For decades, prone positioning has been used as an intervention to improve oxygenation in critically ill patients with acute respiratory distress syndrome (ARDS). Recent data have shown that proning can lead to improved extubation rates and decreased mortality1; however, safely proning a critically ill patient takes time and a concerted effort of several frontline staff.2 Unfortunately, many intensive care units (ICUs) do not have the resources, education, or experience to prone critically ill patients.3 During the COVID-19 pandemic, resources were even more limited given a surge in ARDS patients, which outstripped ICU capacity at many institutions across the world.4 The ability to safely prone patients was severely compromised. To improve the ability to safely prone patients, a hospital proning team was established.
In March, the first cohort of COVID-19 patients was admitted to the medical ICUs (MICUs) at a large, academic, level 1 trauma center in Boston, Massachusetts. These patients, in general, were hypoxic, were experiencing profound air hunger, and had Pao2/FiO2 ratios of less than 150. Standard treatments for this patient population included using sedatives to achieve a Richmond Agitation-Sedation Scale score of −5, using paralytic agents, and alternating proning and supinating positions to improve oxygenation.5,6
Prone positioning improves oxygenation by increasing ventilation-perfusion matching and alveolar recruitment.7-9 To maximize the benefits of proning, it should be instituted within the first 24 hours, and patients should remain proned for at least 16 hours, following the PROSEVA trial.1 Prone positioning is not a benign intervention, and adverse events have been associated with it, such as loss of endotracheal tubes, dislodgement of central lines, and development of pressure injuries.6,10,11 Education, training, and adequate experience should be provided to all ICU providers involved in proning to safely perform this intervention.6
Critical care nurses are generally the health care providers proning patients in the ICU, yet many nurses have not been educated or trained to prone patients and thus should be extremely cautious in undertaking this intervention.6 Fortunately, there are health care clinicians outside the ICU, particularly in surgery and interventional radiology, who are facile at proning patients given that this positioning is required for certain procedures and surgeries. Using the skills and experiences of these clinicians as members of the proning team afforded an opportunity and ability to create a high-functioning proning team who could manage a surge of patients needing this intervention.6,12-14
As the MICU team began caring for critically ill COVID-19 patients, it was determined most of these patients would require prone positioning. In the MICU, most nurses are skilled in the process of proning due to the large amount of ARDS patients who are cared for in that setting. However, when the surge of COVID-19 patients surpassed the capacity of the MICUs, patients were admitted to other dedicated ICUs and makeshift surge ICUs, where nurses were both unfamiliar and uncomfortable with the procedure of proning. On several occasions, the MICU nurses were called to assist nurses in other ICUs with placing a patient in the prone position, which was not a judicious use of staffing resources during a surge. In addition, the proning process often took several members of the patient care team such as doctors and respiratory therapists (RTs), which took them away from other tasks, and was time consuming, taking more than 40 minutes from start to finish.
Despite having proning protocols, nurses in other ICUs with less experience still felt uncomfortable, and the volume of patients was unmanageable. Therefore, a proning team composed of nurses skilled in prone positioning was developed to maximize efficiency, use resources effectively, and ensure patient safety. The purpose of this article is to describe the development, implementation, and impact of a proning team during the surge in ICU patients with COVID.
No ethical concerns were identified during the implementation of this quality improvement initiative. SQUIRE 2.0 guidelines are used as a framework for the reporting of this work.15
The intervention was implemented at Beth Israel Deaconess Medical Center, a 673–inpatient-bed hospital that includes 77 ICU beds. During the peak surge, the total number of ICU beds increased to 133.
