An Educational Video Demonstration of How to Prone a Critically Ill Intubated Patient

Summary

Proning a critically ill patient with severe acute respiratory distress syndrome (ARDS) is a complex but beneficial procedure. Excellent communication skills, team work, and multidisciplinary collaboration are critical for patient and staff safety. A standard procedure should be utilized when proning ventilated patients with tubes, drains, and vascular access devices.

Abstract

Early in the coronavirus disease 2019 (COVID-19) pandemic, it was reported that prone position was beneficial for mechanically ventilated COVID-19 patients with acute respiratory distress syndrome (ARDS). However, for staff in some small and large hospitals, experience with this intervention was low. Select hospitals were able to assemble proning teams; but, as facilities began to experience staffing shortages, they found proning teams unsustainable, and less specialized staff needed to learn how to safely prone patients.

Proning is a high-risk procedure-a lack of a standard approach can result in staff confusion and poor patient outcomes, including unintentional endotracheal tube (ET) loss, vascular access dislodgement, and skin breakdown. Given the acuity and high patient volume, translating a complex procedure into written policy may not be entirely effective. Critical care nurses, respiratory therapists, physical therapists, wound nurses, nurse practitioners, physician assistants, and medical doctors need to be prepared to safely perform this procedure for an acutely ill COVID-19 patient.

Communication, teamwork, and multidisciplinary collaboration are critical for complication avoidance. Interventions to prevent tube and vascular access dislodgement, skin breakdown, and brachial plexus and soft tissue injury must be implemented during the procedure. Repositioning the patient in the prone position, as well as returning the patient to supine positioning, should be components of a comprehensive proning plan.

Introduction

The care for patients with ARDS has greatly improved over the past five decades. Menk et al. reviewed the standards for ventilatory management, pharmacotherapy, and adjuncts to ventilation in treating this inflammatory process¹. Individualized ventilation pressure and volume limitation, use of positive end expiratory pressure (PEEP) for oxygenation and lung recruitment, and spontaneous breathing trials to minimize diaphragm atrophy are mainstays of care that continue to evolve¹. In a multicenter randomized controlled trial, Villar et al. found that the early administration of dexamethasone to patients with moderate-to-severe ARDS reduced time on the ventilator and overall mortality². Additional multicenter randomized clinical trials, such as RECOVERY and CoDex, studied the use of dexamethasone in patients with COVID-19-related ARDS. They found that early administration of dexamethasone to patients with COVID-19 and moderate or severe ARDS, along with standard care, reduced time on the ventilator and resulted in lower 28-day mortality^3,4.

Prone positioning, an effective ventilatory adjunct for patients with moderate-to-severe ARDS, is not a new intervention. Guerin et al. demonstrated that prone positioning for ARDS significantly lowers 28- and 90-day mortality and increases the chance for successful extubation⁵. Yet placing a patient in the prone position is not without risk; iatrogenic complications such as ET obstruction, central catheter displacement, and pressure injury can occur when attempting this maneuver with a mechanically ventilated patient^6,7.

Prior to the COVID-19 pandemic, some institutions initiated prone positioning for moderate-to-severe ARDS ad hoc or infrequently, akin to what Spece et al. reported about the slow adoption of low tidal volume ventilation for ARDS despite compelling evidence of its efficacy^6,8,9. The COVID-19 pandemic though, demanded a rapid implementation of new knowledge, irrespective of previous gaps in the application of clinical research to patient care.

During the pandemic, both early anecdotal reports, as well as well-constructed studies later, established that proning not only improved physiologic parameters but also reduced patient mortality for patients with COVID-19 ARDS. Shelhamer et al. found that one in-hospital death was avoided for every eight patients with moderate-to-severe ARDS, who were proned during their ICU stay¹⁰. Prone positioning was strongly supported as a standard treatment for the COVID-19 patient with ARDS versus being a last-ditch maneuver^1,7. However, staff shortages during the COVID-19 pandemic resulted in redeployment of non-critical care staff to critical care areas. These redeployed staff lacked expertise with this high-volume high-risk procedure¹¹. Stressors on these teams both at work and at home resulted in uncertainty and difficulty in maintaining processes. It was imperative to develop a strategy to mitigate adverse events related to prone positioning¹².

