1) A long-term acute care hospital tested the use of specialty beds that could tilt clients to standing positions to increase mobility and improve outcomes for medically complex patients. 2) The study evaluated 5 beds over 120 days, comparing outcomes for clients who received traditional therapy plus upright tilting in the specialty beds versus traditional therapy alone. 3) Preliminary findings suggested clients who used the tilt beds had shorter hospital stays, greater functional gains, fewer delirium days, and were more likely to be discharged home or to acute rehabilitation than those receiving only traditional therapy.

1. 22 JANUARY 18, 2016 • WWW.AOTA.ORG
In the Clinic
s a growing body of evidence
highlights the importance of
early mobility for critically
ill clients as a predictor of
positive medical and physical
outcomes, hospitals continue to look for
ways to safely and effectively mobilize cli-
ents to achieve these outcomes. At Carolinas
ContinueCare Hospital, a long-term acute
care facility (LTAC) in Charlotte, North
Carolina, that treats medically complex cli-
ents, staff members are actively looking for
ways to maximize outcomes for their unique
population.
Research has noted that prolonged bedrest
and immobility have detrimental effects on
all systems, including respiratory, cardio-
vascular, musculoskeletal, neurological, integ-
umentary, gastrointestinal, metabolic, and
psychosocial (Brower, 2009). While attend-
ing the International
Respiratory Conven-
tion and Exhibition
in 2013, LTAC team
members observed
a hospital-grade spe-
cialty bed that func-
tioned as a standard
hospital bed and
had the capability
to transition a client
to a full standing
position or tilt the
client to any degree
in between. The
tilting mechanism
in the bed, with the
assistance of a foot-
board scale, would
allow staff to mea-
sure and increase
weight-bearing
ratios and upright
positioning during
the course of treat-
ment for accelerated
progressive functional therapy to reduce
immobility among patients.
Purpose
The team initiated a project to determine
whether incorporating this specialty bed
would improve client outcomes through
increased functional interventions while
maximizing staff and client safety. Thera-
pists used the Occupational Therapy Practice
Framework: Domain and Process, 3rd Edition
(American Occupational Therapy Associa-
tion, 2014), Model of Human Occupation
(Lee, Taylor, Kielhofner, & Fisher, 2008),
and Occupational Adaptation Model (Sch-
kade & Schultz, 1992) to help the clients
involved in the project set meaningful goals.
Project
The facility evaluated five beds for 120 days.
Clients were selected based on criteria
related to their medical histories and cur-
rent status (see Figure 1 on p. 23). To ensure
accurate comparison, every client deemed
appropriate would alternately be placed
either on the tilt bed with frequent weight
bearing and upright positioning processes or
would receive only traditional care.
All clients received traditional care
therapies; however; those clients on the tilt
bed performed many of these interventions
while simultaneously tilting upright with
complementing lower extremity weight
bearing. Traditional therapies included (but
were not limited to) cognitive remediation,
neuro-muscular stimulation, motor control
planning, occupational performance,
self-care and leisure retraining, and home
management. Additionally, task-based activ-
ities, such as therapist-assisted therapeutic
exercise, bed mobility, sitting balance, edge-
of-bed weight bearing, sit-to-stand attempts,
and time out of bed, were also included.
The clients on the tilting bed performed
upright positioning approximately three
times daily for a maximum of 20 minutes
A
Janet Combs
Margaret Arnold
Angela Roach
PHOTOGRAPHCOURTESYOFTEHAUTHORS
Vertical Tilt Beds in the Acute Care Setting
Testing an Upright Approach for Medically Complex Clients

2. 23OT PRACTICE • JANUARY 18, 2016
each, 6 days per week. Tilting was not
done if the client presented with any con-
traindications that were defined prior to
project initiation, such as severe delirium
or dementia. Clients would continue
to tilt until they were able to transfer
with moderate assistance or less, which
indicated that the therapy focus should
shift to activity engagement in the natural
environment (e.g., functional transfers,
eating at a table, grooming at the sink). A
variety of data points were collected and
analyzed, including length of stay, mobility
scores, pressure ulcers, discharge disposi-
tion, and ventilator-weaning days, through
quality monitors to determine whether
there were measurable differences as a
result of our intervention.
