We thank Anthony Pietropaoli, Physical Therapists of the Critical Care Service at Strong Memorial Hospital, John Horvath, Michael Maxwell, E. Kate Valcin, and Craig Woeller.

1. Procedure: preparation
<ol>
	<li>Have the team establish that the patient is a good candidate for prone positioning with respect to the hemodynamic status.</li>
	<li>Obtain a provider order for prone positioning, which should ideally indicate the number of hours in prone position.</li>
	<li>Explain the procedure to the patient (if not sedated) and/or significant other. 
	NOTE: Consider the time of day and the staff on hand regarding when to begin the proning cycle. This is especially relevant if there are multiple patients on a unit/ward that need to be placed in the prone position8.</li>
	<li>Ensure all the potential participants are notified of the plan, including the RT.</li>
	<li>Obtain an arterial blood gas sample for analysis, from an indwelling arterial line, or via arterial puncture prior to the procedure8.</li>
	<li>Transfer the patient onto a pressure-redistributing surface prior to beginning the proning cycle19.</li>
	<li>Use a slide sheet or air transfer matt to avoid caregiver injury.</li>
	<li>If a feeding tube is in use, check the integrity of the securement or use a bridle to reduce any chance of dislodgement.</li>
	<li>Stop the tube feed.</li>
	<li>Meticulously secure all intravascular catheters and place foam dressings on the skin under the hubs and ports if the patient will be lying on them when in the prone position. 
	NOTE: If the patient is on isolation, initiate a wearable sensor for continuous glucose monitoring, if applicable and available.</li>
	<li>Make note of the length of the ET at the lips or teeth. Remove the headboard.</li>
	<li>If a commercial ET holder is in use, have the RT and ICU nurse remove this device and secure the tube with tape approved for the securement of critical tubes.</li>
	<li>Place foam dressings on the face, including over the cheeks and the top lip, prior to taping the ET tube. Optional: place foam dressings on the chin, nose, and forehead20 (Table 1).</li>
	<li>Suction the ET and mouth and perform oral hygiene.</li>
	<li>Apply foam dressings to both knees and any other bony prominences or areas of risk, i.e., sternum and under medical devices that cannot be moved20,21.</li>
	<li>Empty drains, urinary collection bag, and ostomy pouches.</li>
	<li>If the patient is pharmacologically paralyzed or if the eyelids are not closed, instill lubrication in eyes, and then close the lids and secure them with gentle tape.</li>
	<li>Check for immediate availability of a team member who is competent in intubation and the accessibility of an emergency intubation kit, code cart, extra electrodes, extra bed linen, pillows, and foam dressings of various sizes.</li>
	<li>Discontinue non-essential infusions and monitoring prior to initiating the procedure. Disconnect tube feeding, remove oximetry probe and blood pressure cuff if the patient also has an arterial line, remove leg devices for deep vein thrombosis prevention and heel boot(s), and unhook urinary catheter securement.</li>
	<li>Monitor pulse oximetry or invasive arterial blood pressure throughout the procedure.</li>
	<li>Assess pain and sedation status immediately prior to proning and treat accordingly by administering medication to optimize sedation and prevent pain.</li>
</ol>
2. Procedure: supine to prone
<ol>
	<li>Have the assigned ICU nurse in collaboration with the charge nurse assemble the adequate number of nursing staff; ideally four (two on either side of the bed) plus the RT, but as many staff as available and needed for the patient size, to facilitate a safe procedure. Let the team members introduce themselves, if needed, and discuss each team member&#39;s role prior to proceeding.
	<ol>
		<li>Put the RT in charge of airway at the head of bed (HOB).</li>
		<li>Put the ICU nurse in charge of monitoring critical intravascular lines and assisting the RT.</li>
		<li>Have other team members monitoring the drains and other tubes and assisting with linens and roll.</li>
		<li>Assign the wound nurse, or skin champion if available, to direct prevention measures for bony prominences and skin under medical devices and assist with bed linen roll.</li>
		<li>Designate a team member to watch the monitor.</li>
		<li>Have a healthcare provider available inside or just outside the room, available to reintubate if necessary.</li>
	</ol>
	</li>
	<li>Check for securement of chest tubes and any other percutaneous tubes.</li>
	<li>Have the RT or Provider, with the ICU nurse, decide the direction in which the patient will be rolled and communicate it to the other team members. 
	NOTE: Ideally plan to roll toward the ventilator, away from central venous lines.</li>
	<li>Have the RT/Provider adjust ventilator settings as ordered/required.</li>
	<li>Lay the patient flat on the bed in the supine position (Figure 1).</li>
	<li>Create a bed roll using an extra slide sheet or air transfer pad, flat bed sheet, and under pad. Inflate the mattress to the maximum extent, if applicable.</li>
	<li>Using the slide sheet or air lift under patient, pull the patient to the edge of the bed that is furthest from the ventilator.</li>
	<li>Place the bed roll so that it can be unrolled onto the side of the bed that is opposite to the ventilator.</li>
	<li>Tuck the linen roll under the patient on the ventilator side. Ensure that only 25%-30% of the roll is tucked under the patient.</li>
	<li>On the count of the team member at the HOB, carefully roll the patient from supine up to a 90&#176; side-lying position with the patient&#39;s face toward the ventilator (Figure 2).</li>
	<li>Move the telemetry electrodes from the patient&#39;s chest to the patient&#39;s back (Figure 3). 
	NOTE: Placement of new electrodes on the back can also occur when the patient is lying prone.</li>
	<li>Place a pillow on the bed that will be positioned under the patient&#39;s chest/shoulders.</li>
	<li>If the patient is inflexible and/or has tight hip flexors, place a pillow under the hip/pelvis and/or an air cushion under the knees.</li>
	<li>On the count of the team member at the HOB, carefully lay the patient prone with a pillow under the upper chest/shoulders, and center the patient in the middle of the bed with the top of patient&#39;s head at the top edge of the bed (Figure 4).</li>