The goal of this protocol is to demonstrate the effectiveness of a team-based, step-by-step approach to the proning maneuver for patients with COVID-19 ARDS. We have shown that this procedure carries a low risk for device dislodgment and other adverse events. In the context of the COVID-19 pandemic, the occurrence of proning is frequent. The advantages of the technique used here include full visual and physical access to the patient with attached tubes, wires, and other equipment, less stress on the patient and healthcare workers by using a breathable transfer matt, and multidisciplinary team participation to decrease adverse outcomes¹³.

With other manual proning methods, such as the "burrito" method, attached tubes, lines, and wires cannot be visualized during the entire proning process¹⁴. Additional techniques found in the wider body of literature rely upon a portable proning frame or a specialized proning bed. Though effective, these methods may be prohibitive if the equipment is not readily available, is too expensive, or if staff lack interprofessional training on management of emergency situations that could occur while using the equipment^14,15,16.

Teamwork
The COVID-19 crisis revealed the need to adopt a team mentality because of the high volume of patients, scarcity of supplies, and human resources among hospital-based healthcare professionals. Although interprofessional collaboration in healthcare is not a new concept, being able to quickly pull together a team and perform a high-risk procedure is not something that most nursing staff and allied health professionals train to do¹⁷. Some staff discovered they had various levels of proficiency and confidence in relation to proning a patient, as well as competing ideas on the best approach with the least amount of patient complications.

Leadership, respect, adaptability, monitoring each other's performance, closed-loop communication, and team orientation are key elements for a safe and effective team¹⁷. Having a shared vision of the critical considerations can be achieved by promoting a standard operating procedure that supports safe and effective care for the patient who needs to be proned. Papazian et al. recommend having a written procedure and detailed training for proning teams¹⁸.

Simulation
Practicing or simulating the proning maneuver using a multidisciplinary staff can be an effective tool for both new staff and a review for incumbent staff¹⁶. Being mindful and attentive to potential complications during and after proning can be achieved through focused education and multidisciplinary teams for proning⁸. An ICU nurse and respiratory therapist (RT) focused on critical tube and vascular access management, a wound specialist or skin champion focused on preventing skin injury, and a physical therapist assessing body mechanics and soft tissue injury prevention are examples of effective workload management. Maximum clinical benefit can be achieved by using the unique strengths of specialized staff¹⁹.

