 2011;38(4):404-412.
43. Sideranko S, Quinn A, Burns K, Froman RD. Effects of position and
mattress overlay on sacral and heel pressures in a clinical population.
Res Nurs Health. 1992;15(4):245-251.

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44. Sanada H, Sugama J, Matsui Y, et al. Randomised controlled trial to evaluate a new double-layer air-cell overlay for elderly patients requiring
head elevation. J Tissue Viability. 2003;13(3):112-114, 116, 118 passim.
45. Niel-Weise BS, Gastmeier P, Kola A, et al. An evidence-based recommendation on bed head elevation for mechanically ventilated patients. Crit
Care (London, England). 2011;15(2):R111.
46. Helman DL Jr, Sherner JH III, Fitzpatrick TM, Callender ME, Shorr AF.
Effect of standardized orders and provider education on head-of-bed
positioning in mechanically ventilated patients. Crit Care Med. 2003;
31(9):2285-2290.
47. Grap MJ, Munro CL, Bryant S, Ashtiani B. Predictors of backrest elevation
in critical care. Intensive Crit Care Nurs. 2003;19(2):68-74.
48. Evans D. The use of position during critical illness: current practice and
review of the literature. Australian Crit Care. 1994;7(3):16-21.
49. Bird D, Zambuto A, ODonnell C, et al. Adherence to ventilator-associated
pneumonia bundle and incidence of ventilator-associated pneumonia in
the surgical intensive care unit. Arch Surg. 2010;145(5):465-470.
50. Ballew C, Buffmire MV, Fisher C, et al. Factors associated with the level
of backrest elevation in a thoracic cardiovascular intensive care unit. Am
J Crit Care. 2011;20(5):395-399.
51. Hanneman SK, Gusick GM. Frequency of oral care and positioning of
patients in critical care: a replication study. Am J Crit Care. 2005;14(5):
378-386.
52. De Jonghe B, Appere-De-Vechi C, Fournier M, et al. A prospective survey
of nutritional support practices in intensive care unit patients: what is
prescribed? What is delivered? Crit Care Med. 2001;29(1):8-12.
53. McClave SA, Sexton LK, Spain DA, et al. Enteral tube feeding in the
intensive care unit: Factors impeding adequate delivery. Crit Care Med.
1999;27(7):1252-1256.
54. Hiner C, Kasuya T, Cottingham C, Whitney J. Clinicians perception of
head-of-bed elevation. Am J Crit Care. 2010;19(2):164-167.
55. Wipke-Tevis DD, Williams DA, Rantz MJ, et al. Nursing home quality
and pressure ulcer prevention and management practices. J Am Geriatr
Soc. 2004;52(4):583-588.
56. Johnson KL, Meyenburg T. Physiological rationale and current evidence
for therapeutic positioning of critically ill patients. AACN Adv Crit Care.
2009;20(3):228-240; quiz 241-222.
57. Li Bassi G, Torres A. Ventilator-associated pneumonia: role of positioning.
Curr Opin Crit Care. 2011;17(1):57-63.
58. Naccarato MK, Kelechi T. Pressure ulcer prevention in the emergency
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CCN Fast Facts

CriticalCareNurse

The journal for high acuity, progressive, and critical care nursing

Head-of-Bed Elevation in Critically Ill Patients: A Review

Facts
There are conflicting guidelines about the use of
head-of-bed (HOB) elevation to prevent aspiration and
pressure ulcers in critically ill patients.
Although the recommendations overlap, a 45
HOB elevation is generally favored to prevent
aspiration in critically ill patients who are receiving mechanical ventilation and tube feedings.
Because aspiration is a threat to oxygenation, it
may be a more immediate concern than are pressure ulcers in critically ill patients.
Aspiration of gastric contents is a primary route of
bacterial entry into the lungs and is an important
factor in the development of ventilator-associated
pneumonia.
Pressure ulcers are also associated with adverse
outcomes and increased hospital costs. A pressure
ulcer is often a marker for coexisting illness and
other risk factors for mortality.
Results from early studies are helpful in current
practice because they clearly show that a 45 HOB
elevation is superior to a flat in bed position in
preventing aspiration.
No randomized controlled trials were identified
that compare aspiration while patients are at a 30
HOB elevation versus a 0 elevation, or a 30 elevation versus a 45 elevation. Thus, although a 30
HOB elevation is commonly recommended in practice settings, there is no direct evidence that it is as
effective as a 45 elevation in reducing aspiration.
Contraindications to an elevated HOB position are
recent lumbar spine injury, hemodynamic instability, trauma of the pelvic region, and severe sacral
pressure ulcers. Even when there are no contraindications to an elevated HOB position, it is not consistently applied.

Standard nursing care often calls for temporary

lowering of the HOB elevation. For example,
because it is difficult to turn patients when the
beds backrest is elevated, nurses usually lower
the bed to 0. There are reports of nurses forgetting to elevate the backrest after completing the
turning procedure. Medical procedures also can
cause temporary interruptions in the desired
HOB elevation. Transitory physiological conditions such as hemodynamic instability or low
cerebral perfusion pressure also may mandate
lowering of the HOB elevation.

Conclusions
Until more research-based evidence is available, caregivers should consider guidelines from expert panels and
ultimately make decisions about HOB elevation in the
context of the patients overall condition. Given current
information, the following recommendations may be
helpful to critical care clinicians:
Unless medically contraindicated, maintain an HOB
elevation of 45 in patients who are receiving mechanical ventilation and tube feedings. If necessary for
comfort, lower the HOB elevation to 30 periodically.
For critically ill patients at less risk for aspiration
(eg, patients who are not receiving mechanical ventilation), maintain an HOB elevation of at least 30
unless medically contraindicated.
Use a pressure-relieving surface for all critically ill
patients to reduce the skin-bed interface pressure
associated with an elevated HOB position. Routinely assess the patients skin for signs of a developing pressure ulcer.
To minimize shear pressure, use a lift sheet to reposition patients (instead of sliding the patient up in
bed). CCN

Metheny NA, Frantz RA. Head-of-Bed Elevation in Critically Ill Patients: A Review. Critical Care Nurse. 2013;33(3):53-67.

