An Educational Video Demonstration of How to Prone a Critically Ill Intubated Patient
November 30th, 2022
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.
This protocol provides nursing staff and health professionals with step-by-step instructions to safely prone in intubated patient and the measures to avoid pressure injury. Team discussion and implementation of the pressure injury prevention interventions before and during proning the patient results in decreased loss of critical tubes and pressure injuries. When proning a patient for the first time, it's crucial to huddle, discuss the procedure, and gather the required supplies.
Hence, watching this visual demonstration will be beneficial. Begin by checking the integrity of the securement of the feeding tube, or use a bridle to reduce chance of dislodgement before initiating proning, then stop the patient's tube feed. 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 as well as bony prominence is such as the knees.
Remove the headboard. If a commercial ET holder is in use, have the respiratory therapist and ICU nurse remove this device and secure the tube with tape approved for the securement of critical tubes. Before taping the ET tube, place foam dressings on the face, including over the cheeks and the top lip.
If required, place foam dressings on the chin, nose, and forehead. Suction the ET tube and mouth and perform oral hygiene. Apply foam dressings to other risk areas such as the sternum and under medical devices that cannot be moved.
Then empty the drains, urinary collection bags, and ostomy pouches. If the patient is pharmacologically paralyzed or if the eyelids are not closed, instill lubrication in the eyes then close the lids and secure them with a gentle tape. Discontinue non-essential infusions and monitoring prior to initiating the procedure as described in the text manuscript.
Check for securement of chest tubes and any other percutaneous tubes and ask the respiratory therapist or provider to adjust ventilator settings as required. Lay the patient flat on the bed in the supine position. Create a bed roll using an extra slide sheet, air transfer pad, flat bed sheet, and an underpad.
Inflate the mattress to the maximum extent if applicable. Using the slide sheet or the airlift, pull the patient to the edge of the bed furthest from the ventilator. Place the bed roll so it can be unrolled onto the side of the bed opposite the ventilator.
Tuck the linen roll under the patient on the ventilator side and ensure that only 25 to 30%of the roll is tucked. Roll the patient from supine up to a 90-degree sideline position with the face toward the ventilator. Move the telemetry electrodes from the chest to the patient's back and carefully lay the patient prone.
Place a pillow on the bed and position it under the patient's upper chest or shoulders. Then center the patient in the middle of the bed with the top of the head reaching the top edge. Rotate the patient's head either left or right and place the bed pillow under the head.
Ensure that the patient's arms are placed in the swimmers crawl position. Place a pillow horizontally to the patient under both the lower legs. Reconnect the monitoring equipment and tubes that were disconnected prior to prone positioning.
Place a protective foam dressing on the sacrum. Place the bed in reverse trendelenburg's position at a 30-degree angle then restart the tube feeding. Empty the drains and urinary collection bag and have a team member watch the monitor while disconnecting non-critical tubing and devices.
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. Carefully straighten the arm across the face and gently place it at the patient's side.
Remove all pillows underneath the patient including the chest, lower legs, and lateral trunk. Pull the patient to the side of the bed furthest from the direction of the turn. Create the bed roll and tuck 20%under the side where the patient will roll.
Gather extra electrodes or wires for the heart monitor and have the respiratory therapist adjust the ventilator settings as required. Then tuck the patient's hand towards the side the patient will be turned, keeping the palm side up under the thigh. Carefully turn the patient 90 degrees onto their side and hold this position briefly while the heart monitoring electrodes are removed from the back and new ones are placed on the chest.
Gently lower the patient to the supine position and reconnect the tubes and monitoring equipment. The respiratory therapist and ICU nurse should check the ET tubes positioning and secure all intravascular lines, tubes, and monitoring equipment. Adjust the angle of the bed as appropriate.
Approximately 1, 100 patients with a diagnosis of COVID-19 ARDS were admitted to the ICU from March 10, 2020 to February 10, 2022 and about 17%of this population were in the prone position at least once during their ICU stay. The occurrence of pressure injuries decreased for all locations, particularly for the chin with 12 fewer injuries. This procedure relies heavily on preparation, communication, teamwork, and the availability of experts to intervene if there's an adverse outcome.