Protocol

1. Procedure: preparation

1. Have the team establish that the patient is a good candidate for prone positioning with respect to the hemodynamic status.
2. Obtain a provider order for prone positioning, which should ideally indicate the number of hours in prone position.
3. Explain the procedure to the patient (if not sedated) and/or significant other.
   NOTE: Consider the time of day and the staff on hand regarding when to begin the proning cycle. This is especially relevant if there are multiple patients on a unit/ward that need to be placed in the prone position⁸.
4. Ensure all the potential participants are notified of the plan, including the RT.
5. Obtain an arterial blood gas sample for analysis, from an indwelling arterial line, or via arterial puncture prior to the procedure⁸.
6. Transfer the patient onto a pressure-redistributing surface prior to beginning the proning cycle¹⁹.
7. Use a slide sheet or air transfer matt to avoid caregiver injury.
8. If a feeding tube is in use, check the integrity of the securement or use a bridle to reduce any chance of dislodgement.
9. Stop the tube feed.
10. Meticulously secure all intravascular catheters and place foam dressings on the skin under the hubs and ports if the patient will be lying on them when in the prone position.
    NOTE: If the patient is on isolation, initiate a wearable sensor for continuous glucose monitoring, if applicable and available.
11. Make note of the length of the ET at the lips or teeth. Remove the headboard.
12. If a commercial ET holder is in use, have the RT and ICU nurse remove this device and secure the tube with tape approved for the securement of critical tubes.
13. Place foam dressings on the face, including over the cheeks and the top lip, prior to taping the ET tube. Optional: place foam dressings on the chin, nose, and forehead²⁰ (Table 1).
14. Suction the ET and mouth and perform oral hygiene.
15. Apply foam dressings to both knees and any other bony prominences or areas of risk, i.e., sternum and under medical devices that cannot be moved^20,21.
16. Empty drains, urinary collection bag, and ostomy pouches.
17. If the patient is pharmacologically paralyzed or if the eyelids are not closed, instill lubrication in eyes, and then close the lids and secure them with gentle tape.
18. Check for immediate availability of a team member who is competent in intubation and the accessibility of an emergency intubation kit, code cart, extra electrodes, extra bed linen, pillows, and foam dressings of various sizes.
19. Discontinue non-essential infusions and monitoring prior to initiating the procedure. Disconnect tube feeding, remove oximetry probe and blood pressure cuff if the patient also has an arterial line, remove leg devices for deep vein thrombosis prevention and heel boot(s), and unhook urinary catheter securement.
20. Monitor pulse oximetry or invasive arterial blood pressure throughout the procedure.
21. Assess pain and sedation status immediately prior to proning and treat accordingly by administering medication to optimize sedation and prevent pain.

2. Procedure: supine to prone

1. Have the assigned ICU nurse in collaboration with the charge nurse assemble the adequate number of nursing staff; ideally four (two on either side of the bed) plus the RT, but as many staff as available and needed for the patient size, to facilitate a safe procedure. Let the team members introduce themselves, if needed, and discuss each team member's role prior to proceeding.
   1. Put the RT in charge of airway at the head of bed (HOB).
   2. Put the ICU nurse in charge of monitoring critical intravascular lines and assisting the RT.
   3. Have other team members monitoring the drains and other tubes and assisting with linens and roll.
   4. Assign the wound nurse, or skin champion if available, to direct prevention measures for bony prominences and skin under medical devices and assist with bed linen roll.
   5. Designate a team member to watch the monitor.
   6. Have a healthcare provider available inside or just outside the room, available to reintubate if necessary.
2. Check for securement of chest tubes and any other percutaneous tubes.
3. Have the RT or Provider, with the ICU nurse, decide the direction in which the patient will be rolled and communicate it to the other team members.
   NOTE: Ideally plan to roll toward the ventilator, away from central venous lines.
4. Have the RT/Provider adjust ventilator settings as ordered/required.
5. Lay the patient flat on the bed in the supine position (Figure 1).
6. Create a bed roll using an extra slide sheet or air transfer pad, flat bed sheet, and under pad. Inflate the mattress to the maximum extent, if applicable.
7. Using the slide sheet or air lift under patient, pull the patient to the edge of the bed that is furthest from the ventilator.
8. Place the bed roll so that it can be unrolled onto the side of the bed that is opposite to the ventilator.
9. Tuck the linen roll under the patient on the ventilator side. Ensure that only 25%-30% of the roll is tucked under the patient.
10. On the count of the team member at the HOB, carefully roll the patient from supine up to a 90° side-lying position with the patient's face toward the ventilator (Figure 2).
11. Move the telemetry electrodes from the patient's chest to the patient's back (Figure 3).
    NOTE: Placement of new electrodes on the back can also occur when the patient is lying prone.
12. Place a pillow on the bed that will be positioned under the patient's chest/shoulders.
13. If the patient is inflexible and/or has tight hip flexors, place a pillow under the hip/pelvis and/or an air cushion under the knees.
14. On the count of the team member at the HOB, carefully lay the patient prone with a pillow under the upper chest/shoulders, and center the patient in the middle of the bed with the top of patient's head at the top edge of the bed (Figure 4).
15. Have team members at the head of the bed rotate the patient's head either left or right, and place the bed pillow under the head. Ensure that the patient's face is on the very edge of the pillow so that the nose is free from pressure, and there is adequate room for the ET and ventilator tubing for suctioning.
16. Ensure that the patient's arms are placed in the swimmer's crawl position: the face is toward the prominent hand, palmar side down, wrist in neutral, elbow lower than the shoulder, and elbow flexed^6,22. Ensure that the contralateral arm is extended down alongside the body, with a pillow under the anterior shoulder and arm, palmar side of the hand facing up.
17. Place a pillow horizonal to the patient under both the lower legs to allow the knees to be slightly flexed and disallow extreme plantar flexion and avoidance of pressure injuries on the feet and toes.
18. Reconnect the monitoring equipment and tubes that were disconnected prior to prone positioning.
19. Complete a skin assessment of the sacrum, coccyx, and buttocks. Place a protective foam dressing on the sacrum in anticipation of returning to supine positioning after the prescribed prone time.
20. Place the bed in reverse Trendelenburg's position, approximately 30° for complication avoidance^8,12.
21. Restart tube feeding if applicable.

