Development of a Prone Team and Exploration of Staff Perceptions During COVID-19

Acceptability of a physiotherapy-led intensive prone positioning service in intensive care: A qualitative study with multidisciplinary clinicians

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic resulted in an increased number of patients with COVID-19-related respiratory failure requiring prone positioning. To reduce pressure on nursing and medical staff in the intensive care unit (ICU), a physiotherapy-led intensive prone positioning (PhLIP) service was implemented.

OBJECTIVES

The aim of this study was to explore the acceptability of the PhLIP service from the perspective of nurses and doctors working in the ICU and the physiotherapists who delivered the service.

METHODS

A qualitative evaluation was conducted using semistructured interviews and focus groups, guided by the theoretical framework of acceptability (TFA). Participants included doctors, nurses, and physiotherapists who interacted with or delivered the PhLIP service.

RESULTS

A total of 19 interviews (eight doctors and 11 physiotherapists) and four focus groups (13 nurses) were conducted. Eleven themes were identified within the eight domains of the TFA. Overall, the PhLIP team was highly valued and appreciated (TFA: affective attitude); enabled high-quality care and improved ICU efficiency (TFA: perceived effectiveness); reduced risks to patients and staff (TFA: perceived safety and risk); and was empowering for the clinicians involved (TFA: self-efficacy). Being in the PhLIP team was physically and mentally exhausting, and the service put strain on the physiotherapy department due to reallocation of staff (TFA: burden). Having trust in the physiotherapists leading the prone positioning service was a key influence on nursing and medical acceptance of the service.

CONCLUSION

The PhLIP team delivered an acceptable service that improved clinical care and efficiency during the COVID-19 pandemic. Other ICUs should consider the availability, skills, and confidence in the team selected to implement an intensive prone positioning service, should the need arise again. Researchers using the TFA to explore acceptability of healthcare innovations should also consider the recipients' trust in those delivering the intervention.

Perceptions and Perceived Barriers regarding Proning among Nurses of a Tertiary Care Center in India

Current study was conducted to assess the perception and barriers regarding proning among nurses. 385 nurses were conveniently surveyed using pre-tested tools. 3.9% of nurses "felt like running away" while providing care to the patients in prone position. 93.5% believed that prone position for COVID-19 patients is beneficial in reducing morbidity and that teamwork is required to be effective (96.6%). 93% nurses believed that inadequate staff-patient ratio is a significant barrier for prone positioning. Other barriers were fear of dislodgement of tubings (91.5%), difficulty in providing routine care (87.3%) and inadequate institutional protocol (83.9%). 12.5% were trained regarding proning.

Strategies to preventing pressure injuries among intensive care unit patients mechanically ventilated in prone position: a systematic review and a Delphi study

Background

Although the incidence of pressure injury in the prone position is high for the mechanically ventilated patients in the intensive care unit, evidence-based strategies are still lacking.

Propose

To conduct a systematic review of current evidence, and to propose a series of strategies to prevent pressure injuries among mechanically ventilated patients with prone position in the intensive care unit.

Methods

The study was guided by the Medical Research Council framework. After a systematic review of current evidence of original articles, guidelines, expert consensus and theories, a strategy draft was developed. Then we invited 20 experts to modify and refine these strategies through two rounds of Delphi consensus method.

Results

After two rounds of Delphi process, the importance of coefficient of variation (Cv) and Kendall's coefficient of concordance in the strategies repository were 0.067 and 0.311, respectively. And the operability of Cv and Kendall's coefficient of concordance in the strategy draft was 0.055 and 0.294, respectively. Ultimately, we established 31 strategies for including 7 themes (assess risk factors, assess skin and tissue, body position management, skin care, nutrition, preventing medical device-related pressure injuries, education and supervision). In addition, we also developed a strategy framework to clarify our strategies.

Conclusion

According to the Medical Research Council framework, we developed 7 themes and 31 strategies to prevention prone-position pressure injuries among the intensive care unit mechanically ventilated patients. This study was considered to improve the clinical management of pressure injuries among prone position patients in the intensive care unit settings.

Lessons learned in mechanical ventilation/oxygen support in COVID19

The clinical spectrum of severe acute respiratory syndrome coronavirus-2 infection ranges from asymptomatic infection or mild respiratory symptoms to pneumonia, with severe cases leading to acute respiratory distress syndrome with multiorgan involvement. The clinical management of patients with coronavirus disease 2019 (COVID-19) acute respiratory distress syndrome (ARDS) changed over the course of the pandemic, being adjusted as more evidence became available. This article will review how the ventilatory management of COVID-19 ARDS evolved and will conclude with current evidence-based recommendations.