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Overview
Proning a critically ill patient with severe acute respiratory distress syndrome (ARDS) is a complex but beneficial procedure. Effective communication, teamwork, and multidisciplinary collaboration are essential for ensuring patient and staff safety.
Key Study Components
Area of Science
- Critical care nursing
- Patient safety
- Multidisciplinary collaboration
Background
- Proning can improve oxygenation in ARDS patients.
- It requires careful planning and execution to avoid complications.
- Pressure injury prevention is crucial during the procedure.
- Team discussions enhance safety and efficiency.
Purpose of Study
- To provide a protocol for safely proning intubated patients.
- To outline measures to prevent pressure injuries.
- To emphasize the importance of teamwork in the proning process.
Methods Used
- Step-by-step instructions for nursing staff.
- Pre-procedure huddles to discuss the plan.
- Securement checks for feeding tubes and catheters.
- Use of foam dressings to protect skin integrity.
Main Results
- Implementation of pressure injury prevention measures reduces complications.
- Team discussions lead to better outcomes during proning.
- Proper securement of tubes minimizes the risk of dislodgement.
- Visual demonstrations enhance understanding of the procedure.
Conclusions
- Proning is beneficial for ARDS patients when done correctly.
- Collaboration and communication are key to success.
- Following a standard protocol improves patient safety.
Frequently Asked Questions
Executive Industry Relevance
Standardized proning protocols for intubated patients address critical safety and workflow challenges in acute care settings, especially during high-volume surges such as the COVID-19 pandemic. Reliable execution reduces preventable complications, supporting operational continuity and cross-disciplinary collaboration. For biopharma R&D, such protocols inform translational research models and risk mitigation strategies in critical care intervention studies.
Strategic Applications in Biopharma R&D
Early Discovery & Target Validation
- Clarifies procedural variables impacting patient outcomes in critical care models.
- Supports mechanistic de-risking by standardizing intervention delivery in translational studies.
- Enables reproducible assessment of intervention effects on physiological endpoints.
Screening & Assay Development
- Facilitates preparation of validated critical care models for device or therapeutic screening.
- Improves reproducibility and standardization of intervention protocols in preclinical workflows.
- Enables quantitative tracking of adverse events and safety endpoints.
Translational & Preclinical Research
- Aligns procedural fidelity with clinical practice for disease-relevant preclinical models.
- Supports continuity from discovery through preclinical validation of critical care interventions.
- Reduces confounding variables in translational biomarker studies involving respiratory distress models.
Pipeline & Workflow Integration
Standardized proning protocols integrate into the discovery-to-preclinical continuum by enabling consistent intervention delivery and outcome measurement in critical care research models.
- Discovery Biology: Supports hypothesis testing on intervention safety and efficacy in acute respiratory models.
- Screening: Provides a reproducible procedural foundation for evaluating device or therapeutic candidates.
- Analytics: Enables quantitative measurement of adverse events, such as pressure injuries and tube dislodgement.
- Translational Research: Ensures procedural alignment with clinical standards for preclinical model validity.
- Enterprise Reuse: Establishes a scalable, cross-team protocol for critical care intervention studies.
Operational & Enterprise Impact
- Scientific Value: Enhances predictive confidence and reduces mechanistic ambiguity in critical care models.
- Operational Value: Promotes standardization, reproducibility, and multidisciplinary collaboration.
- Strategic Value: Improves go/no-go decision quality and reduces late-stage procedural risk.
- Portfolio Impact: Enables risk-adjusted prioritization of critical care intervention candidates.
Implementation Considerations
- Requires multidisciplinary expertise in critical care, nursing, and respiratory therapy.
- Demands access to specialized equipment and monitoring infrastructure.
- Necessitates rigorous cross-team training and protocol adherence.
- Must be adaptable to diverse patient populations and care settings.
- Dependent on real-time communication and expert intervention for adverse events.
