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Using the Beach Chair Position in ICU Patients

Kelly Anne Pennington Caraviello, Lynne S. Nemeth and Bonnie Pleasants Dumas
Crit Care Nurse 2010;30:S9-S11 doi: 10.4037/ccn2010425
2010 American Association of Critical-Care Nurses
Published online http://www.cconline.org

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candidates include patients who require sedation or who are
hemodynamically unstable.

Study
An internally funded, nonrandomized study was con-
ducted by a team of clinicians and faculty (led by author K.C.)
within the surgical-trauma, medical, and neuroscience ICUs at
the Medical University of South Carolina Academic Medical
Center. A total of 200 patients were recruited for the study.
The medical ICU patients were removed because they changed
bed frames after beginning the study and a consistent BCP
was not able to be achieved. Duplicate instances of patients
were combined. A total of 152 patients were included in the
final analyses.
The BCP protocol (Figure 2) was used to identify patients
receiving mechanical ventilation who, on the basis of certain
physiological and pathological data, could be considered can-
didates for the BCP. Each ICU patient was evaluated daily to
see if the patient was an appropriate BCP candidate, and, if so,
the patient was placed in the BCP within 24 hours of meeting
inclusion criteria. Once positioned in the BCP, the patient had
these same parameters monitored and the protocol of hemo-
dynamic criteria followed to ensure that the patient was toler-
ating the BCP (Figure 2). If the patient did not tolerate the
BCP, the bed was simply adjusted and returned to the baseline
Using the Beach Chair Position in position.
ICU Patients Pilot testing an intervention for a quality improvement
Kelly Anne Pennington Caraviello, RN, BSN, CCRN project in patient care generally relies on pre-post data collec-
Lynne S. Nemeth, RN, PhD tion. The BCP intervention was conducted from June 2008 to
Bonnie Pleasants Dumas, PhD

mmobile intensive care unit (ICU) patients are at risk for


I many complications. Those patients who require mechani-
cal ventilation and who are unable to get out of bed because of
their underlying condition and sedation requirements are at
risk for ventilator-associated pneumonia (VAP). VAP is due to
the colonization of the oropharynx and tracheal airway with
bacteria and the aspiration of oropharyngeal secretions into
the lower airway.1 The Centers for Disease Control and Preven-
tion2 has established criteria to diagnose VAP that include
gross aspiration by the patient, laboratory and radiological
findings, and signs and symptoms. VAP occurs in up to 25% of
ventilator patients, usually within 3 to 10 days of intubation.
This incidence is a concern because VAP is the most common
hospital-acquired infection.3 Mechanical ventilation alone
costs an average of $1522 per day,4 and VAP can increase a
patients hospital bill by $40 000.3
The beach chair position (BCP, Figure 1) was conceptual-
ized as a method of early mobilization to help reduce the inci-
dence of VAP in ICU patients who, because of pathological
reason(s) or physiological instability, are unable to get out of
bed. The BCP is defined as having the patients head of bed
elevated to 70 and the foot of bed at a -75 angle, as if the
patient is sitting in a chair. By using the bed frame to place
Figure 1 Patient in beach chair position in the intensive
the patient in the BCP, patients who might not be able to get care unit.
out of bed are able safely to attain a sitting position. BCP