3. Procedure: position changes while lying prone

1. Mobilize the patient every 2-3 h for pressure injury avoidance and to optimize the drainage and suctioning of secretions from the lung segments into the central airway.
   NOTE: The exact frequency of repositioning of the patient may be influenced by both patient factors, such as hemodynamic tolerance and staffing factors⁶.
2. Ensure the availability of a minimum of three caregivers for position changes. Have the RT take charge of managing the ET and two additional caregivers, one an ICU nurse, assist with mobilizing the patient.
3. Take the bed out of the reverse Trendelenburg's position to a flat position, parallel to the floor.
4. Using a slip sheet or air transfer pad, pull the patient up in bed if needed (with mattress inflated to the maximum extent if applicable).
5. Carefully move the arm that is bent at the elbow down to the patient's side.
6. After suctioning the patient's airway and mouth as needed, have the RT secure the ET and lift the patient's head off the pillow.
7. Wait for the nurse at the HOB to pull out the pillow from under the patient's head while the RT rotates the head to the opposite direction. Ensure that the pillow is flipped or the pillow case changed and the head placed back on the edge of the pillow, with no pressure on the nose or ET.
8. Bring up the arm on the side that the head is facing is now in swimmer's position, elbow bent and lower than the shoulder, wrist in neutral.
9. Ensure that the contralateral arm is in neutral alongside the body, with a pillow tucked to support the anterior shoulder and arm, palmar side of the hand facing up.
   ​NOTE: For an inflexible patient and/or those with limited neck rotation, a pillow can be slightly tucked under the abdomen on the side the head is turned toward to facilitate neck rotation and ensure off-loading of nose and chin.

