An Evidence-Based Protocol for Manual Prone Positioning of Patients With ARDS.

BACKGROUND: Manual prone positioning has been shown to reduce mortality among patients with moderate to severe acute respiratory distress syndrome, but it is associated with a high incidence of pressure injuries and unplanned extubations. This study investigated the feasibility of safely implementing a manual prone positioning protocol that uses a dedicated device. REVIEW OF EVIDENCE: A search of CINAHL and Medline identified multiple randomized controlled trials and meta-analyses that demonstrated both the reduction of mortality when prone positioning is used for more than 12 hours per day in patients with acute respiratory distress syndrome and the most common complications of this treatment. IMPLEMENTATION: An existing safe patient-handling device was modified to enable staff to safely perform manual prone positioning with few complications for patients receiving mechanical ventilation. All staff received training on the protocol and use of the device before implementation. EVALUATION: This study included 36 consecutive patients who were admitted to the medical intensive care unit at a large academic medical center because of hypoxemic respiratory failure/acute respiratory distress syndrome and received mechanical ventilation and prone positioning. Data were collected on clinical presentation, interventions, and complications. SUSTAINABILITY: Using the robust protocol and the low-cost device, staff can safely perform a low-volume, high-risk maneuver. This method provides cost savings compared with other prone positioning methods. CONCLUSIONS: Implementing a prone positioning protocol with a dedicated device is feasible, with fewer complications and lower costs than anticipated.

Developing and Implementing a Dedicated Prone Positioning Team for Mechanically Ventilated ARDS Patients During the COVID-19 Crisis.

BACKGROUND: The spread of the COVID-19 pandemic in China demonstrated at an early stage the high rate of moderate to severe acute respiratory distress syndrome (ARDS) in the patient population. An intervention that has proved beneficial is the use of prone positioning (PP) for mechanically ventilated patients with ARDS. In one institution, PP was practiced in the medical ICU for this population. However, with the dramatically increasing patient load, staff anticipated that greater capacity to provide this treatment to all qualifying patients would be required. METHODS: A group of physical therapists and occupational therapists (PT/OTs) with ICU experience was redeployed from their regular roles to receive training in PP from an experienced medical ICU (MICU) RN. After intensive training, the team was ready to provide PP to patients. As the workload increased, additional PT/OTs were recruited to the team. A coordinating structure comprising attending pulmonologists screened and advised on appropriate patients. A communication and feedback structure was also implemented. RESULTS: Over a period of seven weeks, the team provided PP to more than 100 patients, with 577 individual interventions in a total of 14 ICUs and one emergency department. There were no major airway or central venous access complications, and only one anterior pressure injury was recorded. CONCLUSION: The rapid implementation of an interdisciplinary PP team in a crisis situation is feasible. It can provide a safe and efficient alternative to adding to the workload of an overloaded nursing staff.

Rapid implementation of a mobile prone team during the COVID-19 pandemic.

PURPOSE: The coronavirus disease 2019 (COVID-19) is associated with high rates of acute respiratory distress syndrome (ARDS). Prone positioning improves mortality in moderate-to-severe ARDS. Strategies to increase prone positioning under crisis conditions are needed. MATERIAL AND METHODS: We describe the development of a mobile prone team during the height of the crisis in New York City and describe characteristics and outcomes of mechanically ventilated patients who received prone positioning between April 2, 2020 and April 30, 2020. RESULTS: Ninety patients underwent prone positioning for moderate-to-severe ARDS. Sixty-six patients (73.3%) were men, with a median age of 64 years (IQR 53-71), and the median PaO2:FiO2 ratio was 107 (IQR 85-140) prior to prone positioning. Patients required an average of 3 ± 2.2 prone sessions and the median time of each prone session was 19 h (IQR 17.5-20.75). By the end of the study period, proning was discontinued in sixty-seven (65.1%) cases due to clinical improvement, twenty (19.4%) cases due to lack of clinical improvement, six (5.8%) cases for clinical worsening, and ten (9.7%) cases due to a contraindication. CONCLUSION: The rapid development of a mobile prone team safely provided prone positioning to a large number of COVID-19 patients with moderate-to-severe ARDS.