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Introduction In March and April 2020 of the COVID-19 pandemic, site clinical practice guidelines were implemented for prone positioning of awake, alert, spontaneously breathing suspected COVID-19 patients in hypoxic respiratory distress. The purpose of this pandemic disaster practice improvement project was to measure changes in pulse oximetry associated with prone positioning on awake, alert, spontaneously breathing non-intubated adult acute respiratory distress, or ARDS, patients with COVID-19 infection. Methods A retrospective chart review of ED COVID-19 positive patients from 3/30/2020 to 4/30/2020 was conducted for patients with a room air pulse oximetry < 90% and a pre-prone position pulse oximetry ≤ 94% who tolerated prone positioning for at least 30 minutes. The primary outcome was change in pulse oximetry associated with prone positioning, measured on room air, with supplemental oxygen, and approximately 30 minutes after initiating prone positioning. Median differences were compared with the Wilcoxon signed-rank test. Results Of the 440 COVID-19 patients, 31 met inclusion criteria. Median pulse oximetry increased as 83% (IQR= 75%-86%) on room air, 90% (IQR=89%-93%) with supplemental oxygen, and 96% (IQR=94%-98%) with prone positioning (x.xx, p<.001). 45% (N=14) were intubated during their hospital stay and 26% (N=8) of the included patients died. Conclusion In awake, alert, and spontaneously breathing patients with COVID-19, an initially low pulse oximetry reading improved with prone positioning. Future studies are needed to determine the association of prone positioning with subsequent endotracheal intubation and mortality.

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