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Several positive outcomes were realized in this initial
Beach Chair Position Protocol study. Chi-square analysis indicated a significant reduction in
GOAL: Beach Chair Position 1 hr 4 times/day for patients
who are candidates VAP rates (P = .03; Figure 3) in the BCP group. Most patients
(95.2%) were able to tolerate the BCP, with only 4.8% unable
Patients who are candidates:
to sit in the BCP for the full 60 minutes. In this 4.8%, cardio-
Hemodynamically stable patients, as defined by:
No active bleeding vascular events were the reason for patients not tolerating the
HR 60-120 full 60 minutes 36% of the time, followed by neurological
MAP 60 events 21% of the time. Tachycardia or hypertension and the
SpO2 90
RR 30
rare hypotensive events were easily corrected by the staff.
Patients were removed from the BCP due to respiratory con-
Guidelines indicating Beach Chair Position is tolerated cerns only 8% of the time. The staff placed the patients in the
by patient:
HR ~ change 10% from baseline
BCP 4 times per day in conjunction with the daily tasks that
BP ~ change 20% from baseline ICU patients require. At times, placing a patient in the BCP
EKG ~ no changes or arrhythmias that causes symptoms or was not appropriate; for example, during discussions of pallia-
hemodynamic compromise tive care or withdrawal of care, if such positioning was not the
SpO2 ~ remains 90% physicians preference, if the bed was the wrong type, or if the
O2 requirement ~ remains same/weaned patient was on a tracheostomy collar or T-bar trial. The
Patients who are not yet candidates: patient was not placed in the BCP 25.6% of the time because of
Temporary pacemakers physiological concerns such as heart rate, blood pressure, or
Intraaortic balloon pump
other factors listed in the BCP protocol.
Sengstaken-Blakemore/Minnesota tubes
Vasopressor requirement increase Some outcomes were not reduced in the BCP group; these
ICP >20 included ventilator days, ICU length of stay, and hospital
ECMO length of stay. When the severity of illness, which is catego-
Specialty beds/mattress (eg, RotoProne, RotoRest, or KCI rized independently by the hospital team according to the
First Step)
patients diagnosis-related group, was compared in the 2
Paralytics in use
Ordered HOB flat/bed rest groups (Figure 4), 77% of the BCP group was in class 4, or the
Clarify with physician as some are ok: sickest class of patients, in comparison to 57% in class 4 in the
-Recent SSG/flap to lower limbs or trunk historical cohort. This difference could account for the higher
-Recent open abdomen number of ventilator days and the longer ICU and hospital
-Unstable C-spine
lengths of stay in the BCP group.
-Pelvic or spine fractures
-Unstable head bleeds/post craniotomy/deep coma patients
-Require continuous lower extremity elevation
12
Figure 2 Beach chair position protocol.
10
Abbreviations: BP, blood pressure; C-spine, cervical spine; ECMO, extracorpo-
real membrane oxygenation; EKG, electrocardiography; HOB, head of bed;
HR, heart rate; ICP, intracranial pressure; MAP, mean arterial pressure; O2,
8
oxygen; PaO2, partial pressure of oxygen; RR, respiratory rate; SpO2, oxygen
Rate

saturation as shown by pulse oximetry; SSG, split skin graft. 6


Reprinted with permission. Caraviello 2007.
4

2
November 2008 in patients admitted to the surgical trauma
and neuroscience ICUs. To compare outcomes of the BCP 0
BCP group Historical cohort
cohort versus patients not in the BCP cohort, a comparison
2 = 4.8, P = .03
group of ICU patients during the 6-month period from
VAP case rate
November 2007 to May 2008 (the historical cohort) was retro- Odds ratio = 0.321
spectively constructed. It was difficult to match the character- VAP rate per 1000 VD
istics of the retrospective cohort exactly because the BCP
criteria were not assessed in these patients. The BCP inclusion Figure 3 Comparison of ventilator-associated pneumonia
(VAP) case rate and VAP rate per 1000 ventilator days (VD)
and exclusion criteria were not assessed in the retrospective between the beach chair position (BCP) group and the his-
cohort. In the end, data for patients in the medical ICU were torical cohort. Both rates were significantly lower in the
removed from the study because that unit changed bed frames BCP group. The VAP case rate was defined for this study as
after beginning the study and a consistent BCP could not be the number of patients per cohort who had VAP diagnosed.
For the BCP cohort, the VAP case rate was defined as those
achieved. Also, the duration and consistency of use of the BCP patients who had VAP diagnosed while actively being
varied from patient to patient because of other competing placed in the BCP within the past 48 hours.
demands in the ICUs.