	<li>Have team members at the head of the bed rotate the patient&#39;s head either left or right, and place the bed pillow under the head. Ensure that the patient&#39;s face is on the very edge of the pillow so that the nose is free from pressure, and there is adequate room for the ET and ventilator tubing for suctioning.</li>
	<li>Ensure that the patient&#39;s arms are placed in the swimmer&#39;s crawl position: the face is toward the prominent hand, palmar side down, wrist in neutral, elbow lower than the shoulder, and elbow flexed6,22. Ensure that the contralateral arm is extended down alongside the body, with a pillow under the anterior shoulder and arm, palmar side of the hand facing up.</li>
	<li>Place a pillow horizonal to the patient under both the lower legs to allow the knees to be slightly flexed and disallow extreme plantar flexion and avoidance of pressure injuries on the feet and toes.</li>
	<li>Reconnect the monitoring equipment and tubes that were disconnected prior to prone positioning.</li>
	<li>Complete a skin assessment of the sacrum, coccyx, and buttocks. Place a protective foam dressing on the sacrum in anticipation of returning to supine positioning after the prescribed prone time.</li>
	<li>Place the bed in reverse Trendelenburg&#39;s position, approximately 30&#176; for complication avoidance8,12.</li>
	<li>Restart tube feeding if applicable.</li>
</ol>
3. Procedure: position changes while lying prone
<ol>
	<li>Mobilize the patient every 2-3 h for pressure injury avoidance and to optimize the drainage and suctioning of secretions from the lung segments into the central airway. 
	NOTE: The exact frequency of repositioning of the patient may be influenced by both patient factors, such as hemodynamic tolerance and staffing factors6.</li>
	<li>Ensure the availability of a minimum of three caregivers for position changes. Have the RT take charge of managing the ET and two additional caregivers, one an ICU nurse, assist with mobilizing the patient.</li>
	<li>Take the bed out of the reverse Trendelenburg&#39;s position to a flat position, parallel to the floor.</li>
	<li>Using a slip sheet or air transfer pad, pull the patient up in bed if needed (with mattress inflated to the maximum extent if applicable).</li>
	<li>Carefully move the arm that is bent at the elbow down to the patient&#39;s side.</li>
	<li>After suctioning the patient&#39;s airway and mouth as needed, have the RT secure the ET and lift the patient&#39;s head off the pillow.</li>
	<li>Wait for the nurse at the HOB to pull out the pillow from under the patient&#39;s head while the RT rotates the head to the opposite direction. Ensure that the pillow is flipped or the pillow case changed and the head placed back on the edge of the pillow, with no pressure on the nose or ET.</li>
	<li>Bring up the arm on the side that the head is facing is now in swimmer&#39;s position, elbow bent and lower than the shoulder, wrist in neutral.</li>
	<li>Ensure that the contralateral arm is in neutral alongside the body, with a pillow tucked to support the anterior shoulder and arm, palmar side of the hand facing up. 
	&#8203;NOTE: For an inflexible patient and/or those with limited neck rotation, a pillow can be slightly tucked under the abdomen on the side the head is turned toward to facilitate neck rotation and ensure off-loading of nose and chin.</li>
</ol>
4. Procedure: prone to supine
<ol>
	<li>Assign an ICU nurse to collaborate with the charge nurse in assembling an adequate number of staff to complete the procedure. 
	NOTE: Typically, at least four staff members are required, but assemble as many as needed for the patient&#39;s size and to facilitate a safe procedure. Team members introduce themselves if needed and discuss each team member&#39;s role prior to proceeding.
	<ol>
		<li>Ensure that the RT or Provider is in charge of airway at the HOB.</li>
		<li>Put the critical care nurse in charge of monitoring critical intravascular lines and assisting the RT.</li>
		<li>Have the other team member(s) monitor drains and other tubes and assist with linens and the turn.</li>
	</ol>
	</li>
	<li>Empty drains and the urinary collection bag.</li>
	<li>Ensure protective foam dressing is on the sacrum.</li>
	<li>Have a team member watch the monitor.</li>
	<li>Have the provider inside or outside the room, available to reintubate if necessary.</li>
	<li>Allow the decision for the direction in which patient will be rolled to be made jointly by the RT and the critical care/ICU nurse. Roll the patient toward or away from the ventilator, depending on the location of the central venous lines, IV pump locations, and preference of the RT and ICU nurse.</li>
	<li>Disconnect non-critical tubing and devices.</li>
	<li>Take the bed out of the reverse Trendelenburg to a flat position parallel to the floor. Inflate the mattress to the maximum extent, if applicable.</li>
	<li>Carefully straighten the arm/hand that is across from the face and gently place it at the patient&#39;s side.</li>
	<li>Remove all the pillows from underneath the patient, including the chest, lower legs, and lateral trunk if applicable.</li>
	<li>Pull the patient to the side of the bed furthest from the direction of the turn.</li>
	<li>Create the bed roll with a slip sheet or air transfer pad, flat sheet, or under pad. Roll it up lengthwise and tuck 20% under the patient on the side the patient will roll toward.</li>
	<li>Gather extra electrodes/wires for the heart monitor.</li>
	<li>Have the RT adjust the ventilator settings as required/ordered.</li>
	<li>After a clear plan for the turn is established, tuck the patient&#39;s hand on the side that the patient will be turned toward, palm side up under the thigh.</li>
	<li>Carefully turn the patient 90&#176; onto their side, hold the patient briefly in this position while the heart monitoring electrodes are removed from the back, and new ones are placed on the chest. 
	NOTE: If preferred, placement of new electrodes can also occur after the patient is lying supine.</li>
	<li>On the count of the team member at the HOB, gently lower the patient to the supine position.</li>
	<li>Reconnect the tubes/monitoring equipment that were removed for the turn.</li>
	<li>Have the RT with the ICU nurse check the positioning of the ET and securement of all intravascular lines, tubes, and monitoring equipment. Adjust the angle of the bed as appropriate. 
	NOTE: Typically, 30&#176; of head elevation is required.</li>
</ol>

