Implementing Prone Positioning for COVID-19 Patients Outside the Intensive Care Unit

Nurse-led implementation of awake prone positioning

This article discusses the pathophysiology of COVID-19 acute respiratory distress syndrome (ARDS), the evidence supporting the use of awake prone positioning (APP) for adult patients with COVID-19 ARDS cared for in acute care medical units, and a quality improvement initiative to support a standardized APP process on a COVID-19 medical unit.

A Prospective, Descriptive Study on Awake Self-prone in Hospitalized COVID-19 Patients

Purpose/Aims

Healthcare workers internationally continue to look for innovative ways to improve patient outcomes and optimize resource utilization during the coronavirus disease 2019 (COVID-19) pandemic. Proning awake, nonintubated patients has been suggested as a potential intervention in critical care. The aim of this study is to provide a multidisciplinary approach to safely perform awake self-prone positioning in the acute care setting.

Design

This is a prospective, descriptive study.

Method

Patients with COVID-19 were screened and enrolled within 48 hours of a positive test. After approval from the primary team, patients were provided education materials by a multidisciplinary team on the self-prone intervention. Visual cues were placed in the room. Patients were requested to maintain a diary of hours of prone positioning. Patients' baseline characteristics, admission vitals, daily oxygen requirements, and level of care were collected.

Results

Of 203 patients screened, 31 were enrolled. No pressure-related injury or catheter (intravenous or urinary) displacement was identified. Eighty-one percent of patients spent less than 8 hours a day in prone positioning. Among patients enrolled, none required invasive ventilation or died.

Conclusions

Awake self-proning can be performed safely in patients given a diagnosis of COVID-19 in the acute care setting with a multidisciplinary team.

Implementation and Assessment of a Proning Protocol for Nonintubated Patients With COVID-19

INTRODUCTION

The COVID-19 pandemic has caused over 1,250,000 deaths worldwide. With limited therapeutic options, proning nonintubated patients emerged as a safe and affordable intervention to manage hypoxemia.

METHODS

A proning protocol to identify and prone eligible patients was implemented. Patients were encouraged to self-prone for 2-3 hours, 3 times daily. Investigators created educational materials for nurses and patients and developed a COVID-19-specific proning order within the electronic health record (EHR). Investigators completed an 800-person retrospective chart review to study the implementation of this protocol.

RESULTS

From March 22, 2020, to June 5, 2020, 586 patients were admitted to the COVID-19 floor. Of these patients, 42.8% were eligible for proning. Common contraindications were lack of hypoxia, altered mental status, and fall risk. The proning protocol led to a significant improvement in provider awareness of patients appropriate for proning, increasing from 12% to 83%, as measured by placement of a proning order into the EHR. There was a significant improvement in all appropriate patients documented as proned, increasing from 18% to 45% of eligible patients.

CONCLUSIONS

The creation of an effective hospital-wide proning protocol to address the exigencies of the COVID-19 pandemic is possible and may be accomplished in a short period of time.