Improving the Prone Positioning Process for ARDS Patients

In 2019, MMC formed an interprofessional clinical transformation team to reduce practice variation and improve safety and outcomes for mechanically ventilated critical care patients. This team identified prone positioning as a treatment modality for refractory hypoxia in acute respiratory distress syndrome (ARDS) as a widely under-utilized therapy. Some barriers to using the therapy at MMC were also identified:

  • Low patient volume
  • High risk of the procedure leading to a reduced level of patient comfort
  • Limited clinical care team experience with prone positioning therapy

In addition, care team members were concerned because several patients at MMC developed hospital acquired pressure injuries (HAPI), including some deep tissue injuries, on the chin related to the ProneView® head positioner that was being used. Also, the head positioner required disconnection of ventilator tubing from the endotracheal tube leading to the potential de-recruitment of alveoli when patients were on high levels of positive end-expiratory pressure (PEEP). Identification of these barriers to using the prone position in ARDS patients led the team to consider an innovative approach to improve the prone positioning process through the engagement of key stakeholders.

An Innovative New Approach

In January 2019, a subgroup of stakeholders was created to review the current process and literature to identify best practices and potential improvements in equipment. The prone therapy team included Critical Care Clinical Nurse Specialist, Amy Stafford, RN; Clinical Nurse Educator, Alana Trottier, RN; Wound Ostomy Nurse, Janet Colleran, RN; clinical nurse, Emily Weiss, RN; clinical nurse, Laura Barra RN; Safe Patient Handling Specialist, Kaitlin Murphy; critical care providers; and respiratory, physical and occupational therapists.

Through this exploration of the literature as well as other institutions’ policies and procedures, the team identified many opportunities to simplify MMC’s proning process. Alternative head positioning devices were obtained for trial use. These sample devices included the Comfort Foam®, the SANDEL ProForm® and the Slotted Head Rest with DermaPro Layer®.

Key Stakeholder Engagement

The team engaged key stakeholder feedback through simulation sessions. The first simulation session, held on February 26, 2019, included equipment, tubes, lines and drains to simulate the actual pronation process. Care team members practiced using several head positioning devices with feedback from a team member acting as the patient, as well as input from a wound specialist on potential pressure and/or moisture issues. Multiple turns to the prone and supine positions were practiced.

This work helped us identify a step-by-step process for each position. And, with the help of our rehabilitation therapists, positioning best practices were also identified to reduce the risk of flexion or hyperextension of the neck, arms and shoulders to mitigate patient injury. A list of necessary equipment was developed with recommendations on how to prepare the patient’s linen, moisture pads and overhead lift, mesh repositioning sling. Other improvements included:

  • Minimizing special order equipment such as bed extenders and positioners from the OR
  • Using regular bed pillows to reduce complexity and delays in implementation of the therapy.

Subsequent practice simulation sessions took place in March and April 2019 in the SCU with select care team members who had experience in prone therapy for ARDS patients and a strong interest in improving the process. This also included additional bedside staff nurses, respiratory therapists and support staff by bringing the sessions in situ.

At the conclusion of the simulation sessions, the team was able to reach consensus, finalize their recommendations, and take photos to illustrate the new, step-by-step process. This feedback was used to revise the MMC proning/positioning policy.

The Slotted Head Rest with DermaPro Layer® was identified as the best option for head positioning with standard bed pillows for propping chest and pelvis. A one-page, laminated reference sheet was developed and supplied on each unit. The team also created and distributed a prone position supply kit that included items such as the Slotted Head Rest with DermaPro Layer® and cloth tape to secure the ETT. In July 2019, we held a practice ‘prone party’ event at our simulation facility where care team members were able to perform a hands-on trial of the new process and supplies. In August, the updated policy – with procedural details in the appendix – was presented to, and approved by, the MMC Nursing Practice Council.

Patient-Centered Care

Patient education materials were also developed to help families understand the indications and benefits of prone positioning therapy as well as some expected consequences. Prone positioning therapy can be challenging for families and visitors as the position is maintained for 16 hours. This means that visitors cannot see their loved one’s face for long periods of time. Additionally, sequelae such as copious oral secretions and significant facial and orbital edema can be visually alarming for families. However, the evidence-based benefits for improving oxygenation and reducing mortality are important for families to understand. Critical Care Clinical Nurse Specialist, Amy Stafford, RN partnered with Clinical Nurse Educator, Alana Trottier, RN and several clinical nurses to create this resource.

As a result of this innovative work by our nursing team, the use of prone positioning for ARDS patients within the critical care units has increased. Throughout the end of 2019 and early 2020, there were several opportunities to implement the new process. Prone therapy has been implemented several times outside the SCUs, such as in the CICU for patients who met criteria. Overall, this initiative resulted in reduction of HAPI, eliminated ventilator disconnect, and provided a clear and safe process for pronation of mechanically ventilated patients.

In late March 2020, MMC began caring for patients with severe ARDS in the context of COVID-19 infection. Following standard therapy for refractory hypoxemia due to ARDS, the care team initiated prone positioning as a therapy for these patients. The team found that the work we did to identify best practices, perform simulations with interdisciplinary team involvement, create educational resources and revise the procedural policy had a tremendous positive impact in the team’s ability to safely prone these patients – even with the additional challenges of COVID-19.