<ol>
	<li>Menk, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Current+and+evolving+standards+of+care+for+patients+with+ARDS.">Current and evolving standards of care for patients with ARDS.</a> Intensive Care Medicine. 46 (12), 2157-2167 (2020).</li><li>Villar, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Dexamethasone+treatment+for+the+acute+respiratory+distress+syndrome:+a+multicenter,+randomized+controlled+trial.">Dexamethasone treatment for the acute respiratory distress syndrome: a multicenter, randomized controlled trial.</a> The Lancet. Respiratory Medicine. 8 (3), 267-276 (2020).</li><li>The RECOVERY Collaborative Group. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Dexamethasone+in+hospitalized+patients+with+COVID-19.">Dexamethasone in hospitalized patients with COVID-19.</a> The New England Journal of Medicine. 384 (8), 693-704 (2021).</li><li>Tomazini, B. M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Effect+of+dexamethasone+on+days+alive+and+ventilator-free+in+patients+with+moderate+or+severe+acute+respiratory+distress+syndrome+and+COVID-19.">Effect of dexamethasone on days alive and ventilator-free in patients with moderate or severe acute respiratory distress syndrome and COVID-19.</a> Journal of the American Medical Association. 324 (13), 1307-1316 (2020).</li><li>Gu&#233;rin, C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Prone+positioning+in+severe+acute+respiratory+distress+syndrome.">Prone positioning in severe acute respiratory distress syndrome.</a> The New England Journal of Medicine. 368 (23), 2159-2168 (2013).</li><li>Binda, F., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Nursing+management+of+prone+positioning+in+patients+with+COVID-19.">Nursing management of prone positioning in patients with COVID-19.</a> Critical Care Nurse. 41 (2), 27-35 (2021).</li><li>Gu&#233;rin, C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Prone+position+in+ARDS+patients:+why,+when,+how+and+for+whom.">Prone position in ARDS patients: why, when, how and for whom.</a> Intensive Care Medicine. 46 (12), 2385-2396 (2020).</li><li>Rowe, C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Development+of+clinical+guidelines+for+prone+positioning+in+critically+ill+adults.">Development of clinical guidelines for prone positioning in critically ill adults.</a> Nursing in Critical Care. 9 (2), 50-57 (2004).</li><li>Spece, L. J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Low+tidal+volume+ventilation+use+remains+low+in+patients+with+acute+respiratory+distress+syndrome+at+a+single+center.">Low tidal volume ventilation use remains low in patients with acute respiratory distress syndrome at a single center.</a> Journal of Critical Care. 44, 72-76 (2018).</li><li>Shelhamer, M. C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Prone+positioning+in+moderate+to+severe+acute+respiratory+distress+syndrome+due+to+COVID-19:+A+cohort+study+and+analysis+of+physiology.">Prone positioning in moderate to severe acute respiratory distress syndrome due to COVID-19: A cohort study and analysis of physiology.</a> Journal of Intensive Care Medicine. 36 (2), 241-252 (2021).</li><li>Traylor, A. M., Tannenbaum, S. I., Thomas, E. J., Salas, E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Helping+healthcare+teams+save+lives+during+COVID-19:+insights+and+countermeasures+from+team+science.">Helping healthcare teams save lives during COVID-19: insights and countermeasures from team science.</a> The American Psychologist. 76 (1), 1-13 (2021).</li><li>Gonzalez-Seguel, F., Pinto-Concha, J. J., Aranis, N., Leppe, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Adverse+events+of+prone+positioning+in+mechanically+ventilated+adults+with+ARDS.">Adverse events of prone positioning in mechanically ventilated adults with ARDS.</a> Respiratory Care. 66 (12), 1898-1911 (2021).</li><li>Dirkes, S., Dickinson, S., Havey, R., O'Brien, D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Prone+positioning+Is+it+safe+and+effective?.">Prone positioning Is it safe and effective?.</a> Critical Care Nursing Quarterly. 35 (1), 64-75 (2012).</li><li>Wiggermann, N., Zhou, J., Kumpar, D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Proning+patients+with+COVID-19:+a+review+of+equipment+and+methods.">Proning patients with COVID-19: a review of equipment and methods.</a> Human Factors. 62 (7), 1069-1076 (2020).</li><li>Dickinson, S., Park, P. K., Napolitano, L. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Prone-positioning+therapy+in+ARDS.">Prone-positioning therapy in ARDS.</a> Critical Care Clinics. 27 (3), 511-523 (2011).</li><li>Poor, A. D., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Implementing+automated+prone+ventilation+for+acute+respiratory+distress+syndrome+via+simulation-based+training.">Implementing automated prone ventilation for acute respiratory distress syndrome via simulation-based training.</a> American Journal of Critical Care. 29 (3), 52-59 (2020).</li><li>Weller, J., Boyd, M., Cumin, D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Teams,+tribes+and+patient+safety:+overcoming+barriers+to+effective+teamwork+in+healthcare.">Teams, tribes and patient safety: overcoming barriers to effective teamwork in healthcare.</a> Postgraduate Medical Journal. 90 (1061), 149-154 (2014).</li><li>Papazian, L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Formal+guidelines:+management+of+acute+respiratory+distress+syndrome.">Formal guidelines: management of acute respiratory distress syndrome.</a> Annals of Intensive Care. 9 (1), 69 (2019).</li><li>Team, V., Jones, A., Weller, C. D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Prevention+of+hospital-acquired+pressure+injury+in+COVID-19+patients+in+the+prone+position.">Prevention of hospital-acquired pressure injury in COVID-19 patients in the prone position.</a> Intensive &amp; Critical Care Nursing. 68, 103142 (2021).</li><li>. Pressure injury prevention PIP tips for prone positioning Available from: <a target="_blank" href="https://cdn.ymaws.com/npiap.com/resource/resmgr/online_store/posters/npiap_pip_tips_-_proning_202.pdf">https://cdn.ymaws.com/npiap.com/resource/resmgr/online_store/posters/npiap_pip_tips_-_proning_202.pdf</a> (2020)</li><li>Martel, T., Orgill, D. P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Medical+device-related+pressure+injuries+during+the+COVID-19+pandemic.">Medical device-related pressure injuries during the COVID-19 pandemic.</a> Journal of Wound, Ostomy and Continence Nursing. 47 (5), 430-434 (2020).</li><li>Miller, C., O'Sullivan, J., Jeffrey, J., Power, D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Brachial+plexus+neuropathies+during+the+COVID-19+pandemic:+a+retrospective+case+series+of+15+patients+in+critical+care.">Brachial plexus neuropathies during the COVID-19 pandemic: a retrospective case series of 15 patients in critical care.</a> Physical Therapy. 101 (1), 191 (2021).</li></ol>