Findings
We found that using the tilt bed as an
adjunct to traditional therapy interven-
tions appeared to have a positive effect
on client outcomes. Certainly the clients’
introduction to upright positioning and
lower extremity weight bearing would
have otherwise been delayed, given their
overall level of weakness, the period of
time required to safely attempt sit to
stand, and therapists’ ability to elicit and
maintain weight bearing due to client and
therapist fatigue. Tilting allowed occu-
pational therapists access to the clients
in an upright position to elicit a greater
response of the reticular activating system
for improved alertness and more meaning-
ful and natural participation in therapeu-
tic interventions.
Figure 1.
Clients Not Appropriate for
Study Inclusion
• Unstable fractures
• Unstable intra-cranial pressure
• Unstable neurological brain injury
• Previously bed bound and/or with
severe preexisting physical or
mental issue (which may include
dementia)
• Missing lower extremities without
ambulatory potential
• Inability to follow fewer than 25%
of one-step commands at time of
admission
Step one of determining qualified
clients for the tilt bed involves
screening for their level of assistance
needed with mobility intervention.
•The client requires more than
moderate assistance for transfers
and ambulation and/or places
caregiver(s) at risk of injury from
physically assisting the client.
• The effectiveness of focused
therapy time or ability to achieve
therapeutic mobility goals is limited
by client size, debility, or medical
instability.
Case Example: Olivia
O
livia, a 34-year-old, independent
adult, was working in an ancillary
position at a hospital prior to
her illness. She had a history of Tuner’s
syndrome and irritable bowel disease.
Olivia presented to the hospital with
questionable colitis, tonic posturing, and
hypertensive emergency. She was intubat-
ed for airway protection, and her work up
revealed a right vertebral artery occlusion
with extensive bilateral brainstem and
cerebral infarcts. While hospitalized,
Olivia developed MRSA pneumonia, and
because of difficulties liberating from the
ventilator and dysphagia, she underwent
a tracheostomy and peg tube placement.
She was referred to LTAC for continued
care.
Among other things, Olivia presented
with impulsivity and distractibility, following
75% of one-step commands; the need for
moderate assistance with grooming and
rolling, maximum assistance with upper
body self-care and supine to and from sit,
and dependent assistance with all other
mobility and self-care tasks; and poor
static sitting balance.
Assigned to the tilt bed on her third
day of admission, Olivia participated
in two out of the three attempted tilts
per day for a total of 11 days. Initial tilts
ranged from 50° to 60° and progressed to
80°. Olivia was able to tolerate 20 minutes
of tilting for the majority of her sessions.
Physical and occupational therapy
were performed during tilts, with goals of
remediating impairments due to Olivia’s
stroke. Following evaluation and cli-
ent-centered goal planning, occupational
therapy initially focused on attention and
following commands while encouraging
engagement in activities of daily living
during tilts. As a result of tilting, Olivia
was more alert and her visual awareness
of her body and position in space were
much improved. Tasks were introduced
as single-step commands and chaining,
then progressed to multi-step, multi-ac-
tivity without prompting (e.g., brush hair
and teeth while weight bearing into lower
extremities). As Olivia’s cognition, atten-
tion, and strength improved, the therapists
also included trunk stability, mobility, and
upper extremity weight bearing into the
program. At discharge, Olivia had been
decannulated to room air; could follow
100% of two-step commands although
residual impulsivity and executive func-
tioning impairments persisted; had good
static sitting balance; and could ambulate
up to 15 feet with a rolling walker.
On discharge, she was not immediate-
ly able to return to work, but she was able
to return to a familiar setting and continue
her rehabilitative process and focus on
her occupational roles in her personal
environment.

