The positioning of critically ill patients is an independent nursing decision, often has multiple rationales, and may significantly affect morbidity and mortality. Recent evidence suggests that backrest elevation in critically ill patients may reduce ventilator-associated pneumonia. However, use of recommended levels of backrest elevation is infrequent in the critical care environment. In addition, published guidelines for backrest elevation to reduce pneumonia conflict with those for protecting skin integrity. This article reviews the benefits and complications of backrest elevation, data related to current positioning practices, and recommendations for backrest elevation. A quality improvement process to guide evidence-based care related to backrest positioning is also described.

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