key: cord-0887759-w4v2z91f
authors: Callihan, Michael L.; Kaylor, Sara
title: Proning Pains: Recognizing the Red Flags of Body Mechanics for Health Care Workers Involved in Prone Positioning Techniques
date: 2021-02-05
journal: J Emerg Nurs
DOI: 10.1016/j.jen.2021.01.001
sha: 436d78ca0106e7b2796312d7a4bb0612953ea6ab
doc_id: 887759
cord_uid: w4v2z91f

nan

Authors: Michael L. Callihan, PhD, RN, and Sara Kaylor, EdD, RN, Tuscaloosa, AL I t is without doubt that the coronavirus disease (COVID-19) pandemic has significantly affected the emergency and critical care communities in how health care professionals treat patients, both ventilated and nonventilated, with acute respiratory distress syndrome (ARDS). The practice of placing a patient with COVID-19-associated ARDS in the prone position has become part of the routine treatment because this position allows for greater expansion of the posterior portion of the lungs, resulting in more efficient removal of pulmonary secretions and, ultimately, improved oxygenation of the patient. 1,2 From a health care clinician's standpoint, however, this positioning technique can be quite labor-intensive because several health care clinicians and direct care aides are required to safely transition the patient from a supine position to a prone position, all the while maintaining hemodynamic and oxygenation stability. 3 Even more concerning is the recognition that placing a patient in the prone position greatly increases the health care worker's risk for musculoskeletal low back injury 4 ( Figure) , resulting in negative consequences for the injured worker, the staffing needs of the organization, and the overall health care pandemic response.

Although Wendt et al 2 examined responsive patients who were able to primarily reposition themselves with assistance to a prone position, not all patients who would benefit from the prone position are able to reposition themselves and the health care team must perform the position change. Whether manually positioning or using a mechanical lifting device, the harsh reality remains that placing a patient in the prone position requires significant physical handling. In basic terms, initiation of the prone position means that the patient is transferred to 1 side of the bed, rotated into a lateral side-lying position, then carefully transitioned downward onto the abdomen and into the prone position. Such movements necessitate a well-coordinated team effort that can safely and efficiently manage the patient physically and medically, while also promoting proper body mechanics and musculoskeletal preservation of the health care team performing the movements. The biomechanical findings of previous research indicate that the tissues of a health care worker's lumbar spine fail at a higher rate when in a flexed position, specifically at a position greater than 22.5 8 flexion. 5 Although such positioning is difficult for the health care worker to avoid altogether, it must be limited to protect the overall musculoskeletal health of the worker's lower back.

Although seasoned health care workers perform countless patient positioning movements during any given shift at work without giving them much thought, each portion of these common movements places the worker at risk for a musculoskeletal injury. We advocate for conscious attention and respect of musculoskeletal movement and potential for injury during patient positioning. The first step in preparing a patient for prone positioning is to place a draw sheet or lifting straps under the patient. 3 From a lumbar spine protection perspective for the clinician, having 1 of these placed before the patient is placed on the bed or gurney would be ideal. To do this, members of the team first flank the patient. With the bed or gurney raised to working hip height (recognized as a consensus among health care workers of approximately the same height) 6 to midthigh as discussed later in the article, at least 2 team members are needed to reach across the patient to the opposite side; this movement places the nurse in a position of extension for the lumbar spine, 5, 7, 8 which is the first red flag for musculoskeletal injury. Ideally, 1 member grips the patient's shoulder and hip, while the other member grips the patient's upper thighs and midtorso, creating an interlocked force with the first team member. 9 On a count of 3, the 2 team members will generate the force required to rotate the patient into a lateral or side-lying position 4 (musculoskeletal injury red flag 2). Typically, health care workers generate this force from the muscles of the lower back or from the arms and shoulders. 10 Although the force exerted for smaller-statured patients may not pose a significant risk for injury among multiple health care workers, an increased force is required if the number of staff members is reduced or the patient is larger in mass. 4 From here, the patient's body weight is held and supported by the team members, while another team member places a draw sheet or lifting straps. At this point in time, we recommend that any slide boards being used are placed under the patient as well. 11 After rotating the patient back into a supine position, the procedure is then repeated from the opposite side of the bed to facilitate the correct and complete placement of the draw sheet or lifting straps.

The next phase of placing a patient into the prone position involves rolling the patient into a lateral position again and transferring them to the opposite edge of the bed 3 (musculoskeletal injury red flag 3). For this, some members of the team will use a pulling motion of the draw sheet/lifting straps, while those on the opposite side work to support the patient in this side-lying position. Pulling motions typically involve the use of the worker's lower back muscles; starting in a position of extension, the worker reaches forward to grip the load, then moves to a position of flexion, often with a rapid motion. 4,7 This rapid movement from extension to flexion uses the muscles of the lower back to complete the movement rather than those of the legs (as recommended), thus increasing their likelihood for injury. 4 Having a slide board or frictionreduction device under the patient takes up to 70% of the load away from those pulling the patient, 11 which is why such devices are highly recommended, if not altogether required.

The final phase of prone positioning involves lowering the patient to their abdomen. 3 This motion requires team members on 1 side to push and support the weight of the patient, while those on the other side implement pulling movements to support the weight of the patient 4 (musculoskeletal injury red flag 4). Here, all team members find themselves in positions of extension while they work to support the weight of the patient as the patient is gently lowered into the prone position. Final repositioning with pillow placement and limb positioning occurs at this point, and the prone positioning technique is successfully completed. 3 As emphasized here, although prone positioning techniques have demonstrable benefits for patients with COVID-19-associated ARDS who are poorly oxygenated, 2 when the health care team must perform the position change there are greater risks for musculoskeletal injury associated. Despite an evident reduction of weight-bearing load associated with the use of overhead lifting devices, many emergency departments simply are not outfitted with this type of lift equipment. Furthermore, manual lifting, turning, and repositioning of the patient can never truly be eliminated. Even when using overhead lifting devices, the health care worker must still manually reposition the patient so that the lifting straps can be placed.

Despite the lack of access to overhead lifting equipment in many emergency departments, best practice continues to indicate the use of these and friction reduction devices whenever available. These devices provide a significant reduction in patient load, [12] [13] [14] thus reducing the force on the lower back and shoulders of the worker using them. The principles of basic body mechanics also continue to remain important 15 : our recent research advances the science to consider the bed height should be positioned at approximately midthigh for the shortest member of the lifting team. This allows all participants to get into a squatting position for the lift. Lifters should aim for neutrality of their spine when possible, which may require the lifter to grip the sheet further away from the patient. 15 A neutral spine and squatting position best allows the lifter to generate force for the movement with their arms and legs rather than their lower back. 16 Furthermore, when gripping sheets, it is recommended that the lifter use an underhand grip, which best allows the shoulders to remain in proper alignment throughout the lift, 4 resulting in less strain on the joint and surrounding tissue.

Although lifting in these recommended positions does not completely eliminate the risks of musculoskeletal injury for health care workers, it does greatly reduce such risks. 15 Learning to recognize the red flags (Figure) of body mechanics among those involved in prone positioning of patients with COVID-19 can only help to better protect the safety of our patients, our workforce, and our health care organizations as we continue our fight in providing effective care during this time of pandemic.

Conflicts of interest: none to report. 

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