key: cord-0842020-omli3tgc
authors: Cotton, Shannon; Zawaydeh, Qais; LeBlanc, Shannon; Husain, Abdurrahman; Malhotra, Atul
title: Proning During Covid-19: Challenges and Solutions
date: 2020-08-19
journal: Heart Lung
DOI: 10.1016/j.hrtlng.2020.08.006
sha: 65bf14149dab455ba1cb818861601dbc2b87e080
doc_id: 842020
cord_uid: omli3tgc

• We discuss the importance of teamwork in the care of COVID-19 patients. Recent data show a major disconnect between physicians and nurses regarding the benefits of prone positioning in ARDS. We suggest a number of strategies to improve execution of prone positioning via multidisciplinary efforts.

Prone positioning of patients with acute respiratory distress syndrome (ARDS) has been used since the mid-1970s (1) . The 2013 PROSEVA trial found that implementation of early prone positioning of patients with ARDS and severe hypoxemia led to decreased mortality (2) . Several subsequent studies and meta-analyses have found that prone positioning in ARDS improves both oxygenation and clinical outcomes, including mortality and duration of mechanical ventilation (3) . Prone positioning looks to be particularly beneficial in ARDS in the context of open lung protective ventilation (3, 4) . In addition, some data suggest that proning can avoid the need for invasive mechanical ventilation in some patients with COVID-19 (5, 6) . Despite these positive findings, data suggest that prone positioning is not widely appreciated as beneficial to patient care (7) . The Covid-19 pandemic has highlighted the need for additional education and harmonization of care across the healthcare system.

We believe there are multiple barriers to widespread implementation of proning strategies, which we seek to address (8) . Some of these challenges have been amplified by the Covid-19 pandemic (9) . First, the risk of Covid-19 transmission is still a source of concern for some members of the healthcare team. Based on the limited availability of personal protective equipment (PPE) in some centers and the repeated need for bedside visits, prone positioning may be considered a substantial burden. At our institution, five to six personnel wearing PPE are routinely required at the bedside for each position change from supine to prone and prone to supine. In addition, three team members in full PPE are required at the bedside every two hours for head turns and to offload areas at high risk for developing edema or skin breakdown.

Second, the number of personnel needed to reposition the patient safely without any complications, including accidental extubation, is not always readily available. In some centers, the nursing shortage is particularly an issue due to staff exposure/illnesses and burnout during the pandemic, in which a large volume of patients requires prone positioning. In one of our 13 bed units, we have had up to nine Covid-19 patients going supine to prone back to supine on a daily basis.

Third, the Covid-19 pandemic has made apparent the variability in training of members of the healthcare team. In a recent survey, the majority of physicians believed prone positioning would be beneficial, whereas, fewer than half of the nurses had the same opinion (10, 11) . This disconnect highlights the need for improved communication and education throughout the healthcare team. In some cases doctors-in-training are unaware that placing patients in prone position can be burdensome to the nursing staff (8, 12) . These ongoing barriers to the implementation of prone positioning may impede optimum medical treatment in patients diagnosed with Covid-19 ARDS.

We have identified a number of strategies to address these barriers. patients, it is our recommendation that the primary nurse is assigned to only the one patient, and that additional nurses are available to assist as needed. Prior to placing the patient in the prone position, the nurse should ensure hemodynamic stability, that all intravenous lines are secured, and that naso-or oro-gastric feedings have been stopped. A critical care practioner (e.g. MD, NP) should also be at the bedside to assist with hemodynamic assessment and stabilization for patients at high risk of decompensation, or during initial prone positioning of a patient. A respiratory therapist should be positioned at the head of the bed in order to maintain appropriate positioning of the endotracheal tube position throughout the maneuver. Given the importance of pressure ulcer prevention (13) , two additional personnel may be required to apply protective cushions or dressings to support areas at risk for skin breakdown (i.e. shoulders, pelvis, knees). The use of a prone team would standardize care and support healthcare team members in their designated responsibilities. Although we are aware of some centers that have allocated specific personnel for the sole purpose of repositioning the patient, we believe that there is considerable value in empowering the patient's primary ICU healthcare team to execute the entirety of pronation therapy. 3. Education and Collaboration: we advocate for physician interns and residents to be physically present and active during pronation therapy. This approach gives the trainees an appreciation for the burden being placed by prescribed therapies. In addition, we strongly support multidisciplinary rounds, including team huddles, to ensure that all members of the healthcare team share the same short-and longterm goals for each patient. Due to the prolonged intubation course of COVID-19 patients, day-to-day changes in patient status are not always apparent (15) . Thus, we place an emphasis on discussing daily progress even if relatively minor.

In summary, despite the recognized challenges of the Covid-19 pandemic, we have used this as an opportunity to improve communication and to emphasize teamwork in our intensive care units. We are optimistic that, with ongoing efforts, these positive changes will persist even after the pandemic has resolved, and that ultimately, patient outcomes will improve Declaration of competing interests Disclosure: All authors report no relevant conflicts. Dr. Malhotra is funded by the NIH. ResMed provided a philanthropic donation to UC San Diego. Dr. Malhotra has received income related to medical education from Merck and Livanova, unrelated to this manuscript.

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