The authors do not have any conflicts of interest to disclose.

The most important nursing part in the process of proning a critically ill intubated patient is the preparation. For example, there needs to be extensive consideration and gathering of needed supplies to have available, including tape to secure the ET, foam dressings to pad bony prominences, extra electrodes for cardiac monitoring, extra bed linens, pillows and under pads; all essential for an efficient process and safe patient experience.
Availability of needed supplies, skilled staff, clear ...

The care for patients with ARDS has greatly improved over the past five decades. Menk et al. reviewed the standards for ventilatory management, pharmacotherapy, and adjuncts to ventilation in treating this inflammatory process1. Individualized ventilation pressure and volume limitation, use of positive end expiratory pressure (PEEP) for oxygenation and lung recruitment, and spontaneous breathing trials to minimize diaphragm atrophy are mainstays of care that continue to evolve1. In a multicenter randomized controlled trial, Villar et al. found that the early administration of dexamethasone to patients with moderate-to-severe ARDS reduced time on the ventilator and overall mortality2. Additional multicenter randomized clinical trials, such as RECOVERY and CoDex, studied the use of dexamethasone in patients with COVID-19-related ARDS. They found that early administration of dexamethasone to patients with COVID-19 and moderate or severe ARDS, along with standard care, reduced time on the ventilator and resulted in lower 28-day mortality3,4.
Prone positioning, an effective ventilatory adjunct for patients with moderate-to-severe ARDS, is not a new intervention. Guerin et al. demonstrated that prone positioning for ARDS significantly lowers 28- and 90-day mortality and increases the chance for successful extubation5.&#160;Yet placing a patient in the prone position is not without risk; iatrogenic complications such as ET obstruction, central catheter displacement, and pressure injury can occur when attempting this maneuver with a mechanically ventilated patient6,7.
Prior to the COVID-19 pandemic, some institutions initiated prone positioning for moderate-to-severe ARDS ad hoc or infrequently, akin to what Spece et al. reported about the slow adoption of low tidal volume ventilation for ARDS despite compelling evidence of its efficacy6,8,9. The COVID-19 pandemic though, demanded a rapid implementation of new knowledge, irrespective of previous gaps in the application of clinical research to patient care.
During the pandemic, both early anecdotal reports, as well as well-constructed studies later, established that proning not only improved physiologic parameters but also reduced patient mortality for patients with COVID-19 ARDS. Shelhamer et al. found that one in-hospital death was avoided for every eight patients with moderate-to-severe ARDS, who were proned during their ICU stay10. Prone positioning was strongly supported as a standard treatment for the COVID-19 patient with ARDS versus being a last-ditch maneuver1,7. However, staff shortages during the COVID-19 pandemic resulted in redeployment of non-critical care staff to critical care areas. These redeployed staff lacked expertise with this high-volume high-risk procedure11. Stressors on these teams both at work and at home resulted in uncertainty and difficulty in maintaining processes. It was imperative to develop a strategy to mitigate adverse events related to prone positioning12.
The goal of this protocol is to demonstrate the effectiveness of a team-based, step-by-step approach to the proning maneuver for patients with COVID-19 ARDS. We have shown that this procedure carries a low risk for device dislodgment and other adverse events. In the context of the COVID-19 pandemic, the occurrence of proning is frequent. The advantages of the technique used here include full visual and physical access to the patient with attached tubes, wires, and other equipment, less stress on the patient and healthcare workers by using a breathable transfer matt, and multidisciplinary team participation to decrease adverse outcomes13.
With other manual proning methods, such as the &#34;burrito&#34; method, attached tubes, lines, and wires cannot be visualized during the entire proning process14. Additional techniques found in the wider body of literature rely upon a portable proning frame or a specialized proning bed. Though effective, these methods may be prohibitive if the equipment is not readily available, is too expensive, or if staff lack interprofessional training on management of emergency situations that could occur while using the equipment14,15,16.
