ICU team support, training facilitated implementation of prone positioning for COVID-19 ARDS

Hospital support and leadership from bedside clinicians were the primary facilitators for successful implementation of prone positioning for COVID-19 acute respiratory distress syndrome, researchers reported.

Chad H. Hochberg, MD, MHS, pulmonologist at Johns Hopkins University, and colleagues conducted a qualitative study via semi-structured interviews with 40 ICU team members, including attending pulmonary and critical care medicine (PCCM) physicians (n = 7), PCCM fellows (n = 5), registered nurses (n = 12), advanced practice providers (n = 4), respiratory therapists (n = 7) and physical therapists (n = 5) at two academic hospitals in the Johns Hopkins Health System from February to July 2021. Using the Consolidated Framework for Implementation Research, researchers structured the interview guide and thematic interview analyses.

The researchers’ goal was to understand factors that influenced successful adoption and implementation of prone positioning in mechanically ventilated patients with COVID-19 ARDS.

According to study results, ICU clinicians reported that prone positioning was standard early therapy for patients with COVID-19 ARDS during the pandemic, instead of salvage therapy for refractory hypoxemia. Clinicians also reported becoming increasingly comfortable proning patients and now view proning as a highly beneficial, low-risk intervention after having cared for numerous proned patients.

Increased proning use was facilitated in ICUs with adequate numbers of trained staff, team agreement on proning and availability of specific equipment. Hospital-level support for prone positioning included proning teams, centralized educational resources specific to COVID-19 management and an electronic medical record proning order.

In addition, ICU team members reported that on-the-job training and team interactions during routine bedside care were the most important prone positioning implementation processes.

“Greater use of proning in patients with ARDS from COVID-19 was stimulated by changing clinical views and ICU-team cultures and was supported by both deliberate and informal processes for training and dissemination of information,” the researchers wrote in Annals of the American Thoracic Society. “Evaluating how these features may be replicated in non-pandemic settings and among patients with non-COVID-19 ARDS could improve the implementation of proning and other evidence-based critical care interventions.”