Prone positioning is a well-known beneficial intervention for patients with acute respiratory distress syndrome. As the COVID-19 pandemic emerged, hospitals rapidly adapted prone positioning for acutely ill patients into a new process: awake self–prone positioning. Could a large health care system safely and rapidly implement awake self–prone positioning in COVID-19 units to prevent respiratory failure from progressing among a surge of inpatients?

Review of Evidence

The team extensively reviewed the literature. Using evidence from 22 case reports, peer-reviewed standards, and studies, they developed an awake self–prone positioning guideline.


The guideline was implemented in April 2020 in critical care and COVID-19 units. Multimodal education included a concise guideline and real-time support from intensive care unit nurses, clinical nurse specialists, and nursing professional development specialists.


Awake self–prone positioning was a new procedure, and relevant data were obtained from the electronic medical record. From March 18 to August 5, 2020, 1000 COVID-19–related admissions occurred; 272 patients had a high-flow nasal cannula, 111 (41%) of whom had documentation of awake self–prone positioning.


This guideline is now an established part of COVID-19 care and has been integrated into practice in units caring for patients with the disease.


Nurses adapted quickly to using awake self–prone positioning as a plan of care for hypoxic patients. This practice may help hospitals adjust care delivery for these patients and effectively maintain patients in non–intensive care units.

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