Because of the intensity of efforts taken to pronate and supinate patients, the numerous resources involved, and the expected surge of ICU patients, a proposal for the development of a proning team was submitted to the Hospital Incident Command System. Our Hospital Incident Command System team provides guidance in preparedness and response capabilities during any emergency. The initial proposal was for 10 to 12 self-directed, experienced operating room (OR) nurses to redeploy to the ICU proning team. This number was selected because it would provide 4 to 5 nurses every day to cover a 12-hour shift. Given elective surgeries had been canceled and OR staff were available for redeployment, the nursing director of the OR was asked to identify nurses who would be willing and able to be part of this team. While nurses were being identified, the MICU leadership coordinated with the safe patient handling (SPH) team, a group of physical therapists and registered nurses (RNs) that promotes employee and patient safety through supportive programs and educational initiatives to achieve culture change throughout the medical center from manual patient handling to use of SPH equipment, to develop an educational program for the OR nurses. Although the OR nurses had experience with placing patients in the prone position, they did not have experience caring for critically ill patients or familiarity with equipment in the ICUs, specifically ceiling lifts.
A comprehensive plan for education and training was developed and implemented using a team approach to ensure that the newly developed proning team and the ICU staff were prepared for prone positioning. All team members were instructed in donning and doffing personal protective equipment via online modules and just-in-time in-person demonstrations. The SPH team provided proning team members with psychomotor training on safe prone and supine positioning. The education and training programs took an average of 2 hours and were offered multiple times to meet staff needs.
In 2015, an interdisciplinary team of critical care nurses, critical care doctors, RTs, rehabilitation therapists, and members of the SPH team developed a proning protocol for ARDS patients in the MICUs. The protocol included both an algorithm to properly identify patients who would benefit from proning and a preproning checklist to reduce the risk of adverse events during proning (see Table 1). Accompanying educational sessions focused on indications for proning, airway management during proning, skin management, positioning techniques, and safe positioning. Because manual proning techniques described in the literature increased the risk of staff musculoskeletal injury,16 a method to use ceiling lifts was developed.17
TABLE 1 -
|Sedated and may be chemically paralyzed
|Eyes lubricated and taped shut
|Perform subglottic suction
|Perform oral care
|Set up end-tidal CO2 and monitor while prone
|Change ECG leads to back
| • No leads should be on the front.
|Remove the Foley securing device
|Ensure the endotracheal tube is secured with tape
|Apply barrier cream to the area around the mouth and under the nose
|Evaluate central and peripheral lines
| • Consider pausing any infusions
| • If an indwelling port is in place, it must be de-accessed.
|If possible, flush and cap the arterial line
| • Reattach immediately after turning
|Place foam dressings on the face, chest, and bony prominences; gel/soft pillows under pressure areas
|Prone toward the ventilator; position all tubing to ensure a safe turn
Resources for proning were made available in hard copy in a binder for each MICU and electronically in the Critical Care Manual found on the medical center's internal portal to increase access for all employees. In addition, a video was produced and made available on the internal portal demonstrating the process of proning to benefit employee learning styles. These initial resources served as the foundation for the education and preparation of the ICU proning team during the COVID-19 pandemic.
For the current intervention, 9 staff members from the OR and 2 additional nurses from preadmission testing were identified for redeployment to the proning team. Three 2-hour–long training sessions were held in small groups to accommodate social distancing guidelines as well as ensure time for psychomotor learning and practice (see Table 2). The training consisted of a 10-minute introduction by one of the MICU nursing directors, followed by a 10-minute review of proper donning and doffing techniques provided by a MICU nurse educator. This was supplemented with an e-learning module, which was completed by team members independently.
TABLE 2 -
Elements of Proning Team Education and Training
|Introduction to proning team
||MICU RN director
|Donning and doffing PPE
||MICU RN educator
|General ceiling lift training
|Proning and supinating training with ceiling lift and practice
Abbreviation: MICU, medical intensive care unit; PPE, personal protective equipment; RN, registered nurse; SPH, safe patient handling.
The remainder of the training session was led by an SPH team member. This included education on the medical center's SPH policy, the importance of using SPH equipment, and proper body mechanics to reduce the risk of musculoskeletal injuries. Given lack of experience with ceiling lifts, 45 minutes was dedicated to general ceiling lift training including emergency features and available slings. Psychomotor training including how to roll a patient onto a side-lying position, how to laterally transfer, and how to reposition a patient higher in bed was also part of the session. In addition, proning team members were instructed in the use of limb straps to reposition extremities.