4. Procedure: prone to supine

1. Assign an ICU nurse to collaborate with the charge nurse in assembling an adequate number of staff to complete the procedure.
   NOTE: Typically, at least four staff members are required, but assemble as many as needed for the patient's size and to facilitate a safe procedure. Team members introduce themselves if needed and discuss each team member's role prior to proceeding.
   1. Ensure that the RT or Provider is in charge of airway at the HOB.
   2. Put the critical care nurse in charge of monitoring critical intravascular lines and assisting the RT.
   3. Have the other team member(s) monitor drains and other tubes and assist with linens and the turn.
2. Empty drains and the urinary collection bag.
3. Ensure protective foam dressing is on the sacrum.
4. Have a team member watch the monitor.
5. Have the provider inside or outside the room, available to reintubate if necessary.
6. Allow the decision for the direction in which patient will be rolled to be made jointly by the RT and the critical care/ICU nurse. Roll the patient toward or away from the ventilator, depending on the location of the central venous lines, IV pump locations, and preference of the RT and ICU nurse.
7. Disconnect non-critical tubing and devices.
8. Take the bed out of the reverse Trendelenburg to a flat position parallel to the floor. Inflate the mattress to the maximum extent, if applicable.
9. Carefully straighten the arm/hand that is across from the face and gently place it at the patient's side.
10. Remove all the pillows from underneath the patient, including the chest, lower legs, and lateral trunk if applicable.
11. Pull the patient to the side of the bed furthest from the direction of the turn.
12. Create the bed roll with a slip sheet or air transfer pad, flat sheet, or under pad. Roll it up lengthwise and tuck 20% under the patient on the side the patient will roll toward.
13. Gather extra electrodes/wires for the heart monitor.
14. Have the RT adjust the ventilator settings as required/ordered.
15. After a clear plan for the turn is established, tuck the patient's hand on the side that the patient will be turned toward, palm side up under the thigh.
16. Carefully turn the patient 90° onto their side, hold the patient briefly in this position while the heart monitoring electrodes are removed from the back, and new ones are placed on the chest.
    NOTE: If preferred, placement of new electrodes can also occur after the patient is lying supine.
17. On the count of the team member at the HOB, gently lower the patient to the supine position.
18. Reconnect the tubes/monitoring equipment that were removed for the turn.
19. Have the RT with the ICU nurse check the positioning of the ET and securement of all intravascular lines, tubes, and monitoring equipment. Adjust the angle of the bed as appropriate.
    NOTE: Typically, 30° of head elevation is required.

Representative Results

Following a review of step-by-step instructions of how to prone a critically ill intubated patient, critical care staff were able to return a safe demonstration of proning. Additional nursing leadership, e.g., a clinical nurse specialist, certified wound nurse, and/or a physical therapist is recommended to provide rapid decision-making during critical points, e.g., taping and repositioning the ET tube, as well as head and arm positioning. After a few practices, it is estimated that the procedure takes approximately 10-15 min and requires at least four health care workers, including the RT or other qualified healthcare provider, to securely manage the ET.

Validation of protocol
In regard to the efficacy of the technique being presented, we reviewed COVID ICU data from the electronic medical record system and Events Reporting system from a large academic tertiary care facility in upstate New York for the time period of March 10, 2020 through February 10, 2022. Roughly 1,100 patients with a diagnosis of COVID19 ARDS were admitted to the ICU during this period. Roughly 17% of this population were in the prone position at least once during their ICU stay. The longest number of proning sessions for a single patient was 22. Most patients were proned for 16 consecutive hours; a few outliers had longer proning cycles. Using safety as a proxy for validation of this protocol to prone critically ill intubated patients, the dislodgement of only one jejunostomy tube was reported. Additionally, there was one concern reported when the protocol was not followed, and the RT was not notified that a patient needed to be repositioned. In regard to the occurrence of pressure injuries on the face, including the chin, nose, forehead/face, and lip/tongue, the counts decreased for all locations, particularly for the chin with 12 fewer injuries (Table 2). Given the low incidence of proning complications, this protocol is preliminarily valid in these rapidly changing times, and further research and testing is needed.

Figure 1: Patient in supine position. Please click here to view a larger version of this figure.

Figure 2: Patient being moved from supine to prone position. Endotracheal tube secured by the respiratory therapist. Please click here to view a larger version of this figure.

Figure 3: Electrodes being placed on the patient's back. Please click here to view a larger version of this figure.

Figure 4: Patient in prone position. Pillows being adjusted; foam pieces on face; ballard being passed through endotracheal tube. Please click here to view a larger version of this figure.

Body Location	Dressing size in inches
Face - cheeks	3 x 3 or 4 x 4
Over lip	Cut 1 x 4 strip
Chin	3 x 3 or 4 x 4
Forehead	4 x 4
Sternum	6 x 6
Knees	6 x 6
Anterior iliac crest (optional)	6 x 6
Sacrum	Sacrum-shaped

Table 1: Foam dressing sizes for body locations. Six body locations are provided, and recommended dressing sizes are included in the table.