S10 CRITICALCARENURSE Vol 30, No. 2, APRIL 2010 Supplement www.ccnonline.org


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not be related to the patients disease but may be due to the
90
position change. Respiratory rate, heart rate, and blood pres-
80 sure did change, but the changes were minimal and well
70 tolerated. Use of the BCP is not a benign treatment option;
60 physiological changes that could harm the patient can occur.
However, in patients who are still too ill to walk or even to be
Percent

50
transferred to a chair, the BCP is a practical method of early
40
mobilization that presents minimal risk to the patient and
30
caregivers until the patient can ambulate. The BCP is better
20 than doing nothing in relation to mobility and is better than
10 getting patients out of bed unsafely in order to increase their
0 pulmonary function.

2010 American Association of Critical-Care Nurses


Historical cohort BCP group

SOI 1 SOI 3 doi: 10.4037/ccn2010425


SOI 2 SOI 4
Acknowledgments
Kelly Ann Pennington Caraviello thanks the staff of the surgical/trauma, neu-
Figure 4 Comparison of severity of illness (SOI) between roscience, and medical ICUs at the Medical University of South Carolina Hos-
the historical cohort and the patients in the Beach Chair pital for their participation. Special thanks to Dr John Welton for his support.
Position (BCP) group. All patients admitted to the hospital
have their SOI calculated on the basis of their diagnosis- Financial Disclosures
related group. Most patients in the BCP group were SOI The Medical University of South Carolina Hospital Authority provided finan-
class 4, or the sickest classification, when compared with cial support for this study.
the historical cohort. It is striking that the rate of ventilator-
associated pneumonia was lower in the BCP group, when References
the patients in the BCP group had a higher SOI, were in the 1. American Thoracic Society and the Infectious Diseases Society of Amer-
ica. Guidelines for the management of adults with hospital-acquired,
intensive care unit longer, and had a longer duration of ventilator-associated, and healthcare-associated pneumonia. Am J Respir
mechanical ventilation. Crit Care Med. 2005;171:388-416.
2. Horan TC, Andrus M, Dudeck MA. CDC/NHSN surveillance definition
of health careassociated infection and criteria for specific types of infec-
tions in the acute care setting. Am J Infect Control. 2008;36(5):309-332.
3. Rello J, Ollendorf DA, Oster G, et al. Epidemiology and outcomes of ven-
As critical care patients require a collaborative effort tilator-associated pneumonia in a large US database. Chest. 2002;
between nurses, respiratory therapists, and physicians, it is 122:2115-2121.
best to begin with a team effort to implement this change in 4. Vollman KM. Ventilator-associated pneumonia and pressure ulcer pre-
vention as targets for quality improvement in the ICU. Crit Care Nurs
practice. The physicians play a key role in understanding the Clin North Am. 2006;18:453-467.
protocol so that they can clear the patients to participate.
Nurses share a key role in incorporating the BCP into their
daily care and in minimizing any barriers that may occur. Res-
piratory therapists offered valuable insights into the pul-
monary stability and ventilator tolerance of the patient. The
multidisciplinary team approach also helped to ensure that
BCP sessions are coordinated within the patients daily care
and necessary assessments and procedures.

Conclusion
Is it beneficial to use the BCP? The BCP was safely used for
early mobility of ICU patients enrolled in this study and was
associated with decreased rates of VAP when compared with
the historical comparison group. The BCP can be considered a
method of early mobilization to improve pulmonary function.
An added benefit is that placing patients in the BCP requires
fewer personnel than other interventions require, and therefore
the patient may be mobilized more quickly and easily and with
less risk of injury to the caregiver. As with any position change
in a critically ill patient, use of the BCP is associated with a slight
risk. The tradeoff with increasing mobility in critically ill patients
is that because of the patients underlying disease, their normal
physiological responses are changed. The side effects of agita-
tion or increased intracranial pressure noted in this study may

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CE Test Test ID C102S: Progressive Mobility in the Critically Ill
Learning objectives: 1. Identify the risks associated with bed rest and immobility in intensive care unit patients 2. Describe the process of progressive
mobility 3. Discuss challenges and barriers to making positioning and mobility of patients a priority of practice in the intensive care unit

