PRONE POSITION FOR SEVERE ARDS
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PRONE POSITION FOR SEVERE ARDS
Type of Staff Required for Prone
Category Original Protocol Modifications Rational
Type of clinician • Only ICU • Eliminated: the use • Allowed ICU physicians
used for proning trained staff of physicians and and nurses to attend to
events (nurses, nurses in the turn medical management of
physicians, position, line nurse, patients.
Respiratory Physician and RN
therapists) leader • Freed critical care staff to
attend to emergencies.
• Added: Trained core
group of PT/OT staff • Allowed for more proning
to carry out prone and supining events to
turn with hands on occur in succession
training. leading to multiple
proning events in one
• Created an official shift.
“Prone Team”.
2
Equipment Modifications
Category Original Protocol Modifications Rational
Pre- prone equipment/ • Gel head positioner • Added: Extra foam • Helped to mitigate increase
patient preparation • Second glide/flat sheet pads to place on development of pressure
• Chest roll x1 anterior chest and injuries with longer proning
• Hip roll x1 face and under events and multiple prone
• Second set of ECG leads central venous and events.
with electrodes attached arterial access.
• Train of four (TO4) machine • Not all patients required
to assess paralysis • Eliminated: TO4 continuous paralysis, limited
• ETC02 module/tubing machine. number of TO4machines.
• 10 Foam protective pads to
be placed over all anterior • Paralysis when used was
bony prominences (anterior titrated for ventilator
toes, knees, hips, shoulders, synchrony.
chest)
• IVP doses of a paralytic were
used when necessary to
assist with prone turn *patient
had to be adequately
sedated
3
Number of Staff Required for Proning
Category Original Policy Modification Rational
Required 9 ICU Clinicians: Decrease staff to 5 Clinicians: • Allowed for
Staff • 1 Physician Leader • Eliminate: Physician & RN leader, proning during
• 1 RN Leader line RN 2 RT at head crisis with limited
• 2 RT (head of bed) • 1 Physician or CRNA to secure staffing
• 4 Turn Nurses airway and control head
• 1 Line Nurse repositioning
• Use 4 turn clinicians (replace • Decreased
RN’s with PT/OT staff) unnecessary
• Same staffing requirements used exposure of
with supine events COVID-19 to large
numbers of staff
4
Intravenous Tubing and Line Management
Category Original Protocol Modifications Rational
IV tubing and line • All lines positioned above • All intravenous lines and arterial • During COVID -19 each
management the waist were drawn up access were clamped and patient was on an
towards the head
disconnected with team ONLY in extraordinary amount of
• All lines positioned below
the waist were drawn down the “ready” position. drips.
to the feet • NIBP obtained just prior to turn. • IV pumps were
• All unnecessary drips were • Total disconnection time allowed 10 positioned outside of the
disconnected seconds – just enough time to rooms, which added
• All anterior surface devices complete the turn. multiple feet of
removed
• All HD and ECMO access remained extension tubing.
• IV pumps positioned to
avoid dislodgement attached. • Allowed for elimination
• Turn was initiated • For external devices i.e. urinary of line nurse and
depending on placement of catheters, rectal tubes – original mitigate the risk of vital
lines with tubing connected protocol followed. access point
dislodgement.
5
Intravenous and Arterial Access Points
Category Original Protocol Modifications Rational
Required intravenous • All patients to be • The placement of • Allowed for more
access proned must have A-lines and central emergent proning
a sutured central lines was now of decompensating
and A-line in place required based on patients without
the patient's waiting for line
medical placement.
management.
• May prone with
two large bore
working
intravenous
access points
(20G/18G).
6
Turning Procedure
Category Original Protocol Modification Rational
Turning • Second set of leads to • ECG leads disconnected when all • Removal of original ECG wires just
Procedure be placed during the team members were in the ready prior to the prone events eliminated
Steps turn to the posterior position just prior to initiating the turn. the need to pause during the turn to
chest with a slight Once patient in the prone position place new leads.
pause while in the (total of 10 seconds) a second fresh • Pre-prone discussion time eliminated
upright lateral position set of ECG leads were placed to delay allowing for prone events to be
posterior chest. conduct more quickly.
• Prone turn initiated • No time to reposition multiple
based on head • Turning prone initiated based on what extension tubing - avoided
position and critical was easiest for clinicians not on IV and dislodgement.
line placement (as not arterial access. In cases where this • For supine events: “The Nose
to drag tubing under was not possible – original protocol Knows)” and not having to manage
the patient while was followed. multiple IV access points allowed for
during the prone the patient to be turned more quickly
event) • All supine events including but not in the direction that was safest for
limited t o emergency turn back airway securement.
initiated based on “The Nose Knows”.