3. 24 JANUARY 18, 2016 • WWW.AOTA.ORG
On average, clients who were tilted
three times per day stayed fewer days and
were more frequently discharged within
a pre-determined time frame appropri-
ate for their condition, made greater
functional gains based on admission and
discharge scores, had fewer delirium days,
and were more likely discharged to acute
rehabilitation or home than those clients
who received traditional therapy only.
Conclusion
Although we cannot prove that the tilt
bed expedited client progress, the quality
improvement project data, as well as staff,
client, and family perceptions, provide
the basis for stating that tilting may have
had a positive impact on overall out-
comes. Although many clients admitted
to the LTAC setting make measurable
medical and functional gains, the tilt
bed performance improvement project
demonstrated that medically complex
and physically challenging clients may be
able to reach those outcomes at a faster
rate through frequent tilting. Tilting also
appears to have had a lasting impression
on the clients and caregivers regarding
overall perception of care, quality of life,
and duration of hospitalization.
As a result of the project, the tilt bed
is now used as an option for treatment
with this client population. Employing the
same client criteria used in the project,
staff members are able to request the bed
for clients who they feel will benefit from
additional and/or frequent weight bearing
during their hospitalization. Information
continues to be gathered and analyzed to
see whether outcomes remain meaningful
with a larger sample size. Changes to the
program will also help to determine best
practice (e.g., whether two tilts per day are
just as effective as three per day).
Further research is recommended to
determine the impact of a more system-
atic use of tilting beds on client outcomes.
Larger numbers of clients, along with
variable tilting frequencies and care plans
based on protocols, will allow medical
professionals, researchers, and therapy
staff to determine best practice for upright
positioning and weight bearing interven-
tions in acute care.
References
American Occupational Therapy Association.
(2014). Occupational therapy practice frame-
work: Domain and process (3rd ed.). American
Journal of Occupational Therapy, 68, S1–S48.
http://dx.doi.org/10.5014/ajot.2014.682006
Brower, R. G. (2009). Consequences of bed rest.
Critical Care, 37, S422–428. http://dx.doi.
org/10.1097/CCM.0b013e3181b6e30a
Lee, S. W., Taylor, R., Kielhofner, G., Fisher, G.
(2008). Theory use in practice: A national sur-
vey of therapists who use the Model of Human
Occupation. American Journal of Occupational
Therapy, 62, 106–117. http://dx.doi.org/10.5014/
ajot.62.1.106
Schkade, J. K., Schultz, S. (1992). Occupational
adaptation: Toward a holistic approach for
contemporary practice, part 1. American Journal
of Occupational Therapy, 46, 829–837. http://
dx.doi.org/10.5014/ajot.46.9.829
Janet Combs, OTR/L, CPHM, is the regional director of
rehabilitation at Carolinas ContinueCare Hospitals, in Charlotte
and Kings Mountain, North Carolina.
Margaret Arnold, PT, CEES, CSPHP, is a physical therapist
and early mobility and safe patient handling consultant at
Inspire Outcomes, in Bay City, Michigan.
Angela Roach, RN, BSN, CDONA, is a clinical solutions
specialist at Universal Hospital Services, in Minneapolis,
Minnesota.
Learn More About
What You Read in OT Practice!
To order, call
877-404-AOTA, or
visit store.aota.org
A must-have publication for
Clinicians and Students
Choose appropriate tools for clinical practice.
Educators
Select assessment procedures for the classroom.
Researchers
Find instruments that are designed for research
purposes or will benefit from further investigation.
Flash Drive With Matrix of All Assessments
Nearly 600 instruments are reviewed in this new edition of occupational
therapy’s classic publication, including many developed by occupational therapists.
Order #900353. AOTA Members: $99, Nonmembers: $140
BK-403
Your primary source for research on the effectiveness and efficiency of
occupational therapy practice.
A subscription to the American Journal of Occupational Therapy (AJOT) is FREE
with your AOTA membership! AJOT is the most highly cited scholarly journal in the
occupational therapy profession and an essential practice resource. Now find it online
at otjournal.net.