Purpose: The purpose of this retrospective study was to describe the effect of awake prone positioning (APP) on acute care patients with COVID-19 following implementation of nurse and patient education and standardization of care on an acute care medical unit.
Background/significance: With the rapid surge of patients with COVID-19 in fall 2020, non-ventilated patients with COVID-19 and acute respiratory distress syndrome (ARDS) were admitted to a 22-bed acute care medical unit within our 596-bed level I trauma community teaching hospital. Given therapeutic management of ARDS in the critical care setting, including postural changes and prone positioning to improve arterial oxygenation, implementing prone positioning became a needed nursing intervention on acute medical nursing units. Limited research was published on the effect of APP on non-ventilated patients cared for on acute care medical units where nurses were unfamiliar with this patient population and intervention. In December 2020, a standardized process to implement APP for patients diagnosed with COVID-19 was developed using the Intensive Care Society Guidance for Prone Position on the Conscious COVID Patient 2020. Education about APP was provided to nursing staff through various media including video tutorials, handouts, assigned education, and hands-on training. Clinical nurses were instructed to document the SpO2 with accompanying FiO2 to allow the electronic medical record to calculate the SpO2/FiO2 (S/F) ratio. The S/F ratio served as a tool to identify and trend patient acuity based on associated ARDS categories: mild ARDS S/F 235314, moderate ARDS S/F 150-234, and severe ARDS S/F < 150.
Methods: Institutional review board approval was given to conduct a study using a pre–post intervention design. Adults > 18 years of age diagnosed with COVID-19 cared for on an acute care medical unit were included preintervention (November 2020) and post-intervention (March 2021). Data were collected retrospectively. Groups were compared for age, gender, race, ethnicity, and Charlson co-morbidity index. Outcomes evaluated included transfer to ICU, in-hospital mortality, and length of stay.
Results: The pre-intervention group (n=52) and post-intervention group (n=100) were similar for age, race, ethnicity, and Charlson co-morbidity index. There were significantly more females in the pre-group (65.4% vs. 45%, p=.017). No differences were found in morality, ICU transfer, or length of stay.
Conclusion/implications: Complexity of patient conditions along with ongoing changes in the acute care medical unit personnel and missing documentation limited the ability to demonstrate statistically significant improvement. Despite the inability to demonstrate significant improvement in a large cohort, evaluation of patient response to active engagement in APP demonstrated clinically significant improvement in S/F ratios. Standardizing procedures and providing clinicians with education and resources to implement APP is essential for successful execution of evidence-based practice.
Evidence-based references 1. Adams JY, Rogers AJ, Schuler A, et al. Association between peripheral blood oxygen saturation (SpO2)/fraction of inspired oxygen (FiO2) ratio time at risk and hospital mortality in mechanically ventilated patients. Perm J, 2020; 24:19.113. doi: 10.7812/TPP/19.113 2. Bamford P, Bentley A, Dean J, Whitmore D, Wilson-Baig N. ICS guidance for prone positioning of the conscious COVID patient 2020. Intensive Care Society. Accessed July 10, 2020. https://emcrit.org/wpcontent/uploads/2020/04/2020-04-12-Guidance-for-conscious-proning.pdf 3. Ehrmann S, Li J, Ibarra-Estrada M, et al. Awake prone positioning for COVID-19 acute hypoxaemic respiratory failure: A randomized, controlled, multinational, open-label meta-trial. Lancet Respir Med. 2021;9(12):1387-1395. doi: 10.1016/S2213-2600(21)00356-8. 4. Francisco, MA, Pierce, NL, Ely, E, Cerasale, MT, Anderson, D, Pavkovich, D, Puello, F, Tummala, S, Tyker, A, D’Souza, FR. Implementing prone positioning for COVID-19 patients outside the intensive care unit. J Nurs Care Qual, 2021; 36(2): 105-111. 5. Paul, V, Patel, S, Royse, M., Odish, M., Malhotra, A., & Koenig, S. Proning in non-intubated (PINI) in times of COVID19: Case series and a review. Journal of Intensive Care Medicine. 2020; 35(8): 818–824. 6. Sryma, PB, Mittal, S, Madan, K, Mohan, A, Hadda, V, Tiwari, P, & Guleria, R. Reinventing the wheel in ARDS: Awake proning in COVID-19. Archivos De Bronconeumologia, 2020; 56(11): 747–749