Teamwork 
The COVID-19 crisis revealed the need to adopt a team mentality because of the high volume of patients, scarcity of supplies, and human resources among hospital-based healthcare professionals. Although interprofessional collaboration in healthcare is not a new concept, being able to quickly pull together a team and perform a high-risk procedure is not something that most nursing staff and allied health professionals train to do17. Some staff discovered they had various levels of proficiency and confidence in relation to proning a patient, as well as competing ideas on the best approach with the least amount of patient complications.
Leadership, respect, adaptability, monitoring each other&#39;s performance, closed-loop communication, and team orientation are key elements for a safe and effective team17. Having a shared vision of the critical considerations can be achieved by promoting a standard operating procedure that supports safe and effective care for the patient who needs to be proned. Papazian et al. recommend having a written procedure and detailed training for proning teams18.
Simulation 
Practicing or simulating the proning maneuver using a multidisciplinary staff can be an effective tool for both new staff and a review for incumbent staff16. Being mindful and attentive to potential complications during and after proning can be achieved through focused education and multidisciplinary teams for proning8. An ICU nurse and respiratory therapist (RT) focused on critical tube and vascular access management, a wound specialist or skin champion focused on preventing skin injury, and a physical therapist assessing body mechanics and soft tissue injury prevention are examples of effective workload management. Maximum clinical benefit can be achieved by using the unique strengths of specialized staff19.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>HoverMatt</td>
			<td>HoverTech International</td>
			<td>HM34SPU-B</td>
			<td>Single patient use</td>
		</tr>
		<tr>
			<td>Mepilex 4x4</td>
			<td>Molnlycke Healthcare</td>
			<td>294199</td>
			<td>Strip cut and placed over top lip</td>
		</tr>
		<tr>
			<td>Mepilex Border Flex 3x3</td>
			<td>Molnlycke Healthcare</td>
			<td>595200</td>
			<td>Chin</td>
		</tr>
		<tr>
			<td>Mepilex Border Flex 4x4</td>
			<td>Molnlycke Healthcare</td>
			<td>595300</td>
			<td>Cheeks (and forehead if needed)</td>
		</tr>
		<tr>
			<td>Mepilex Border Flex 6x6</td>
			<td>Molnlycke Healthcare</td>
			<td>595400</td>
			<td>Knees (and anterior iliac crests if needed)</td>
		</tr>
		<tr>
			<td>Mepilex Border Sacrum 8x9</td>
			<td>Molnlycke Healthcare</td>
			<td>282455</td>
			<td>Sacrum</td>
		</tr>
	</tbody>
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an educational video demonstration of how to prone a critically ill intubated patient

Early in the coronavirus disease 2019 (COVID-19) pandemic, it was reported that prone position was beneficial for mechanically ventilated COVID-19 patients with acute respiratory distress syndrome (ARDS). However, for staff in some small and large hospitals, experience with this intervention was low. Select hospitals were able to assemble proning teams; but, as facilities began to experience staffing shortages, they found proning teams unsustainable, and less specialized staff needed to learn how to safely prone patients.
Proning is a high-risk procedure-a lack of a standard approach can result in staff confusion and poor patient outcomes, including unintentional endotracheal tube (ET) loss, vascular access dislodgement, and skin breakdown. Given the acuity and high patient volume, translating a complex procedure into written policy may not be entirely effective. Critical care nurses, respiratory therapists, physical therapists, wound nurses, nurse practitioners, physician assistants, and medical doctors need to be prepared to safely perform this procedure for an acutely ill COVID-19 patient.
Communication, teamwork, and multidisciplinary collaboration are critical for complication avoidance. Interventions to prevent tube and vascular access dislodgement, skin breakdown, and brachial plexus and soft tissue injury must be implemented during the procedure. Repositioning the patient in the prone position, as well as returning the patient to supine positioning, should be components of a comprehensive proning plan.

