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?
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. (Critical Care Nurse. Published online April 13, 2021)
The outbreak of the novel coronavirus first identified in Wuhan, China, in 2019, rapidly evolved into a pandemic, challenging health care systems throughout the world.1 The virus was renamed severe acute respiratory syndrome coronavirus 2, the cause of COVID-19.1 The first case was reported in the United States in January 2020.2
A main complication of COVID-19 is the development of acute hypoxemic respiratory failure,3 which is characterized by significant hypoxemia (PaO2/fraction of inspired oxygen [FIO2] ≤ 300 mm Hg) and an increased respiratory rate and other signs of respiratory distress without related causes such as chronic obstructive pulmonary disease or immediate postoperative or postextubation status.4 Before the COVID-19 pandemic, most patients with acute hypoxemic respiratory failure would have been treated in critical care units. Because of the large volume of patients, which increased as the pandemic progressed, the need also increased for treatment modalities that could safely be performed in both critical care and non–critical care areas. Prone positioning has long been used as a beneficial intervention for patients with acute respiratory distress syndrome (ARDS). As the COVID-19 pandemic progressed, providers in hospitals rapidly adapted their knowledge of prone positioning for acutely ill patients to a new process termed awake self–prone positioning (ASPP). Could a health care system with 1100 beds safely and rapidly implement ASPP in both inpatient units and COVID-19 intensive care units (ICUs) to prevent the progression of respiratory failure among a surge of inpatients?
As the COVID-19 pandemic progressed, providers rapidly adapted their knowledge of prone positioning for acutely ill patients to a new process termed awake self–prone positioning.
Review of Evidence
The team searched for evidence by reviewing the literature about the use of ASPP to manage patients with COVID-19. We evaluated each source using the levels of evidence described by the American Association of Critical-Care Nurses5 (Table 1). Because the literature evolved rapidly, we needed to frequently update the compilation of sources.
Prone positioning for treating ARDS was first described in the literature more than 40 years ago6,15 ; it is recommended for 16 hours daily in patients with ARDS who have a PaO2/FIO2 ratio less than 150 mm Hg.20 With this technique, a bedside team orchestrates careful repositioning—for example, from the supine (on the back) to the prone (on the abdomen) position—of a critically ill patient with ARDS, who may have an artificial airway, be receiving mechanical ventilation, or be sedated. Prone positioning improves oxygenation by recruiting collapsed alveoli from the former dorsal lungs; improving management of secretions; and shifting perfusion toward healthy, open alveoli, thereby improving ventilator-perfusion matching.21 In addition, it reduces lung strain, leading to a more even distribution of inflation and ventilation, which minimizes ventilator-associated lung strain.16,17
Awake Self–Prone Positioning
Prone positioning without intubation was described in the literature before COVID-19, particularly for patients with acute hypoxemic respiratory failure; the intervention helped improve PaO2 in patients with a PaO2/FIO2 ratio more than 100 mm Hg.12,24 In March 2020, Sun et al25 published a sentinel case analysis that used the term awake prone position in describing a triad of critical care management techniques for patients with COVID-19 with signs of respiratory distress. Patients who met criteria (respiratory rate > 30/min, oxygen saturation [SpO2] < 93% on room air, or heart rate > 120 beats/min) were given critical care management, which consisted of a high-flow nasal cannula or noninvasive ventilation, fluid restrictions, and awake prone positioning.25 Although Sun et al did not analyze data to determine statistical significance, they believed this management process contributed to the low mortality and high discharge rates among their patients.
