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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Beach Chair Position Protocol
GOAL: Beach Chair Position 1 hr 4 times/day for patients
who are candidates
Patients who are candidates:
Hemodynamically stable patients, as defined by:
No active bleeding
HR 60-120
MAP 60
SpO2 90
RR 30
Guidelines indicating Beach Chair Position is tolerated
by patient:
HR ~ change 10% from baseline
BP ~ change 20% from baseline
EKG ~ no changes or arrhythmias that causes symptoms or
hemodynamic compromise
SpO2 ~ remains 90%
O2 requirement ~ remains same/weaned
Patients who are not yet candidates:
Temporary pacemakers
Intraaortic balloon pump
Sengstaken-Blakemore/Minnesota tubes
Vasopressor requirement increase
ICP >20
ECMO
Specialty beds/mattress (eg, RotoProne, RotoRest, or KCI
First Step)
Paralytics in use
Ordered HOB flat/bed rest
Clarify with physician as some are ok:
-Recent SSG/flap to lower limbs or trunk
-Recent open abdomen
-Unstable C-spine
-Pelvic or spine fractures
-Unstable head bleeds/post craniotomy/deep coma patients
-Require continuous lower extremity elevation
Figure 2 Beach chair position protocol.
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,
oxygen; PaO2, partial pressure of oxygen; RR, respiratory rate; SpO2, oxygen
saturation as shown by pulse oximetry; SSG, split skin graft.
Reprinted with permission. Caraviello 2007.
November 2008 in patients admitted to the surgical trauma
and neuroscience ICUs. To compare outcomes of the BCP
cohort versus patients not in the BCP cohort, a comparison
group of ICU patients during the 6-month period from
November 2007 to May 2008 (the historical cohort) was retro-
spectively constructed. It was difficult to match the character-
istics of the retrospective cohort exactly because the BCP
criteria were not assessed in these patients. The BCP inclusion
and exclusion criteria were not assessed in the retrospective
cohort. In the end, data for patients in the medical ICU were
removed from the study because that unit changed bed frames
after beginning the study and a consistent BCP could not be
achieved. Also, the duration and consistency of use of the BCP
varied from patient to patient because of other competing
demands in the ICUs.
S10 CRITICALCARENURSE Vol 30, No. 2, APRIL 2010 Supplement
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Several positive outcomes were realized in this initial
study. Chi-square analysis indicated a significant reduction in
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
to sit in the BCP for the full 60 minutes. In this 4.8%, cardio-
vascular events were the reason for patients not tolerating the
full 60 minutes 36% of the time, followed by neurological
events 21% of the time. Tachycardia or hypertension and the
rare hypotensive events were easily corrected by the staff.
Patients were removed from the BCP due to respiratory con-
cerns only 8% of the time. The staff placed the patients in the
BCP 4 times per day in conjunction with the daily tasks that
ICU patients require. At times, placing a patient in the BCP
was not appropriate; for example, during discussions of pallia-
tive care or withdrawal of care, if such positioning was not the
physicians preference, if the bed was the wrong type, or if the
patient was on a tracheostomy collar or T-bar trial. The
patient was not placed in the BCP 25.6% of the time because of
physiological concerns such as heart rate, blood pressure, or
other factors listed in the BCP protocol.
Some outcomes were not reduced in the BCP group; these
included ventilator days, ICU length of stay, and hospital
length of stay. When the severity of illness, which is catego-
rized independently by the hospital team according to the
patients diagnosis-related group, was compared in the 2
groups (Figure 4), 77% of the BCP group was in class 4, or the
sickest class of patients, in comparison to 57% in class 4 in the
historical cohort. This difference could account for the higher
number of ventilator days and the longer ICU and hospital
lengths of stay in the BCP group.
12
10
8
Rate
6
4
2
0
BCP group Historical cohort
2 = 4.8, P = .03
VAP case rate
Odds ratio = 0.321
VAP rate per 1000 VD
Figure 3 Comparison of ventilator-associated pneumonia
(VAP) case rate and VAP rate per 1000 ventilator days (VD)
between the beach chair position (BCP) group and the his-
torical cohort. Both rates were significantly lower in the
BCP group. The VAP case rate was defined for this study as
the number of patients per cohort who had VAP diagnosed.
For the BCP cohort, the VAP case rate was defined as those
patients who had VAP diagnosed while actively being
placed in the BCP within the past 48 hours.
www.ccnonline.org
 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
Figure 4 Comparison of severity of illness (SOI) between
the historical cohort and the patients in the Beach Chair
Position (BCP) group. All patients admitted to the hospital
have their SOI calculated on the basis of their diagnosis-
related group. Most patients in the BCP group were SOI
class 4, or the sickest classification, when compared with
the historical cohort. It is striking that the rate of ventilator-
associated pneumonia was lower in the BCP group, when
the patients in the BCP group had a higher SOI, were in the
intensive care unit longer, and had a longer duration of
mechanical ventilation.
As critical care patients require a collaborative effort
between nurses, respiratory therapists, and physicians, it is
best to begin with a team effort to implement this change in
practice. The physicians play a key role in understanding the
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.
Acknowledgments
Kelly Ann Pennington Caraviello thanks the staff of the surgical/trauma, neu-
roscience, and medical ICUs at the Medical University of South Carolina Hos-
pital for their participation. Special thanks to Dr John Welton for his support.
Financial Disclosures
The Medical University of South Carolina Hospital Authority provided finan-
cial support for this study.
References
1. American Thoracic Society and the Infectious Diseases Society of Amer-
ica. Guidelines for the management of adults with hospital-acquired,
ventilator-associated, and healthcare-associated pneumonia. Am J Respir
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-
tilator-associated pneumonia in a large US database. Chest. 2002;
122:2115-2121.
4. Vollman KM. Ventilator-associated pneumonia and pressure ulcer pre-
vention as targets for quality improvement in the ICU. Crit Care Nurs
Clin North Am. 2006;18:453-467.

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

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

Kb Kb Kb Kb Kb Kb Kb Kb Kb Kb Kb Kb
Kc Kc Kc Kc Kc Kc Kc Kc Kc Kc Kc Kc
Kd Kd Kd Kd Kd Kd Kd Kd Kd Kd Kd Kd
Test ID: C102S Form expires: April 1, 2012 Contact hours: 1.0 Fee: AACN members, $0; nonmembers, $10 Passing score: 9 correct (75%) Category: Synergy CERP A
Test writer: Ann Lystrup, RN, BSN, CEN, CFRN, CCRN
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