The next 45 minutes were used to review the process of proning and supinating a patient with the use of the ceiling lift. Proning team members practiced the maneuver multiple times. A peer volunteer was used for practice under varied conditions to allow for problem solving together; this included the volunteer wearing a bariatric suit and variable starting positions. There was a brief review regarding proper patient positioning in the prone position for head and arm placement into swimmer's position. By the end of each session, teams were able to complete the proning and supinating maneuvers in 3 minutes or less.
A standard work document was developed that detailed the role and expectations of the proning team (see Table 3). This document, along with the resources from the proning binder and contact information for the SPH team, was emailed to the proning team members.
TABLE 3 -
Proning Team Standard Work Document
|1. Safe patient handling training
| 1. Video
| 2. Hands-on training for the use of ceiling lifts with the SPH team
| 3. “Procedure for proning” checklist
|2. Donning and doffing training
| 1. PowerPoint presentation
| 2. Hands-on training
|3. Proning pamphlet
| Currently, the proning team should be staffed with 4 members from 8:00 am to 8:00 pm. This will flex based on the number of patients proned at any given time.
| The proning team will be scheduled for 12-hour shifts based on their FTE. A schedule will be made on a 4-week basis by the staffing office. The primary manager is responsible for submitting payroll based on what is entered from the staffing office.
| Issues with supplies for proning maneuver can be directed to the SPH team via email.
| All proning team members will be added to the COVID-19 (Redeploy) ICU Prone Team list-serve.
| OR West has provided a locker to store personal items.
Responsibilities of the proning team
| • Report to the OR West front desk for sign out at 8 am
| • Assist in the proning and supinating of ICU patients
| • Maintain a log of proned patients
| • Requests for assistance with safe patient handling are within the scope of this role.
General outline of a shift
| At the start of their shift, the proning team will report to the staffing office and retrieve a pager. Report will be given based on information gathered during the 3:30 am bed meeting, including the number of patients mechanically ventilated and those proned. This will allow the team to prioritize their rounds on each unit. ICU RNs will use the pager to contact the proning team if there are any immediate requests or new patients to be proned.
|After the report, the team will begin rounding on all units, prioritizing units that have patients proned. Typically, patients will be proned in the late afternoon/early evening (4-7 pm) and turned supine between 8 and 11 am.
Abbreviations: FTE, Full Time Employee; ICU, intensive care unit; RN, registered nurse; SPH, safe patient handling.
In addition to the training of the proning team, the ICU nurses also received proning education. Intensive care unit nurses were provided with multiple 30-minute training sessions by the SPH team on the process of proning with ceiling lifts. Medical/surgical nurses from surge ICU units were also welcomed to attend. Nurses attending the training learned the process of proning and what to expect when the proning team was assisting with their patients. Training this group was critical for proning patients on the night shift when the proning team would be unavailable and they would be responsible for the maneuver.
The proning team began working within 1 to 2 weeks of training sessions. A proning team schedule was created to provide 12-hour shift support from 8 am to 8 pm, 7 days a week. Four skilled proning team members were determined to be the minimum number of staff needed to ensure safe and efficient patient proning. One member of the proning team carried a text pager to receive requests for assistance. The team member with the pager communicated with the rest of the team via cell phone text message for assignments. The proning team kept a list of patients for each shift, which could be referenced the following day for potential patients who would need to be proned or supinated again. In addition, the proning team rounded in the ICUs daily to assess and discuss proning needs with the ICU nurses.
Initially, all 4 members of the proning team on shift would be present for the proning maneuver. As the team became more confident and efficient, the number of proning team members needed for each proning or supinating maneuver was reduced to 2. The primary nurse was typically present for the maneuver and responsible for documenting the positioning in the online medical record. Together, the proning team nurses and the patient's primary nurse managed the lines and ceiling lift. An RT or RT aide was also present for proning to manage the airway. Respiratory therapist aides were redeployed staff from the rehabilitation department and pulmonary function laboratory trained in managing the airway and changing ventilator settings under the guidance of the RT. The proning team assisted with proning and supinating between 3 and 30 patients per 12-hour shift.