Following a review of step-by-step instructions of how to prone a critically ill intubated patient, critical care staff were able to return a safe demonstration of proning. Additional nursing leadership, e.g., a clinical nurse specialist, certified wound nurse, and/or a physical therapist is recommended to provide rapid decision-making during critical points, e.g., taping and repositioning the ET tube, as well as head and arm positioning. After a few practices, it is estimated that the procedure takes approximately 10-15...

Watch this Scientific Journal Video about An Educational Video Demonstration of How to Prone a Critically Ill Intubated Patient at JoVE.com

An Educational Video Demonstration of How to Prone a Critically Ill Intubated Patient

Proning a critically ill patient with severe acute respiratory distress syndrome (ARDS) is a complex but beneficial procedure. Excellent communication skills, team work, and multidisciplinary collaboration are critical for patient and staff safety. A standard procedure should be utilized when proning ventilated patients with tubes, drains, and vascular access devices.

Early in the coronavirus disease 2019 (COVID-19) pandemic, it was reported that prone position was beneficial for mechanically ventilated COVID-19 ...

an-educational-video-demonstration-how-to-prone-critically-ill

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Medicine

3.0K Views.  University of Rochester Medical Center/Strong Memorial Hospital. Proning a critically ill patient with severe acute respiratory distress syndrome (ARDS) is a complex but beneficial procedure. Excellent communication skills, team work, and multidisciplinary collaboration are critical for patient and staff safety. A standard procedure should be utilized when proning ventilated patients with tubes, drains, and vascular access devices.

Video: An Educational Video Demonstration of How to Prone a Critically Ill Intubated Patient

Manual Muscle Testing:  A Method of Measuring Extremity Muscle Strength Applied to Critically Ill Patients

Survivors of acute respiratory distress syndrome (ARDS) and other causes of critical illness often have generalized weakness, reduced exercise tolerance, and persistent nerve and muscle impairments after hospital discharge.1-6 Using an explicit protocol with a structured approach to training and quality assurance of research staff, manual muscle testing (MMT) is a highly reliable method for assessing strength, using a standardized clinical examination, for patients following ARDS, and can be completed with mechanically ventilated patients who can tolerate sitting upright in bed and are able to follow two-step commands. 7, 8 
This video demonstrates a protocol for MMT, which has been taught to &ge;43 research staff who have performed &gt;800 assessments on &gt;280 ARDS survivors. Modifications for the bedridden patient are included. Each muscle is tested with specific techniques for positioning, stabilization, resistance, and palpation for each score of the 6-point ordinal Medical Research Council scale.7,9-11 Three upper and three lower extremity muscles are graded in this protocol: shoulder abduction, elbow flexion, wrist extension, hip flexion, knee extension, and ankle dorsiflexion. These muscles were chosen based on the standard approach for evaluating patients for ICU-acquired weakness used in prior publications. 1,2.

Survivors of acute respiratory distress syndrome (ARDS) and critical illness frequently develop long-lasting muscle weakness. Manual muscle testing (MMT) is a standardized clinical examination commonly used to measure strength of peripheral skeletal muscle groups. This video demonstrates MMT using the 6-point Medical Research Council scale.

Survivors of acute respiratory distress syndrome (ARDS) and other causes of critical illness often have generalized weakness, reduced exercise tolerance, ...

How to Measure Cortical Folding from MR Images: a Step-by-Step Tutorial to Compute Local Gyrification Index

Cortical folding (gyrification) is determined during the first months of life, so that adverse events occurring during this period leave traces that will be identifiable at any age. As recently reviewed by Mangin and colleagues2, several methods exist to quantify different characteristics of gyrification. For instance, sulcal morphometry can be used to measure shape descriptors such as the depth, length or indices of inter-hemispheric asymmetry3. These geometrical properties have the advantage of being easy to interpret. However, sulcal morphometry tightly relies on the accurate identification of a given set of sulci and hence provides a fragmented description of gyrification. A more fine-grained quantification of gyrification can be achieved with curvature-based measurements, where smoothed absolute mean curvature is typically computed at thousands of points over the cortical surface4. The curvature is however not straightforward to comprehend, as it remains unclear if there is any direct relationship between the curvedness and a biologically meaningful correlate such as cortical volume or surface. To address the diverse issues raised by the measurement of cortical folding, we previously developed an algorithm to quantify local gyrification with an exquisite spatial resolution and of simple interpretation. Our method is inspired of the Gyrification Index5, a method originally used in comparative neuroanatomy to evaluate the cortical folding differences across species. In our implementation, which we name local Gyrification Index (lGI1), we measure the amount of cortex buried within the sulcal folds as compared with the amount of visible cortex in circular regions of interest. Given that the cortex grows primarily through radial expansion6, our method was specifically designed to identify early defects of cortical development.
In this article, we detail the computation of local Gyrification Index, which is now freely distributed as a part of the FreeSurfer Software (<a href="http://surfer.nmr.mgh.harvard.edu/">http://surfer.nmr.mgh.harvard.edu/</a>, Martinos Center for Biomedical Imaging, Massachusetts General Hospital). FreeSurfer provides a set of automated reconstruction tools of the brain's cortical surface from structural MRI data. The cortical surface extracted in the native space of the images with sub-millimeter accuracy is then further used for the creation of an outer surface, which will serve as a basis for the lGI calculation. A circular region of interest is then delineated on the outer surface, and its corresponding region of interest on the cortical surface is identified using a matching algorithm as described in our validation study1. This process is repeatedly iterated with largely overlapping regions of interest, resulting in cortical maps of gyrification for subsequent statistical comparisons (Fig. 1). Of note, another measurement of local gyrification with a similar inspiration was proposed by Toro and colleagues7, where the folding index at each point is computed as the ratio of the cortical area contained in a sphere divided by the area of a disc with the same radius. The two implementations differ in that the one by Toro et al. is based on Euclidian distances and thus considers discontinuous patches of cortical area, whereas ours uses a strict geodesic algorithm and include only the continuous patch of cortical area opening at the brain surface in a circular region of interest.

