Backrest elevation may not impact pressure injuries

Mar 01, 2018

Added to Collection

Study in American Journal of Critical Care finds no association between level of backrest elevation and changes in sacral tissue integrity

ALISO VIEJO, Calif. – March 1, 2018 –It’s a dilemma faced every day in hospitals as they seek to reduce healthcare-associated infections and complications: how much to elevate a critically ill patient receiving mechanical ventilation.

Placing patients in backrest positions of less than 30 degrees is believed to reduce pressure on bony prominences that are most at risk for pressure injury, while higher backrest positions are recommended to reduce the risk of ventilator-associated pneumonia (VAP).

Pressure injuries and VAP are two of the most common and costly complications for critically ill patients receiving mechanical ventilation, but the direct conflict in body position recommendations forces clinicians to make a difficult choice as to which is best for their patient.

A study published in the American Journal of Critical Care (AJCC) may help resolve the struggle related to backrest elevation, finding that changing backrest elevation in critically ill patients receiving mechanical ventilation may not be as important or as effective in preventing pressure injuries as once thought.

Lack of Association of High Backrest With Sacral Tissue Changes in Adults Receiving Mechanical Ventilation” provides new insights related to the effects of backrest elevation on the integrity of sacral tissue, an area at high risk for pressure injury development.

The research team included representatives from Virginia Commonwealth University’s (VCU’s) nursing school, engineering school and the department of surgery at the VCU Health System, along with colleagues from the University of Miami and the Air Force Institute of Technology at Wright-Patterson Air Force Base.

Principal investigator Mary Jo Grap, PhD, RN, nursing alumni distinguished professor at VCU’s School of Nursing, said, “The theory that higher backrest elevation heightens the risk for pressure injury has led to recommendations that may not provide expected outcomes. We found no association between backrest elevation and changes in tissue integrity.”

The research is based on a longitudinal, descriptive study of tissue integrity of 150 patients receiving mechanical ventilation in three intensive care units at VCU Health System. A total of 84 patients enrolled in the study had data on both backrest elevation and skin integrity for evaluation of daily tissue changes for one or more of the 24-, 48- or 72-hour observation periods.

Assessments indicated participants were high-acuity patients at high risk for pressure injury, and all had a barrier to help prevent pressure injuries in the sacral area.

Overall, the largest proportion of time was spent at a backrest elevation of 20 to 30 degrees, whether participants had no pressure injury, an injury with no change, an injury that was improving or an injury that was worsening. The amount of time spent at less than 20 degrees or greater than 30 degrees was fairly evenly divided for participants with no injury or for those with an injury that had no change during the observation period, but it varied widely for those whose injury had changed (worsened or improved).

Data analysis showed no significant difference among the proportions of time spent at various backrest elevations between the four injury categories. Further, effect sizes for the injury categories were small.

Overall, the researchers found that backrest elevation had no effect on the integrity of sacral tissue. They recommend that future research focus on position types, turning frequency and other factors that may influence the development of pressure injuries.

The research was funded by a three-year, $1.4 million grant from the National Institute of Nursing Research. The journal published an article with other findings from the research team’s work on backrest elevation in May 2016.

The American Association of Critical-Care Nurses (AACN), which publishes AJCC, has a variety of clinical resources related to prevention of pressure injuries, including materials from AACN Clinical Scene Investigator (CSI) Academy innovation projects.

To access the article and its full-text PDF, visit the AJCC website at

About the American Journal of Critical Care: The American Journal of Critical Care (AJCC), a bimonthly scientific journal published by the American Association of Critical-Care Nurses, provides leading-edge clinical research that focuses on evidence-based-practice applications. Established in 1992, the award-winning journal includes clinical and research studies, case reports, editorials and commentaries. AJCC enjoys a circulation of more than 110,000 acute and critical care nurses and can be accessed at

About the American Association of Critical-Care Nurses: Founded in 1969 and based in Aliso Viejo, California, the American Association of Critical-Care Nurses (AACN) is the largest specialty nursing organization in the world. AACN represents the interests of more than half a million acute and critical care nurses and includes more than 200 chapters in the United States. The organization’s vision is to create a healthcare system driven by the needs of patients and their families in which acute and critical care nurses make their optimal contribution.

American Association of Critical-Care Nurses, 101 Columbia, Aliso Viejo, CA 92656-4109; 949-362-2000;;;