In a pilot study of 50 patients with COVID-19 in an emergency department, Caputo et al7 showed that SpO2 did improve after ASPP for most patients; ASPP failed (ie, patients required intubation within 24 hours) in 13 patients (24%). Caputo et al also demonstrated that ASPP could be done safely in a busy emergency department when excluding patients who were not capable of turning themselves. A small case series of 10 patients revealed a low intubation rate of 10% (1 patient) among a population of patients receiving supplemental oxygen who performed ASPP; in that series, among a similar hospital population who did not receive ASPP, 60% (12 of 20 patients) required intubation.19
Several other small studies contributed to proof of concept. In a prospective before-and-after study of 24 patients with COVID-19, Elharrar et al13 found that 15 patients (63%) tolerated ASPP for more than 3 hours. They deemed 6 of those 15 patients (40%) to be “responders” because their PaO2 increased 20% or more between prone positioning and resupination.13 In a retrospective cross-sectional review of 15 patients with COVID-19 who were receiving noninvasive ventilation outside the ICU, Sartini et al23 found that SpO2 and the PaO2/FIO2 ratio improved in 12 patients (80%) who did ASPP, and that it was feasible and safe in patients receiving noninvasive ventilation. In a retrospective review of 10 patients with COVID-19, Damaria et al10 found that 2 patients (20%) required intubation and 100% were discharged from the hospital by day 28. The study protocol alternated patients between the prone and the supine position every 2 hours as tolerated, with reminders given to nurses.10
In a larger prospective feasibility cohort study of 54 patients with COVID-19 who were receiving oxygen or noninvasive ventilation, researchers found that ASPP for a minimum of 3 hours was achieved in 47 patients (83.9%) and that a statistical improvement in oxygenation occurred during prone positioning.8 Although oxygenation improved after resupination in 23 patients (50%), the improvement was not statistically significant.8 In an observational prospective pilot study of 26 patients with COVID-19 receiving helmet continuous positive airway pressure in a pulmonary high-dependency unit, Retucci et al22 found a higher success rate in patients who were able to be fully prone (9 of 12 episodes [75%]) than in patients who turned laterally (10 of 25 episodes [40%]).
From April to July 2020, several guidelines on how to implement ASPP were published and made available concurrently.14,18,26 In addition, COVID-19 treatment guidelines published in July 2020 recommend ASPP for patients with persistent hypoxemia despite increases in supplemental oxygen.9 This recommendation refers to patients for whom endotracheal intubation is not otherwise recommended (Table 2).9 The guidelines do not recommended ASPP as rescue therapy for refractory hypoxemia in patients who require intubation.9 Although the literature has continued to evolve rapidly during the pandemic, with several large randomized controlled studies in development, findings show that ASPP can be safely achieved and may help improve oxygenation in a subset of patients with COVID-19.
Development of ASPP Guidelines
During March and April 2020, the population of patients diagnosed with COVID-19 steadily grew. During these uncertain times, the health care system met with the challenge of providing appropriate and effective care to these patients. As our institution, along with organizations worldwide, searched for evidence to support best practices for treating this viral infection, those directly at the bedside sought guidance from their leaders. Many at the bedside felt anxious about contracting the virus, and the uncertainty about the ever-changing policies and guidelines surrounding COVID-19 and patient care exacerbated those feelings. Nurse and physician leaders worked relentlessly to provide up-to-date, clear guidelines for the institution while continuing to search the literature for any evidence-based interventions to treat COVID-19.
From mid-March to early April 2020, all patients with COVID-19 who required supplemental oxygen were admitted to the medical ICU (MICU) at Christiana Hospital in Newark, Delaware, which became the facility’s primary designated COVID-19 critical care unit. As the number of patients surged, because of limited capacity the plans changed regarding which patients needed to be admitted to the MICU. To ensure beds remained available for unstable individuals, physicians and nurses discussed ways to combat respiratory distress and decompensation in patients with COVID-19 in both ICUs and non-ICU areas. Physicians from pulmonary, critical care, infectious disease, and internal medicine disciplines, along with nurse leaders from the MICU and intermediate care, reviewed available guidelines and research for mention of ASPP by nonintubated patients with COVID-19. In the MICU, the teams began implementing ASPP for patients with COVID-19 who required any supplemental oxygen, and they quickly witnessed improvements in oxygenation for many patients. Although the MICU team has years of experience in placing critically ill patients with ARDS into the prone position, ASPP is a different process. The guidelines for prone positioning of patients with ARDS and those for ASPP for patients with COVID-19 contain several differences, but the essential goal of improving oxygenation is the same, and the MICU team adapted easily. The MICU team then shared the intervention with providers and nurse leaders in the designated COVID-19 intermediate care unit and medical floors.
