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-se....

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....

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.......

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 .......

Materials

List of materials used in this article

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