7
Head Repositioning
Category Original Protocol Modification Rational
Head • Required • No head repositioning. • Due to limited staffing
Repositioning every 2 hours • Gel head positioner and multiple patients
with: used as per original requiring prone and
RT/Physician, protocol. supine events – unable
two RN’s • Primary RN/RT to gather necessary
instructed to re-hollow staff to safely turn the
anterior facial pressure head and secure the
points every time care airway.
was delivered.
8
Proning Patients in the ICU: Review
of Methods and a New Approach
Neal Wiggermann, PhD
neal.wiggermann@hillrom.com
Neal Wiggermann, PhD
10Why isn’t proning more common?
https://youtu.be/ECdxhNFLwVo https://youtu.be/qx2z26IL6g8
11https://bit.ly/3ifVcUe
Methods of Review
▪ Academic Literature Review
▪ Internet Video Search
▪ Expert Review of Findings
▪ Registered nurses (3), Physical therapist, Occupational therapist
▪ All specialized experience in safe patient handling
▪ Considerations
▪ Patient Safety
▪ Staff required
▪ Injury risk
▪ Equipment required, patient weight limit
13Methods Identified
▪ Manual Proning
▪ Draw Sheet
▪ Sliding sheets
▪ Air Assisted Devices
▪ Lift Assisted
▪ Specialized Automated Proning Bed
14Current Manual Technique
15Lift Assisted Technique – Repositioning Sheet
16
https://youtu.be/0ksD7B64T7AAutomated Proning Bed
17Limitations of Current Methods
▪ Manual or Lift Assisted Methods
▪ Manual patient lowering
▪ Risk of injury remains, particularly lowering patient
▪ Too many staff required
▪ Weight limit - ???
▪ Automated Proning Bed
▪ Availability & Cost
▪ Weight limit – 350 lbs
▪ Pressure Injury
18New Lift Assisted Technique
▪ Equipment required
▪ Ceiling lift (ideal) or mobile lift
▪ 2x MultiStraps™ (lift straps)
19Placement of the straps
Connect these Connect these
to sling bar to sling bar
Turning directionNew Lift Assisted Technique
New Lift Assisted
Technique
https://youtu.be/72QO3X9_LusManual vs. Lift Assisted
23Considerations for Selecting Proning Methods
▪ Patient Safety – Mechanical vs. manual lowering
▪ Staff required – 3 to 7 (or 9)
▪ Equipment required – None, Lift equipment, straps, slide sheets
▪ Patient weight limit – 350 lbs, 440+ lbs, Strength of team
▪ Injury risk
▪ Most caregiver musculoskeletal injuries are caused by manually handling patients
(Nelson, 2006)
▪ Caregivers can lift at most 35 lbs before exceeding guidelines for spine loading
(Waters, 2007)
24Resources
Staff
Category Method Equipment Required Patient Descent Source
Required
https://youtu.be/yb1ppe8Y-70
Manual technique - Draw sheet Draw sheet and flat sheet 5 to 7 Manual
https://youtu.be/qx2z26IL6g8
Manual technique - Friction reducing Friction reducing sheet and https://youtu.be/lcBPaHQUvXY
5 to 7 Manual
device flat sheet https://youtu.be/g9EDcOzuL7g
Manual
Manual technique - Air assisted Flat sheet and https://www.linkedin.com/feed/update/urn:li
5 to 7 Manual
lateral transfer device 2x Air assisted sheets :activity:6651526505816031232/
Vollman & Bander (1996). Int. care med.,
Vollman prone positioner Vollman prone positioner 5 to 7 Manual
22(10), 1105-1111
Mechanical Lift and
Repositioning Sheet for Rotation 5 Manual https://youtu.be/0ksD7B64T7A
1x or 2x Sheets
Repositioning Sheet and positioning Mechanical Lift, 2x Sheets,
Lift assisted 5 Manual https://youtu.be/Gh9JDmETtyI
sling Positioning Sling
Mechanical Lift and Mechanically
Lift Straps for Rotation 3 https://youtu.be/gniNns_6C2Q
2x Straps controlled
Specialized Mechanically
Automated Proning Bed Proning Bed 2 to 3
Bed controlled
Proning Methods Review Article: https://bit.ly/3ifVcUe
NPIAP – Pressure injury prevention tips for prone positioning: https://bit.ly/2T1zUPt
Treatment of ARDS Webinar: https://bit.ly/3bqeTo5 25Power Point References/Studies
• Bellani, G., Laffey, J. G., Pham, T., Fan, E., Brochard, L.,
Esteban, A., ... & Ranieri, M. (2016). Epidemiology, patterns of
care, and mortality for patients with acute respiratory distress
syndrome in intensive care units in 50
countries. Jama, 315(8), 788-800.
• Chertoff, J. (2016). Why is prone positioning so
unpopular?. Journal of Intensive Care, 4.
• SGuérin, C., Reignier, J., Richard, J. C., Beuret, P., Gacouin,
A., Boulain, T., ... & Clavel, M. (2013). Prone positioning in
severe acute respiratory distress syndrome. New England
Journal of Medicine, 368(23), 2159-2168.
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