66

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Vol 33, No. 3, JUNE 2013

www.ccnonline.org

CNE Test Test ID C1332: Head-of-Bed Elevation in Critically Ill Patients: A Review
Learning objectives: 1. Discuss guidelines for head-of-bed (HOB) elevation to prevent aspiration and pressure ulcers 2. Distinguish relevant studies recommending HOB elevation to prevent aspiration and aspiration-related conditions 3. Critique studies relevant to HOB elevation for pressure ulcer prevention
1. Which of the following statements regarding head-of-bed (HOB) elevation
recommendations is true?
a. HOB positioning has been studied more extensively for the prevention of aspiration
than for the prevention of pressure ulcers.
b. More research on pressure ulcers has been conducted on critically ill patients
than in healthy persons.
c. The optimal HOB elevation to balance risks for aspiration and pressure ulcers is
known.
d. There is sufficient research to support guidelines for HOB elevation to prevent
aspiration and pressure ulcers.

7. Which of the following recommendations can be helpful to critical care

clinicians?
a. Avoid use of lift sheets for repositioning critically ill patients to minimize
shear pressure.
b. Maintain a HOB elevation of no more than 30 for mechanically ventilated
patients receiving tube feedings.
c. Maintain a HOB elevation of at least 45 for critically ill patients who are not
receiving mechanical ventilation.
d. Use a pressure-relieving surface to reduce the skin-bed interface pressure
associated with HOB elevation.

2. Risk factors for pulmonary aspiration include all of the following except:
a. An empty stomach
c. Presence of a gastric tube
b. Decreased gag reflex
d. Tracheal intubation

8. Lung injury associated with aspiration is characterized by all of the

following except:
a. Increased alveolar elasticity
b. Capillary leakage
c. Oxidative damage
d. Pulmonary inflammation

3. Which of the following is defined as a pressure ulcer by the National Pressure

Ulcer Advisory Panel?
a. Generalized injury of the skin
b. Injury that occurs only over a bony prominence
c. Localized injury of the skin that results from pressure
d. Tissue injury resulting from tearing force
4. Which of the following is the bony prominence most affected by pressure ulcers?
a. Heels
c. Sacrum
b. Occiput
d. Trochanters
5. Which of the following is a true statement regarding studies of 30 HOB
elevation?
a. Evidence from descriptive studies is as strong as that obtained from a randomly
assigned controlled trial.
b. Several studies suggest HOB elevation of greater than 30 is associated with
fewer adverse respiratory outcomes.
c. Several trials have identified that 30 elevation is superior to HOB flat.
d. Thirty-degree HOB elevation is as effective as 45 elevation in reducing aspiration.
6. Which of the following is the optimal HOB elevation to balance the risks for
aspiration and pressure ulcers?
a. Less than 30
b. 30 to 45
c. Greater than 45
d. Unknown

9. Nurses who participated in a study by Helman et al that implemented a

standardized order for placing patients in a 45 elevated position reported
which of the following?
a. Greater comfort and improved sleep
b. Greater pressure exerted on the patients lumbar region
c. Increased probability of the patient sliding down in bed
d. More difficulty moving the patient up in bed
10. Which of the following is a result reported in a 2006 study by Metheny et al?
a. At least one aspiration event was identified in each participant.
b. HOB elevation less than 30 does not significantly increase risk of aspiration.
c. Mean HOB elevation less than 30 was found significantly more often in
patients with pneumonia.
d. There was no difference in percentage of aspiration depending on degree of
HOB elevation.
11. Which of the following is a result reported in a 2010 study by Metheny et al?
a. HOB elevation and small-bowel tube feeding can significantly reduce the
incidence of aspiration.
b. Pressure ulcers were higher in the intervention group than in the usual care group.
c. Statistically significant reduction in ventilator-associated pneumonia was not
achieved between treatment groups.
d. There was no significant difference between the supine and semirecumbant
groups in diagnosis of ventilator-associated pneumonia.

Test answers: Mark only one box for your answer to each question. You may photocopy this form.

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2. q a
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Test ID: C1332 Form expires: June 1, 2016 Contact hours: 1.0 Pharma hours: 0.0 Fee: AACN members, $0; nonmembers, $10 Passing score: 8 correct (73%)
Synergy CERP Category A Test writer: Lori Williams Black, DNP, RN, RNC-NIC, CCRN, NNP-BC

Program evaluation

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or mail this entire page to:
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Objective 3 was met
Content was relevant to my
nursing practice
q
My expectations were met
q
This method of CNE is effective
for this content
q
The level of difficulty of this test was:
q easy q medium q difficult
To complete this program,
it took me
hours/minutes.

No
q
q
q
q
q
q

Member #

Address
City

State

Country

ZIP

Phone

E-mail
RN Lic. 1/St
Payment by:
Card #

RN Lic. 2/St
q Visa

q M/C

q AMEX

q Discover

q Check
Expiration Date

Signature

The American Association of Critical-Care Nurses is accredited as a provider of continuing nursing education by the American Nurses Credentialing Centers Commission on Accreditation.
AACN has been approved as a provider of continuing education in nursing by the State Boards of Nursing of Alabama (#ABNP0062), California (#01036), and Louisiana (#ABN12). AACN
programming meets the standards for most other states requiring mandatory continuing education credit for relicensure.

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