Measuring gyrification (cortical folding) at any age represents a window into early brain development. Hence, we previously developed an algorithm to measure local gyrification at thousands of points over the hemisphere1. In this paper, we detail the computation of this local gyrification index.

Cortical folding (gyrification) is determined during the first months of life, so that adverse events occurring during this period leave traces that will ...

A New Single Chamber Implantable Defibrillator with Atrial Sensing: A Practical Demonstration of Sensing and  Ease of Implantation

Implantable cardioverter-defibrillators (ICDs) terminate ventricular tachycardia (VT) and ventricular fibrillation (VF) with high efficacy and can protect patients from sudden cardiac death (SCD). However, inappropriate shocks may occur if tachycardias are misdiagnosed. Inappropriate shocks are harmful and impair patient quality of life. The risk of inappropriate therapy increases with lower detection rates programmed in the ICD. Single-chamber detection poses greater risks for misdiagnosis when compared with dual-chamber devices that have the benefit of additional atrial information. However, using a dual-chamber device merely for the sake of detection is generally not accepted, since the risks associated with the second electrode may outweigh the benefits of detection. Therefore, BIOTRONIK developed a ventricular lead called the LinoxSMART S DX, which allows for the detection of atrial signals from two electrodes positioned at the atrial part of the ventricular electrode. This device contains two ring electrodes; one that contacts the atrial wall at the junction of the superior vena cava (SVC) and one positioned at the free floating part of the electrode in the atrium. The excellent signal quality can only be achieved by a special filter setting in the ICD (Lumax 540 and 740 VR-T DX, BIOTRONIK). Here, the ease of implantation of the system will be demonstrated.

Dual-chamber implantable cardioverter-defibrillators (ICDs) may improve detection of atrial fibrillation as well as differentiation of tachycardias. However, this advantage is undermined by complications associated with the second electrode, which is required in conventional dual chamber devices. Therefore, BIOTRONIK has developed a new electrode called the LinoxSMART S DX that, when used in conjunction with the Lumax DX ICD, offers dual-chamber detection without the risks associated with the second electrode.

Implantable cardioverter-defibrillators (ICDs) terminate ventricular tachycardia (VT) and ventricular fibrillation (VF) with high efficacy and can protect ...

Surgical Technique for Spinal Cord Delivery of Therapies: Demonstration of Procedure in Gottingen Minipigs

This is a compact visual description of a combination of surgical technique and device for the delivery of (gene and cell) therapies into the spinal cord. While the technique is demonstrated in the animal, the procedure is FDA-approved and currently being used for stem cell transplantation into the spinal cords of patients with ALS. While the FDA has recognized proof-of-principle data on therapeutic efficacy in highly characterized rodent models, the use of large animals is considered critical for validating the combination of a surgical procedure, a device, and the safety of a final therapy for human use. The size, anatomy, and general vulnerability of the spine and spinal cord of the swine are recognized to better model the human. Moreover, the surgical process of exposing and manipulating the spinal cord as well as closing the wound in the pig is virtually indistinguishable from the human. We believe that the healthy pig model represents a critical first step in the study of procedural safety.

Short visual description of the surgical technique and device used for the delivery of (gene and cell) therapies into the spinal cord. The technique is demonstrated in the animal but is entirely translatable and currently being used for human application.

This is a  compact visual description of a combination of surgical technique and device  for the  delivery of (gene and cell) therapies into the spinal ...

Using Quantitative Real-time PCR to Determine Donor Cell Engraftment in a Competitive Murine Bone Marrow Transplantation Model

Murine bone marrow transplantation models provide an important tool in measuring hematopoietic stem cell (HSC) functions and determining genes/molecules that regulate HSCs. In these transplant model systems, the function of HSCs is determined by the ability of these cells to engraft and reconstitute lethally irradiated recipient mice. Commonly, the donor cell contribution/engraftment is measured by antibodies to donor- specific cell surface proteins using flow cytometry. However, this method heavily depends on the specificity and the ability of the cell surface marker to differentiate donor-derived cells from recipient-originated cells, which may not be available for all mouse strains. Considering the various backgrounds of genetically modified mouse strains in the market, this cell surface/ flow cytometry-based method has significant limitations especially in mouse strains that lack well-defined surface markers to separate donor cells from congenic recipient cells. Here, we reported a PCR-based technique to determine donor cell engraftment/contribution in transplant recipient mice. We transplanted male donor bone marrow HSCs to lethally irradiated congenic female mice. Peripheral blood samples were collected at different time points post transplantation. Bone marrow samples were obtained at the end of the experiments. Genomic DNA was isolated and the Y chromosome specific gene, Zfy1, was amplified using quantitative Real time PCR. The engraftment of male donor-derived cells in the female recipient mice was calculated against standard curve with known percentage of male vs. female DNAs. Bcl2 was used as a reference gene to normalize the total DNA amount. Our data suggested that this approach reliably determines donor cell engraftment and provides a useful, yet simple method in measuring hematopoietic cell reconstitution in murine bone marrow transplantation models. Our method can be routinely performed in most laboratories because no costly equipment such as flow cytometry is required.