The clinical nurse specialist (CNS), the nursing professional development specialist (NPDS), and the medical director from the MICU promptly identified a need for standardized education on this process for the multiple designated COVID-19 units and interdisciplinary health care team members. Without a tangible reference, many well-intentioned but conflicting recommendations about ASPP began to circulate, resulting in many questions for the MICU team. The NPDS and CNS from the COVID-19 intermediate care unit also noted variations in instructions about the ASPP process. The NPDS and CNS from the MICU teamed up with a system-wide NPDS to expedite the development of a formal educational guideline for ASPP in patients with COVID-19 (see Figure). The primary goals were to develop clear, concise, evidence-based instructions and considerations that team members could easily apply at the bedside for appropriate patients in both ICUs and non-ICU areas. Once finalized, the information was posted to the system’s COVID-19 intranet site and sent to leaders of areas where ASPP may be used. To ensure understanding of this new intervention, multiple team members collaborated to provide multimodal education throughout all nursing shifts.
Rapid Response Team Assistance With Education
Rapid response team (RRT) nurses work within the MICU at our institution, and they were the first to start implementing the ASPP intervention in patients with COVID-19. The RRT both responds to acute RRT calls and proactively performs rounds among patients. During rounds, the RRT nurses use an early warning score to identify patients at risk of decompensation. While performing rounds on the COVID-19-designated units (non-ICU areas), the RRT nurses met with unit charge nurses to identify any patients who were not captured with the tool used during rounds. This process also provided opportunities for them to discuss ASPP and answer any questions, which strengthened the relationship between the RRT and intermediate care nurses. As the population of patients with COVID-19 grew at the hospital throughout the disease surge between March and June 2020, the rate of RRT calls from the COVID-19–designated units increased approximately 40%.
Education and Implementation on Non–ICU Inpatient Units
Even though nurse support was provided from the start because of the observed benefits of ASPP, it was not an intervention with which the intermediate-level nurses were familiar outside of an RRT event. As this practice was rapidly unfolding, it was important to provide the nurses with clear and concise guidelines for this new process to meet the needs of these adult learners.27 In addition, the NPDSs and CNSs in the non-ICU areas also reviewed the literature to acclimate themselves to the benefits of ASPP and how to best support the staff as they implemented the new process. They developed an education plan that included didactic learning followed by hands-on demonstration of this new skill. Staff were educated on where and how to document the patient’s position to capture those who received this intervention.
A key component of compliance with ASPP was ensuring that the patient was thoroughly educated on the process by using the teach-back method.
After the ASPP guideline was created, education was disseminated to non-ICUs. The NPDS and CNS in the non-ICUs presented the education during daily unit-based huddles and provided the information on the nursing communication board. They reviewed the components—why, who, what, when, and how—as presented in the guideline (see Figure). The guideline was available on the system’s COVID-19 intranet site, shared through email, and posted throughout the units. Availability of a written guideline has many benefits, including use as a portable resource that can be accessed any time for reinforcement or clarification.26 This benefit was particularly useful when nurses implemented this intervention in real time and when the NPDS and CNS were not present. The RRT nurses served as a resource to assist other nurses in identifying appropriate candidates for ASPP. During active RRT calls and proactive rounds, they also educated nurses who had not yet implemented this intervention and helped guide patients through repositioning.
After nurses reviewed the guideline and understood the ASPP process, they began implementing it with patients. Nurses used various methods to instruct patients to get into the prone position, including video communication via an iPad or verbal instructions given either while standing at the doorway of the patient’s room or after entering the room (for patients who needed more assistance with pillow placement). Attempting these alternative methods of communication, nurses were able to limit their exposure to the virus and conserve personal protective equipment. The NPDS and CNS were also available to support the nurses in real time during situations and, when necessary, to prompt the nurses to have a patient attempt ASPP.
