key: cord-0886631-stbic6vd authors: Ng, Jillian A; Miccile, Lauren A; Iracheta, Christine; Berndt, Carolyn; Detwiller, Meredith; Yuse, Carolyn; Tolland, Joseph title: Prone Positioning of Patients With Acute Respiratory Distress Syndrome Related to COVID-19: A Rehabilitation-Based Prone Team date: 2020-07-16 journal: Phys Ther DOI: 10.1093/ptj/pzaa124 sha: 578584ce0c1b813fe1a61acfe8aee18914cda4e3 doc_id: 886631 cord_uid: stbic6vd OBJECTIVE: Prone positioning is an effective intervention for acute respiratory distress syndrome (ARDS). An increasing number of patients with ARDS related to coronavirus disease 2019 (COVID-19) required prone positioning, which posed a challenge to the intensive care unit (ICU) staff at Brigham and Women’s Hospital. METHODS (CASE DESCRIPTION): A prone team service of physical therapists and occupational therapists with critical care experience was established to assist with increasing demands for prone positioning of patients who were mechanically ventilated. The goals of the rehabilitation-based prone team were to provide support to nursing and respiratory therapy; create a consistent, efficient process; and ensure patient and staff safety. RESULTS: The service evolved over 7 weeks, expanding to 24-hour coverage and adding responsibilities to support the staff as patient volume grew. Volume of requests to the rehabilitation-based prone team generally increased to week 4 and has since then declined. Key points for successful implementation included identification of rehabilitation therapists with ICU experience and leadership qualities, multidisciplinary collaboration, availability of needed positioning devices and supplies to protect the integument, and well-defined roles of all disciplines participating in position change process. CONCLUSION: The description of the development, operations, evolution, and utilization of a rehabilitation therapist prone team acts as a guide for future development and implementation. IMPACT: This case report is one of the first reports of a rehabilitation-based prone team established to assist with positioning patients in prone as an intervention for ARDS related to COVID-19 and will help guide other institutions. The novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was first reported in Wuhan, China, in December 2019 and causes an acute respiratory illness named coronavirus disease 2019 (COVID-19). 1 Initial data from the United States reported that 20 to 31 percent of patients with COVID-19 develop respiratory symptoms requiring hospitalization and 4.9 to 11.5 percent of patients require admission to the intensive care unit (ICU). 2 Patients with COVID-19 can develop hypoxemic respiratory failure, and chest imaging has shown ground-glass opacities that progress to a mixed presentation with consolidation primarily in the bases of the bilateral lungs. 3 Coronavirus Disease 2019 can be complicated by acute respiratory distress syndrome (ARDS), a condition that results in hypoxemia and acute lung injury. 1, 4 As COVID-19 progressed to a pandemic, hospital clinicians worldwide collaborated to establish guidelines for management of patients with COVID-19 and ARDS. 5 Prone positioning was successfully implemented as a treatment for ARDS in 1976. 6 Effects of prone positioning include homogenous lung pressures, uniform alveolar size, and improved ventilation of the posterior lung fields. 7 Perfusion is improved due to decreased intrapulmonary shunting. 5, 7 These factors improve oxygenation and reduce overall mortality associated with ARDS. 8, 9 Therefore, prone positioning is recommended as a treatment for patients with moderate to severe ARDS from COVID-19. 5 The first presumed case of COVID-19 in Massachusetts was documented on March 2, 2020. 10 Within one week, the number of cases increased to 40 presumed and one confirmed by the United States Centers for Disease Control and Prevention. 11 An additional week of testing resulted in 197 presumed cases in Massachusetts. 11 As the number of patients with COVID-19- related ARDS increased at our institution, teams consisting of one respiratory therapist and typically four ICU nurses began to position patients who were mechanically ventilated into prone. Positioning patients into prone is a complex task that carries risks including displacement of endotracheal tubes and other vital lines during the procedure, hemodynamic instability, corneal abrasions, nerve injury and skin breakdown with prolonged time in prone. 5 Managing the escalating number of patients requiring prone positioning became challenging for ICU staff. Rehabilitation therapists with ICU experience have unique training and expertise for positioning patients into prone during the COVID-19 pandemic. 