Location	Pre-count	Post-count	Delta
Chin	17	5	12
Nose	16	7	9
Forehead/face	9	1	8
Lip/tongue	22	15	7

Table 2: Facial pressure injuries pre- and post-education. Four locations are provided with pre- and post-counts with accompanying delta scores.

Discussion

The most important nursing part in the process of proning a critically ill intubated patient is the preparation. For example, there needs to be extensive consideration and gathering of needed supplies to have available, including tape to secure the ET, foam dressings to pad bony prominences, extra electrodes for cardiac monitoring, extra bed linens, pillows and under pads; all essential for an efficient process and safe patient experience.

Availability of needed supplies, skilled staff, clear two-way communication, and effective team work are critical to successful completion of this procedure with the highest levels of complication avoidance. The presence of a Provider who is qualified to reintubate or reestablish central intravascular access if needed, is imperative⁸. Careful securement of the ET and central intravascular lines and any other critical tubes can prevent events that may lead to negative outcomes. This procedure resulted in zero unplanned extubations and zero loss of central intravenous access lines during the multiple proning sessions of approximately 185 patients.

Safe patient handling using an air transfer device, plastic slip sheet, or other method that decreases friction with patient movement and decreases caregiver injury should be strongly considered⁸. If the patient is lying on a low air loss or alternating pressure mattress, maximum inflation of the mattress will make it easier on the caregivers to pull and turn the patient. A bariatric or wider bed should be considered for a patient who is morbidly obese. For a patient on a wider bed, caregivers may need to stand on a stool to avoid injury and/or difficulties moving the patient.

Modifications and troubleshooting
Alternative methods of proning a patient, including wrapping the patient between two sheets (the burrito method), can interfere with the observation of the patient, including critical lines during all aspects of the procedure and placement of cardiac monitoring electrodes, until the patient is fully prone. Specialized beds and frames are available to decrease caregiver burden and optimize safe patient handling, but may not be appropriate for bariatric patients, or patients who need to be in the prone position for long periods of time¹⁴.

Limitations/alternative methods
The safety outcomes of a manual proning method are affected in part by the knowledge, experience, and strength of the healthcare workers performing the procedure. We opted for a manual method of proning since the staff had previous experience with this procedure, the weight limits associated with a specialized proning bed, as well as its cost and availability, were considered problematic.

Future applications
Although prone positioning is primarily used to improve oxygenation in a patient with ARDS, the use of this technique for patients with extensive full thickness/Stage 4 pressure injuries in the sacral region could be explored if other off-loading methods are ineffective. This procedure may also be useful for patients with burns on the dorsal aspect of the body to promote healing of grafts and/or for adjunctive pain control.

Attention needs to be paid to the risk of hospital-acquired pressure injuries, specifically related to prone positioning. Team et al. reported that pressure injuries are the most common complication of proning, and the main risk factors included days on mechanical ventilation, length of proning sessions, and the number of consecutive proning sessions¹⁹. The National Pressure Injury Advisory Panel (NPIAP) recommends addressing prevention prior to proning, during the prone position, and with return to the supine position²⁰. Of note, padding bony prominences and under and around medical devices with soft silicone multilayered foam dressings may be specific to the body habitus of the patient, as well as the presence and absence of medical devices.

In conclusion, proning critically ill patients improves ventilation and survival, but it is a labor-intensive, complicated procedure that requires skilled hospital staff and diligent monitoring to prevent iatrogenic complications.

Materials

Name	Company	Catalog Number	Comments
HoverMatt	HoverTech International	HM34SPU-B	Single patient use
Mepilex 4x4	Molnlycke Healthcare	294199	Strip cut and placed over top lip
Mepilex Border Flex 3x3	Molnlycke Healthcare	595200	Chin
Mepilex Border Flex 4x4	Molnlycke Healthcare	595300	Cheeks (and forehead if needed)
Mepilex Border Flex 6x6	Molnlycke Healthcare	595400	Knees (and anterior iliac crests if needed)
Mepilex Border Sacrum 8x9	Molnlycke Healthcare	282455	Sacrum