As more COVID-19–positive patients were admitted to the intermediate care unit, the nurses became proficient in ASPP. Whenever a patient decompensated, ASPP became part of the plan of care. If an RRT was called for a patient with hypoxia, the patient was typically already in the prone position before initiation of RRT. This intervention helped maintain appropriate patients at an intermediate level of care and lessen demand for the limited number of intensive care beds.20
A key component of compliance with ASPP was ensuring that the patient was thoroughly educated on the process by using the teach-back method. Some COVID-19–positive patients are generally asymptomatic early during the course of the disease: despite profound hypoxemia and a left shift of the oxyhemoglobin curve, their lung mechanics are well preserved and they do not experience respiratory distress.11 These patients have been labeled as having “happy hypoxemia,” and they may experience sudden and rapid respiratory decompensation.11 This phenomenon occurred frequently at our hospital, and in some cases the patients were unable to understand the urgency of the situation. To involve these patients in their care, nurses provided additional education on this disease process and why ASPP is important.
Nurses used multiple educational methods to meet the learning needs of each patient. Each room on the COVID-19 intermediate unit was equipped with an iPad, through which the nurse and patient could have a video conversation about ASPP. In addition, written materials with instructions and pictures were provided to patients. Nurses would introduce this education to the patient early during the disease process to ensure the patient understood how to perform ASPP before any emergent situation occurred. If an emergent situation did occur, nurses educated the patient in real time and assisted them with pillow placement to ensure they were comfortable in the prone position.
As the pandemic progressed, the number of Spanish-speaking patients in the hospital system increased, and in-person interpreters were no longer available. Instead, nurses used interpreters through an online system available through the iPads, and all printed materials were made available in Spanish.
One of the biggest barriers to ASPP compliance is that the patient controls the duration on the basis of how well they can tolerate the position. Although the guideline recommends that a patient lie in the prone position for up to 4 hours, this duration often was not feasible. A common concern from patients was back, neck, and shoulder discomfort. For some patients, body habitus prevented them from maintaining the prone position comfortably. The prone position should not be avoided because of a large body habitus if the patient is monitored and can tolerate the position.21
As mentioned earlier, a subset of patients were not feeling dyspneic and could not conceptualize the benefits and importance of ASPP. This lack of understanding was especially challenging during mealtimes, when patients could become hypoxic due to resupination. When hypoxia occurred, the nurses reeducated the patient and promoted ASPP soon after the meal. The ASPP guideline recommends waiting 60 minutes after a meal before attempting ASPP to prevent reflux. Occasionally, however, a patient’s condition required immediate intervention. In these instances, even though the head of the bed was not elevated during prone positioning, there were minimal reports of reflux.
When a patient could not tolerate ASPP, they were instructed to attempt a lateral position. On the basis of the patient’s lung impairment, nurses would encourage lateral positioning with the more affected side up. Although limited information describes the benefits of lateral positioning, some patients had better oxygenation levels in, and better tolerated, the lateral position in our study.
Another challenge was the lack of visibility in patient rooms in areas outside the ICU. Although the nurses could coach or assist a patient into the prone position, their view was often obstructed by wooden room doors or by the curtains used in semiprivate rooms. The organization’s guideline recommended keeping the door closed to rooms housing patients with COVID-19; however, nurses had to open the door to visualize patients or to watch noncentralized pulse oximetry waveforms. Providers in the non–ICUs and the infection prevention team collaborated to create a safe method for visualizing patients while minimizing exposure. The guideline was modified to include an option to have the patient’s door open if the patient could be positioned at least 6 ft (1.8 m) from the doorway. Nurses also had the option of using video (via an iPad) to monitor patients; however, this option required the patient to activate the camera, which at times was unsuccessful because patients were unable to operate this technology.
Each room on the COVID-19 unit was equipped with an iPad, through which the nurse and patient could have a video conversation about ASPP.
