Head-of-bed elevation is the intervention most consistently prescribed and least consistently delivered. Studies that measure the actual angle, rather than the ordered one, routinely find beds well below where the chart says they are — pushed flat for a procedure, for turning, for a transfer, and never restored.
The fix is not a new protocol. It is naming a number. Include the current head-of-bed angle in the ventilated patient's handover alongside the ventilator settings and the sedation score, and it stops being invisible. Whoever flattened the bed for a line insertion is then the person who has to say so.
The same applies after every procedure and every transfer: restoring the angle is part of finishing the task, not something the next shift discovers. And if a patient genuinely cannot be sat up — spinal precautions, severe shock — that should be an explicit, documented decision with a review point, rather than a default that persists for days.
- State the head-of-bed angle at handover, with the ventilator settings.
- Restore the angle as the last step of any procedure or transfer, before leaving the bedside.
- Where elevation is contraindicated, document why and when it will be reviewed.
- Check the bed's own angle indicator rather than estimating by eye — estimates run low.
- Inspect the sacrum and heels daily in any patient nursed head-up; the pressure moves with the angle.
Why it matters
The commonest reason a ventilated patient is flat is that nobody noticed, and nobody noticed because nobody says the number.
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