12 This article is a description of the establishment, operation and evolution of a rehabilitation therapist staffed prone team. The prone team assisted nursing and respiratory therapy to complete the task of positioning patients who were mechanically ventilated into prone over several weeks. The experience, progression and preliminary data may inform and guide future work. The prone team service was created when leadership of the rehabilitation department at Brigham and Women's Hospital, a large academic medical center, in collaboration with the nursing department identified the need for assistance with prone positioning of patients with COVID-19related ARDS. Rehabilitation therapists did not assist with positioning patients into prone prior to the COVID-19 pandemic. The prone team service was made up of physical therapists and occupational therapists from the rehabilitation department with experience in the ICU. Three members of the prone team service covered each shift and were defined as the prone team. The role of the prone team was to assist nursing and respiratory therapy with position changes and positioning in prone. Positioning changes included prone to supine, supine to prone, repositioning of the head and neck of patients in prone and turns of patients in the supine position. As requests for assistance increased, a support prone team of 2 additional rehabilitation therapists was created to assist the prone team with position changes. The goals of creating a prone team service were to provide support to nursing and respiratory staff with increasing patient care demands, to establish consistency and efficiency during the prone positioning process and to ensure the safety of patients and staff. The prone team service members were identified by rehabilitation leadership based on their ICU were performed with a multidisciplinary team consisting of at least one nurse, one respiratory therapist and the prone team. All three disciplines functioned within their scope of practice and per physician orders. The prone team was contacted by the physician or nurse when the need for patients to be placed in the prone position was identified. A dedicated pager was established for direct contact with the prone team. [H1] Outcomes The first patient with COVID-19 was admitted to our institution on March 14, 2020. The first time that the rehabilitation-based prone team assisted with positioning a patient with COVID-19- related ARDS into prone was on April 3, 2020. Subsequently, the prone team service was established for assistance during a 10-hour day shift, 7 days per week on April 6, 2020. As the volume of patients requiring prone positioning increased, the prone team service availability expanded to 24 hours, 7 days per week on April 12, 2020. The support prone team was available during 10-hour day shifts starting April 19, 2020 (Fig. 1) . The prone team recorded preliminary information regarding process operations for scheduling and positioning purposes. The prone team did not record adverse events that may have occurred during mobility or intolerance criteria per the physicians. The prone team did not enter patients' electronic medical records, record any patient information or follow any outcome data. As planning for the COVID-19 pandemic began, hospital leadership took steps to prepare for the Complications occurring during prone session:  Airway complication or compromise: unscheduled extubation, ETT obstruction, significant hemoptysis, worsening hypoxemia (SpO 2 < 85% or PaO 2 <55 mmHg for more than 5 minutes)  Cardiovascular complications: cardiac arrest, hypotension (systolic blood pressure < 60 mmHg for more than 5 minutes), bradycardia (HR <30 beats/min for more than 1 minute), unstable tachyarrhythmia  Any other life-threatening reason at the discretion of the medical team Indications to terminate prone therapy: Improvement in oxygenation with PaO 2 /FiO 2 ≥ 150 mmHg with PEEP ≤ 10cm H 2 O and FiO 2 ≤ 0.6 to meet SpO 2 ≥ 92% or PaO 2 ≥ 65) which persisted 4 hours after the end of the prior prone session PaO 2 /FiO 2 ratio deterioration by more than 20% relative to supine after 2 consecutive prone sessions a ARDS = Acute respiratory distress syndrome; ETT = Endotracheal tube; FiO 2 = Fraction of inspired oxygen; PaO 2 = Partial pressure of oxygen; PEEP = Positive end expiratory pressure; SpO 2 = Oxygen saturation. Week 1 (4/5-4/11) 54 Week 2 (4/12-4/18) 183 Week 3 (4/19-4/25) 145 Week 4 (4/26-5/2) 181 Week 5 (5/3-5/8) 155 Week 6 (5/10-5/16) 137 Week 7 (5/17-5/23) 79 World Health Organization. Clinical management of severe acute respiratory infection when COVID-19 is suspected: Interim guidance of-severe-acute-respiratory-infection-when-novel-coronavirus-(ncov)-infection-issuspected CDC COVID-19 Response Team; Centers for Disease Control and Prevention. Severe Outcomes Among Patients with Coronavirus Disease 2019 (COVID-19) -United States Radiological findings from 81 patients with COVID-19 pneumonia in Wuhan, China: A descriptive study ARDS Definition Task Force. Acute Respiratory Distress Syndrome Surviving Sepsis Campaign: guidelines on the management of critically ill adults with Coronavirus Disease Use of extreme position changes in acute respiratory failure A comprehensive review of prone position in ARDS The authors thank the Brigham and Women's Hospital Rehabilitation Services leadership and staff, critical care nursing staff, respiratory therapy department, and Wound, Ostomy and Continence nursing specialists for their support, guidance, and participation. The authors completed the ICMJE Form for Disclosure of Potential Conflicts of Interest and reported no conflicts of interest.