Having the Right Tool: A Highly Visible Angle Indicator Improved HOB Elevation

Abstract & Commentary

By Leslie A. Hoffman, PhD, RN, Department of Acute/Tertiary Care, School of Nursing, University of Pittsburgh, is Associate Editor for Critical Care Alert.

Dr. Hoffman reports no financial relationship to this field of study.

Synopsis: A highly visible angle indicator placed on ICU beds increased compliance with 30° head-of-the-bed elevation from 23% to 72%.

Source: Williams Z, et al. A simple device to increase rates of compliance in maintaining 30-degree head-of-bed elevation in ventilated patients. Crit Care Med 2008;36:1155-1157.

The purpose of this study was to determine whether use of a simple, easy-to-view, color-coded device could increase adherence to head-of-bed (HOB) elevation guidelines. The device consisted of a piece of glossy printer paper cut into a triangle. The base of the triangle was colored red (right half) or green (left half). A silk suture was fastened to the apex of the triangle and a steel nut tied to the distal end of the suture. The angle indicator was placed on the bed so that the weight hung in the green zone when the HOB was elevated > 30° and in the red zone when elevated < 30°.

The study was conducted over 4 weeks. During the first 2 weeks, nursing staff were e-mailed to remind them of the HOB elevation policy and > 30° HOB orders were written by the medical staff. Over the next 2 weeks, the device was placed on the bed of all surgical, medical, thoracic, and trauma ICU patients who did not have an indication to be kept in a less elevated position. A total of 268 HOB elevation measurements was taken.

The average HOB elevation without the device was 21.8° (n = 166) and with the device 30.9° (n = 102) (P < 0.005). When compliance was defined as ≥ 28° elevation, 23% of beds without the device were in compliance, compared to 72% with the device. The majority (72%) of nurses found the device to be an improvement over existing methods, 88% found it helpful, and 84% felt it should be routinely used.


Findings of this study support the adage that a simple solution can be very effective and, in this example, incur minimal cost. The authors note that their study was independently funded at a material cost of $42. Prior studies indicate poor adherence to recommendations for 30° HOB elevation despite strong supporting evidence, published national recommendations, and educational initiatives that promote this strategy as a means of preventing ventilator-associated pneumonia (VAP). The challenge is to determine ways to insure that guidelines are consistently implemented and preventable complications avoided. Congress has observed that some characteristics of our current reimbursement system can be viewed as allowing a negative incentive—hospitals that improve patient safety and decrease preventable complications see their revenues and, consequently, their profit decreased.

In 2005, Congress instructed the Secretary of Health and Human Services to select at least 2 conditions that are: a) high cost or high volume or both; b) result in the assignment of a case to a diagnosis-related group (DRG) that has a higher payment when present as a secondary diagnosis; and c) could reasonably have been prevented through the application of evidence-based guidelines.1 The Centers for Medicare and Medicaid Services selected eight conditions that were deemed preventable complications that no longer qualify for reimbursement. Additional conditions, possibly including VAP, will likely be added in the future. Hence, the intervention described in this study is of great interest.

In the control phase of the study, the authors were unable to demonstrate compliance with HOB elevation despite standardized orders to maintain the HOB > 30°, the presence of traditional HOB indicators, and in-service teaching. Lack of knowledge was not an issue, as 94% of those surveyed indicated they were aware of the importance of maintaining adequate HOB elevation. Prior studies indicate that ICU clinicians overestimate the angle of elevation and commercial angle indicators are often small and not highly visible. The angle indicator used in the present study was clearly visible from the patient's doorway, clearly displayed whether the bed was adequately elevated using a color-coded (red/green) indicator and accurate in Trendelenburg position. As such, it seems a particularly cost effective way to promote adherence to HOB guidelines.


  1. Rosenthal MB. Nonpayment for performance: Medicare's new reimbursement rule. N Engl J Med 2007;357:1573-1575.