Increasing Rates of Prone Positioning in Acute Care Patients with COVID-19

Abstract

Background Prone positioning improves mortality in patients intubated with acute respiratory distress syndrome and has been proposed as a treatment for non-intubated patients with COVID-19 outside the ICU. However, there are substantial patient and operational barriers to prone positioning on acute floors. Our objective was to increase the frequency of prone positioning among acute care patients with COVID-19. Methods We conducted a retrospective analysis of all adult patients admitted to the acute care floors with COVID-19 respiratory failure. We used a run chart to quantify the frequency of prone positioning over time. For the subset of patients assisted by a dedicated physical therapy team, we compared oxygen before and after positioning. Our initiative consisted of four separate interventions: (1) nursing, physical therapy, physician, and patient education; (2) optimization of supply management and operations; (3) an acute care prone positioning team; and (4) electronic health record optimization. Results From March 9, 2020 to August 26, 2020, 176/875 (20.1%) patients were placed in prone position. Among these, 43 (24.4%) were placed in prone position by the physical therapy team. Only 2/94 (2%) eligible patients admitted in the first two weeks of the pandemic were ever documented in prone position. After launching our initiative, weekly frequency peaked at 13/28 (46.4%). Mean oxygen saturation was 91% prior to prone positioning versus 95.2% after ( p < 0.001) in those positioned by physical therapy. Conclusion A multidisciplinary quality improvement initiative increased frequency of prone positioning by proactively addressing barriers in knowledge, equipment, training, and information technology.

The Use of Quality Improvement in the Physical Therapy Literature: A Scoping Review

“…The second most common service level involved QI efforts in orthopedics (n 5 11, 15.7%). 30,31,50,60,61,64,69,70,79,89,99 The service level described as "system" comprised seven studies (10%), 36,37,48,58,81,88,105 and included QI projects related to system processes or outcomes in PT practice that were not specific to a given service level.…”

“…We defined QI models and tools as formal methods applied to structure the intended QI effort. Twentytwo studies (31%) 27,29,30,32,[39][40][41]48,50,60,70,74,79,81,88,89,96,98,99,101,102,105 used none of these to guide their QI effort. The most commonly cited model/tool was Plan-Do-Study-Act cycles (n 5 19, 27%) 35,38,46,52,54,55,57,58,[63][64][65][66]73,75,78,80,93,100,103 followed by the Model for Improvement (N 5 8, 11%).…”

“…Of the 70 total included studies in this review, 18 (26%) 28,37,39,40,[43][44][45]48,52,60,68,70,73,74,77,79,96,102 were approved by local ethics boards, 19 (27%) [32][33][34]36,41,46,47,49,50,53,55,56,58,63,64,67,81,97,100 sought approval but were considered exempt, 15 (21%) 19,35,38,42,57,59,61,62,65,71,72,75,78,80,…”

Modified Prone Position pada Pasien Long COVID-19 untuk Meningkatkan Saturasi Oksigen Perifer

“…Penelitian yang dilakukan Zaretsky et al, (2022) mengatakan bahwa posisi tengkurap meningkatkan mortalitas pada pasien yang diintubasi dengan sindrom gangguan pernapasan akut dan telah diusulkan sebagai pengobatan untuk pasien COVID-19 yang tidak diintubasi di luar ICU. Namun, ada banyak pasien dan hambatan operasional untuk posisi tengkurap akut di lantai.…”

Evaluation of the efficiency and complications of the consecutive proning in COVID-19 ICU: a retrospective study

“…Prone position which has shown to be beneficial in ARDS improves the ventilation-perfusion matching and the oxygenation by recruiting the dorsal atelectatic lung areas [6,7]. During the COVID-19 pandemic, as recommended by the World Health Organization, many intensivists considered prone positioning as a part of invasive ventilation strategy in ARDS patients [8][9][10]. When looking at COVID-19-related prone position studies, the duration and the number of prone sessions vary.…”