Two survey tools, one for ICU nurses (20 questions) and another for the proning team (40 questions), were developed via an iterative process by a multidisciplinary team that included nursing, an SPH team member, and physicians. The surveys, which included demographic questions and questions related to comfort with proning, were administered via an anonymous email link to all ICU nurses and all members of the proning team. A retrospective analysis of the proning team log was also conducted.
Data were reported as means and medians as appropriate based on the distribution of data. Survey responses were reported as values and percentages.
Between March 5 and May 31, 2020, a total of 146 unique patients were placed in the prone position in the ICU. The specialized prone positioning team assisted in at least 142 turns to the prone position and 169 turns to the supine position.
Nursing Survey Results
Of the 345 registered ICU nurses who received the survey, 118 (34.2%) completed it. Of the respondents, 37 (31.6%) worked only day shifts (7 am to 7 pm), 18 (15.4%) worked only night shifts (7 pm to 7 am), and 62 (53.0%) worked rotating shifts. The most common site of practice among respondents was the MICU and/or mixed ICU (41.5%). Eighty-six respondents (72.9%) reported at least 21 years of nursing experience.
Nurses working day and rotating shifts (n = 110, 93.2%) learned how to prone patients with peer training (n = 83, 75.5%), watching the video on the portal (n = 64, 58.2%), and observing/assisting the proning team (n = 59, 53.6%). The nurses cared for a significantly higher number of patients who required proning (median, 10; interquartile range [IQR] 5, 15; P < .01) between January through May 31, 2020, compared with their recollection of 2019 with 1 patient (IQR 0, 2). Most daytime shift nurses strongly agreed that the proning team saved time in their day (n = 62, 56.3%), was easy to contact (n = 69, 62.7%), and reduced reliance on other staff in the ICU (n = 54, 49.0%). Respondents did not, however, feel that the proning team reduced their in-room COVID-19 exposure time (n = 63, 57.3%). Twenty-one nurses (19.1%) reported endotracheal dislodgement or migration as a common adverse event. Almost all respondents would like to see the proning team return in the event of another COVID-19 surge (n = 102, 92.7%).
Some representative constructive comments suggested that the proning team added to role confusion and occasional “power struggles.” This is highlighted by mixed responses to the question regarding who was in charge of proning initiation, with 47 respondents (43.5%) identifying the primary nurse as lead and 46 respondents (42.6%) identifying a proning team member as lead. Of the 41 night shift nurses who responded to a question regarding extended hours of proning team availability, 15 (36.6%) felt that extended hours/night coverage would have been helpful.
Proning Team Survey Results
Ten of 11 proning team members (90.9%) responded to the survey. Eight (80.0%) were OR nurses, and 2 (20%) were Preadmission testing nurses. Years of experience was more dichotomized with 4 (40%) reporting 21+ years of nursing experience and 3 (30%) reporting 0 to 3 years of experience. A median of 2 members (IQR 2, 3) of the proning team were present for turns. Proning team members reported prone/supine positioning a median of 26 patients (IQR 25, 27) on their busiest day and 4 patients (IQR 4, 5) on the slowest day. In general, proning team members felt that their work was useful, with 9 respondents (90%) noting that they would like to see a return of the proning team if there is another surge.
Most proning team members (70%) reported that they did not know that a standard work document existed or that it did not clearly define the role of the proning team. Similar to the results of the ICU nursing survey, proning team members also reported a lack of clarity regarding who was in charge of initiating the proning maneuver; 50% reported that proning team members initiated the maneuver, whereas 20% indicated the primary RN initiated and 20% indicated the RT/RT aide initiated. Eighty percent of respondents noted that the preproning checklist was not completed before the arrival of the team. Fifty percent of respondents felt completely prepared from training to perform the checklist. The proning team members also commented on the need for head and airway management training as well as bedside nursing basics to improve their ability to assist the primary RN. Almost all respondents (90%) reported supplies needed for proning were available in the patient's room or on the unit, but 20% reported wound care supplies and cushions/pillows for positioning required delivery from central processing, which delayed efficiency.