Optimizing nursing workload in the intensive care unit during the COVID-19 pandemic: Planning prone positioning

Background

Prone positioning is a complex, time-consuming task, involving significant intensive care unit staff. The increased workload during the COVID-19 pandemic and the reduced staffing boosted the burden of intensive care unit nurses, which might have a negative impact on patients' safety and outcomes.

Methods

Retrospective chart review, analysing the hourly distribution of pronation and supination procedures in mechanically ventilated critically ill patients during the first and the second wave of the COVID-19 pandemic (March 2020-May 2021).

Results

303 procedures were analysed: 77 pronation manoeuvres out of 156 (49.3%) and 82 supination out of 147 (55.8%) were performed in dedicated time slots in the afternoon (15.30-19.00) and in the morning (9.30-12.30) shifts, when the nursing staff was increased. At least five healthcare providers performed pronation manoeuvres. Six device displacements were registered.

Conclusions

Planning complex activities such as prone positioning needs an effective strategy to optimize nursing staff workload in the intensive care unit. This organization allowed to perform pronation cycles with a duration of at least 16 h, according to current clinical recommendations.

Skin damage prevention in the prone ventilated critically ill patient: A comprehensive review and gap analysis (PRONEtect study)

Background

Ventilating critically ill patients with acute respiratory distress syndrome in the prone position is a life-saving strategy, but it is associated with adverse consequences such as skin damage.

Aim

To identify, review and evaluate international proning and skin care guidelines and make an inventory of commonly used equipment and training resources.

Design

A gap analysis methodology was applied.

Methods

1) Comprehensive search and evaluation of proning and skin care guidelines, 2) extensive search and listing equipment and educational resources, and 3) international consultation with 11 experts (8 countries).

Data sources

A variety of sources researched through July 2021 were used to identify relevant literature: (1) scientific literature databases and clinical trials registries, (2) intensive care and wound care associations, (3) healthcare organisations, (4) guideline development organisations, and (5) the Google search engine. Eleven international experts reviewed the literature and provided insights in two, 2-h online sessions.

Findings

The search yielded 24 guidelines. One clinical practice guideline had high methodological quality. Twenty-five devices/equipment and sixteen teaching materials were identified and discussed with the expert panel. The gap analysis identified a lack of concise, accessible, evidence-based guidelines and educational materials of short duration.

Conclusion

This analysis forms the basis for designing a competency-based education and training intervention for an interdisciplinary team caring for the skin of critically ill patients in the prone position.

Impact

The results can assist the multidisciplinary team to review their current protocol for prone positioning. This is a first step in developing a training package for clinicians.

Innovative Partnership Between Intensive Care Unit Nurses and Therapists to Care for Patients With COVID-19

BACKGROUND

When patients with COVID-19 began presenting to hospitals in early 2020, medical professionals were unprepared to handle the severity of disease and the number of severely ill patients.

LOCAL PROBLEM

In response to critical needs of patients with COVID-19 and the threat of nurse burnout, a special operations team comprising physical and occupational therapists was convened to (1) provide help to intensive care unit nurses, (2) help therapists be productive, and (3) use therapists' specialties for critical patients.

METHODS

Two therapists teamed up each shift to work with every critical patient with COVID-19, performing numerous nursing and therapy activities. Activity frequency was documented by the therapists daily, and duration was estimated and data were summarized by nursing leadership.

RESULTS

During the 9-week program, 35 critical patients with COVID-19 were included in the special operations program. During the program, the teams performed 10 activities, including prone positioning, turning, and mobilization, 1937 times with the patients with COVID-19. The partnership saved between 5 and 40 minutes of intensive care nurse time per activity, which resulted in a total of 677.2 hours of nursing time saved.

DISCUSSION

Implementation of the special operations program had a positive impact on patients, nurses, and therapists. Patients benefited both clinically and socially from additional time with special operations teams. Nurses benefited from having help caring for critical patients, and therapists benefited from increased productivity during redeployment.

CONCLUSION

Deployment of nonnursing clinical staff could be an effective strategy to leverage available resources while maintaining clinical standards of care and reducing nursing burden during a pandemic or crisis surge.