1. What is the major long-term complication resulting from the physical 7. Patients receiving continuous lateral rotation therapy (CLRT) should have the
deconditioning that takes place during a patients stay in the intensive care continuous rotation for how many hours per day?
unit (ICU)? a. 12 c. 16
a. Loss of orthostatic tolerance/disturbed equilibrium b. 14 d. 18
b. Onset of depressive mood disorders
c. Diminished quality of life after discharge 8. Which of the following is a recommendation included in all pressure ulcer
d. Increased susceptibility to autoimmune disorders prevention guidelines?
a. Repositioning of patients at least every 2 hours
2. Which of the following is the result of a patients developing gravitational b. Use of a therapy bed with a low-density foam surface
equilibrium? c. A planned repositioning schedule tailored to each individual patient
a. Increased orthostatic tolerance d. Use of a sling transfer aid when turning and/or repositioning patients
b. Difficulty adapting to a change in position
c. Stabilization of the plasma volume reduction that occurs during the 9. Which of the following statements regarding the use of CLRT is true?
first few days of bed rest a. CLRT alonethe right and left rotation of 20-40is the only pressure ulcer
d. Improved function of the bodys autonomic feedback loop prevention therapy necessary if the CLRT bed has a pressure distribution mattress.
b. Bolsters, pillows, and other positioning devices may be used during times when
3. Progressive mobility is defined as a series of planned movements in a CLRT is stopped, but they should be removed before use of active CLRT.
sequential manner with what final goal? c. CLRT is designed specifically for supporting pulmonary toileting, and should not be used
a. Returning to the patients baseline level of mobility for patients who are at high risk for developing pressure ulcers.
b. Achieving 75% of the patients pre-ICU activity level d. Incontinent patients receiving CLRT should have diapers and specially designed pads
c. Prevention of ventilator- and hospital-acquired pneumonia placed between them and the surface of the CLRT bed.
d. Patients ability to ambulate for a distance of at least 100 feet by the time
of ICU discharge 10. Which of the following is the definition of the beach chair position?
a. Elevation of the patients head of bed to 90 and the foot of bed at a -90 angle
4. What was the main cause of functional limitations occurring in patients b. Elevation of the patients head of bed to 75 and the foot of bed at a -75 angle
within 1 year after discharge from the ICU? c. Elevation of the patients head of bed to 70 and the foot of bed at a -75 angle
a. Heart muscle deconditioning d. Elevation of the patients head of bed to 90 and the foot of bed at a -70 angle
b. Skin breakdown/delayed wound healing
c. Joint contractures 11. Evidence-based practices to facilitate daily delivery of early ICU mobility include
d. Muscle wasting best practices in which of the following areas?
a. Management of sedatives and analgesics; promotion of sleep for ICU patients
5. When do this articles authors recommend assessing each ICU patients b. Using physical therapists to initiate progressive mobility programs; prioritization of
readiness for mobility? procedures by ICU nurses
a. During the initial nursing assessment following admission c. Use of beds that allow for patients to be positioned with backrest, hips, and knees
b. Each time a patients condition changes significantly angled at 90 without getting out of bed; protocols that include daily passive range of
c. Daily motion exercises
d. At the time of initiation of a progressive mobility protocol d. Physician-ordered out-of-bed activity (early mobility); staff education regarding the
complications associated with immobility and bed rest
6. The decreased muscle mass that occurs in critically ill patients is most
pronounced in what area of the body? 12. The study designed to evaluate staff perceptions of patient readiness for mobility
a. Upper limbs found that the most common facilitator identified by the nurses who planned out-of-
b. Lower limbs bed activity for their patients was which of the following?
c. Diaphragm a. Adequate staffing today
d. Abdomen b. Physician order
c. Patient is cooperative
d. New beds make getting the patient out of bed easier

1. K a 2. K a 3. K a 4. K a 5. K a 6. K a 7. K a 8. K a 9. K a 10. K a 11. K a 12. K a


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