When patients became hypoxic, nurses quickly intervened and were at the bedside for an extended period to assess the patient and provide therapeutic interventions (eg, oxygen titration and chest physiotherapy). Although patients would be placed in the prone position, documentation was not always captured in real time. In addition, the limited amount of time patients were able to tolerate the prone position made accurate documentation difficult, limiting our understanding of whether a patient was able to perform ASPP or whether it had been attempted with the patient earlier during their hospitalization.
Anxiety and fear were noted in patients who experienced symptoms of hypoxemia. Two main factors contributed to their anxiety: the lack of visitors and family support, and concern for the health and well-being of family members who were simultaneously admitted to the hospital or the ICU. When appropriate, family members with COVID-19 who were admitted to the same unit were housed in the same room as a means of reducing this anxiety. In addition, phones with video communication capabilities were provided to patients to help connect them with their families. Patients were offered anxiolytic medications (as appropriate to their clinical condition) when nonpharmacological interventions were unsuccessful.
Our institution admitted its first patient with COVID-19 on March 18, 2020. From that date until August 5, 2020, approximately 1000 patients with COVID-19 were admitted. Among them, 272 patients needed a high-flow nasal cannula, 111 (41%) of whom had ASPP documented. As the data for ASPP were obtained from nursing documentation in the electronic medical record, and because such documentation was new for the non–ICUs treating inpatients, we do not know whether it accurately conveys the complete story of a patient’s use of ASPP.
Anxiety and fear were noted in patients who experience symptoms of hypoxemia.
The ASPP guideline is an established part of COVID-19 care and has been integrated into practice in the COVID-19 cohort units. As the institution continues to maintain preparedness for further potential surges in the number of patients with COVID-19, it is imperative that both new and experienced staff members be supported in understanding the practice of ASPP. The ASPP guideline will continue to be part of the system-wide intranet site containing all resources for the care of patients with COVID-19 in both ICUs and non–intensive care settings. Drifts in practice, however, are expected with any new process change. Therefore, the NPDSs, CNSs, and RRT team members experienced with COVID-19 will continue to educate and engage providers on the COVID-19 units in the ASPP process.
Since the initial COVID-19 surge, the cohort units have changed. Therefore, the education of staff on the new cohort units is a priority. To this end, NPDSs who have experience with COVID-19 have been instrumental in orienting the NPDSs of the new cohort units and assisting with educating their staff. The RRT team and the unit-based NPDSs are at the forefront of ensuring that staff are educated—whether through nursing communication boards or during unit-based huddles, proactive rounds, or active RRT calls. Physicians, whether they practice in the ICU or a non–intensive care setting, have also engaged in promoting the ASPP process for patients with COVID-19, and discussion has begun about adding ASPP as an ordered intervention in the patient’s electronic medical record.
The new practice of ASPP was implemented rapidly when resources were stretched during a surge of the pandemic. Evidence-based practice and implementation of new patient procedures usually take place after high-level literature assessments, multiple interdisciplinary meetings, agreement on the level of evidence, and development of a procedure or policy. These interventions evolved into best practices during a pandemic in order to provide to patients a therapeutic modality that could potentially improve care, would do no harm, and could be provided safely in both ICUs and non–intensive care areas.
Although outcome data related to this intervention are limited, the initial findings seem to be positive. Future research on ASPP by nonintubated patients with COVID-19 is needed to accurately quantify its impact on patient outcomes, including the need for and duration of intubation, length of stay in the ICU and in the hospital, and survival rate.
To purchase electronic or print reprints, contact the American Association of Critical-Care Nurses, 27071 Aliso Creek Rd, Aliso Viejo, CA 92656. Phone, (800) 899-1712 or (949) 362-2050 (ext 532); fax, (949) 362-2049; email, firstname.lastname@example.org.
To learn more about caring for patients with COVID-19, read “Experiences of Nurses During the COVID-19 Pandemic: A Mixed-Methods Study” by LoGiudice and Bartos in AACN Advanced Critical Care, 2021;32(1):14-26. Available at www.aacnacconline.org.