Setting and Study Design
This prospective cohort study took place at a 640-bed (62 intensive care unit (ICU) beds) quaternary care center and enrolled 250 adult inpatients between December 2013 and March 2015. All intubated ICU patients who had provided consent for use of their electronic health record data for research purposes were screened for eligibility by a research nurse. Patients were excluded if they were intubated solely for airway protection, had a history of pleurodesis, pneumonectomy, or video-assisted thoracoscopic surgery, had been extubated or had been intubated for > 24 hours before a first PU , had been transitioned to comfort care, or were imminently dying (Figure 1). Due to physician availability, daily enrollment was limited to the 3 most recently intubated patients each morning. The protocol was approved by an institutional review board (Schulman Associates IRB, Inc. Approval No. 4080-2E).