2021 Annual Conference

CNS Improving Outcomes
Role of CNS in COVID-19 Pandemic
Capture Value of the CNS
Interprofessional Collaboration

Prone position therapy has been an evidence-based treatment recommendation for patients with moderate to severe Acute Respiratory Distress Syndrome (ARDS) for decades, and more recent studies support statistical significance in reducing mortality with the early initiation of prone positioning for greater than 12 hours per day (Guérin, 2013). Different techniques and equipment, for example the RotoProne® bed, exist to assist nurses in turning patient to the prone position.

Prior to March 2020, a community hosital Intensive Care Unit (ICU) had low volumes of patients needing prone positioning, utilizing this therapy via the RotoProne® only 3 times in 2019. With anticipation of a surge of patients with ARDS due to Covid-19, options for how to prone position patients was investigated. The supply of RotoProne® beds in central Indiana could not match the demand, causing delays of upward of 5-7 days. Delaying prone positioning greatly impacts effectiveness of the therapy. Implementation of manual prone positioning was needed to meet the needs of an ICU that grew from a capacity of 8 to 32 beds during the pandemic.

Methods: Intervention

The Clinical Nurse Specialist (CNS) reviewed guidelines, protocols and literature to develop criteria, prone preparation checklist and manual prone technique. This new manual prone process was vetted with the Intensivists and communicated to all ICU RNs, PCAs and Respiratory Therapists. After the CNS completed rapid experiments to determine best techniques to safely prone and reduce complications (i.e. pressure injuries, tube and line dislodgement), a quick 1-minute video was created and disseminated. Bedside coaching by the CNS and daily collaboration with the CNS, primary RN, RT and Intensivist focused on coordinating the patient’s plan of care to include prone therapy.    

Results: Impact and Significance

Data was collected on all patients with confirmed Covid-19 requiring mechanical ventilation (MV) admitted to the ICU from March 1 to June 30, 2020. Of the 55 total patients, 14 were manually prone positioned based on criteria met for moderate to severe ARDS for an average 3.5 days (range 1-10 days; median 3 days). Six of the 14 patients (43%) survived to discharge. Manual prone positioning was initiated on all 14 patients on day therapy was ordered. Three patients were over the recommended weight limit to manual prone position, and the RotoProne® was used with up to a 6-day delay on receiving the bed due to other hospitals’ demand. Four patients did experience mucosal membrane breakdown on the lip due to the Endotracheal tube, which is taped prior to prone positioning to ensure tube securement.  

Direct Cost Savings

Manual prone therapy was completed for a total of 50 days in Quarter 2, 2020. The RotoProne® bed rental cost is $1520 per day, equaling savings of $76,000. The only additional cost to manual prone positioning was each patient received a waffle mattress and cushion for skin protection and repositioning. This added approximately $60 per patient for a total of $840 for 14 patients. For 3 months, the direct cost savings from initiating manual prone positioning was $75,160.

Discussion

Rapid implementation of manual prone positioning during the Covid-19 pandemic ensured timely initiation of an evidence-based therapy. Without execution of this project, delays in prone therapy could have led to worsened patient outcomes and mortality. Next steps include formalizing the prone positioning guidelines and employing additional techniques to reduce prone complications. In the event of another Covid-19 surge, the ICU is prepared to meet the needs of patients with moderate to severe ARDS who need prone positioning.

Guérin, C., et al. (2013). Prone positioning in severe acute respiratory distress syndrome. The New England Journal of Medicine, 368(23), 2159-68.