Themes of constructive feedback from the open-ended questions included a need for additional training regarding management of skin breakdown and positioning in prone, better orientation to the ICUs and available supplies, and a more dedicated space and in-house manager for the proning team. Over time, the proning team members felt that they improved in efficiency, especially in regard to performing the preproning checklist and knowing what supplies were needed before entering a patient room. The proning team also reported clearer communication with nurses over time.
The unprecedented COVID-19 surge required all health care providers to be flexible. Creation of the proning team allowed for the safe and effective management of a large and medically complex patient population.18,19 The development and implementation of the proning team occurred quickly. The proning team was successful in safely performing more than 300 proning and supinating maneuvers for critically ill patients, thus off-loading the work of the ICU RNs. There is overwhelming support within the institution for a proning team for future COVID-19 surges, and this work may serve as a guide for other health care institutions.
Feedback from both the proning team and the ICU RNs indicated that there were unclear roles and expectations. If a proning team is to be formed again, the standard work document must be updated to reflect expectations and clearly define roles to avoid the perception of “power struggles” during proning. This will also allow for a shared mental model between proning team nurses and ICU nurses.
Additional training for the proning team regarding the preproning checklist, management of the airway, and proper head positioning during the proning process is necessary for another surge. As the census for patients with COVID-19 decreased, the proning team was able to assist nurses with repositioning patients for skin management as well as transporting patients within the medical center. Additional tasks that the proning team members could assist with should also be outlined in the standard work document.
Patients with COVID-19 required an unprecedented amount of time proned, which resulted in skin impairments.20-22 At the end of April, wound care staff provided an in-service to the proning team members and the RT aides regarding recommendations for positioning, support surfaces, and placement of foam dressings to prevent pressure injuries in the prone position. A handout was provided to the proning team members and staff in the ICUs regarding these recommendations. These are additional topics that must be covered in future proning team trainings.
Over time, the proning team developed a kit of all the supplies consistent with the preproning checklist, including wound care supplies, tape for the endotracheal tube, eyelid management, and so forth. A mobile supply cart with all items for the proning process would be beneficial to reduce fetching supplies. A future proning team would benefit from a clear manager and a dedicated space with a computer to be able to access patient records and track patients over time.
The process for proning can be taught to staff with patient care experience to comprise the team. This would allow redeployed nurses to use their RN skills to best meet the needs of critically ill patients and the institution in case of a larger surge.
A major strength of this quality improvement initiative was a thoughtful and seamless rapid development and implementation of an ICU proning team during the COVID-19 pandemic. Despite the success of the intervention, there were a few limitations. The experience described is from 1 institution, which may limit generalizability to other institutions. Another limitation is the low ICU RN survey response rate, which may be attributed to the overall increase in both work and life stress during the pandemic. Nurses were sent an open link to the survey; respondents could have completed the survey more than once. Although it cannot be confirmed that there was no nonresponse bias, the respondents generally represent the perceptions of the nurses, given our informal discussions.
During the COVID-19 pandemic, there were many examples of extraordinary teams that rapidly coalesced with a single, focused goal to improve nursing practice and patient care. At the onset of the surge, we identified the need to support bedside clinicians with a proning team to facilitate safe and timely prone positioning. Because of the professionalism and dedication of staff from multiple collaborating departments, a proning team was successfully developed and implemented for a short period. This endeavor maximized the resources at Beth Israel Deaconess Medical Center, facilitated timely interventions, and fostered multidisciplinary support for this initiative.
Thank you to the clinical staff at Beth Israel Deaconess Medical Center for their dedication and commitment to quality and safety.
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