Determining donor cell engraftment presents a challenge in mouse bone marrow transplant models that lack well-defined phenotypical markers. We described a methodology to quantify male donor cell engraftment in female transplant recipient mice. This method can be used in all mouse strains for the study of HSC functions.

Murine bone marrow transplantation models provide an important tool in measuring hematopoietic stem cell (HSC) functions and determining genes/molecules ...

EEG Mu Rhythm in Typical and Atypical Development

Electroencephalography (EEG) is an effective, efficient, and noninvasive method of assessing and recording brain activity. Given the excellent temporal resolution, EEG can be used to examine the neural response related to specific behaviors, states, or external stimuli. An example of this utility is the assessment of the mirror neuron system (MNS) in humans through the examination of the EEG mu rhythm. The EEG mu rhythm, oscillatory activity in the 8-12 Hz frequency range recorded from centrally located electrodes, is suppressed when an individual executes, or simply observes, goal directed actions. As such, it has been proposed to reflect activity of the MNS. It has been theorized that dysfunction in the mirror neuron system (MNS) plays a contributing role in the social deficits of autism spectrum disorder (ASD). The MNS can then be noninvasively examined in clinical populations by using EEG mu rhythm attenuation as an index for its activity. The described protocol provides an avenue to examine social cognitive functions theoretically linked to the MNS in individuals with typical and atypical development, such as ASD.&#160;

Assessment of the EEG mu rhythm provides a unique methodology for examining brain activity and when combined with behaviorally based assays, can be a powerful tool for elucidating aspects of social cognition, such as imitation, in clinical populations.

Electroencephalography (EEG) is an effective, efficient, and noninvasive method of assessing and recording brain activity. Given the excellent temporal ...

Demonstration of the Rat Ischemic Skin Wound Model

The propensity for chronic wounds in humans increases with ageing, disease conditions such as diabetes and impaired cardiovascular function, and unrelieved pressure due to immobility. Animal models have been developed that attempt to mimic these conditions for the purpose of furthering our understanding of the complexity of chronic wounds. The model described herein is a rat ischemic skin flap model that permits a prolonged reduction of blood flow resulting in wounds that become ischemic and resemble a chronic wound phenotype (reduced vascularization, increased inflammation and delayed wound closure). It consists of a bipedicled dorsal flap with 2 ischemic wounds placed centrally and 2 non-ischemic wounds lateral to the flap as controls. A novel addition to this ischemic skin flap model is the placement of a silicone sheet beneath the flap that functions as a barrier and a splint to prevent revascularization and reduce contraction as the wounds heal. Despite the debate of using rats for wound healing studies due to their quite distinct anatomic and physiologic differences compared to humans (i.e., the presence of a panniculus carnosus muscle, short life-span, increased number of hair follicles, and their ability to heal infected wounds) the modifications employed in this model make it a valuable alternative to previously developed ischemic skin flap models.

The rat, due to its size, availability, and rather docile behavior, has been utilized as a research model for many years. The goal of this protocol is to utilize the rat as an ischemic skin wound healing model to provide valuable insight into the pathophysiology of chronic wounds.

The propensity for chronic wounds in humans increases with ageing, disease conditions such as diabetes and impaired cardiovascular function, and ...

Using the Sleeve Technique in a Mouse Model of Aortic Transplantation - An Instructional Video

Orthotopic aortic transplantation using the sleeve technique reduces injury to the aorta with failure rate of only 10-20%. The time to anastomose the aorta in mice using the sleeve method was short and easy averaging 20 min, permitting studies of iso/allo grafts. The following article describes the aortic transplantation procedure used in our laboratory. The mice were anesthetized with a mixture of 1.5% volume isoflurane and 100% oxygen through a face mask. At this point, the segment of the aorta between the renal arteries and its bifurcation was separated from the vena cava, freely prepared and clampedat the proximal and distal segments with a single silk suture. Prior to the removal of the aorta, a saline solution containing heparin was injected into the inferior vena cava. Then the aorta was cut between the clamps and a saline heparin solution was used to flush the lumen. The sleeve technique with monofilament sutures was used in order to transplant the abdominal aorta in the orthotopic position.

We present an orthotopic aortic transplantation model using the sleeve technique in mice. It is a very rapid anastomosis method, which can be employed in studies of vascular disease.

Orthotopic aortic transplantation using the sleeve technique reduces injury to the aorta with failure rate of only 10-20%. The time to anastomose the ...

Endotoxin Activity Assay for the Detection of Whole Blood Endotoxemia in Critically Ill Patients

Lipopolysaccharide, also known as endotoxin, is a fundamental component of gram-negative bacteria and plays a crucial role in the development of sepsis and septic shock. The early identification of an infectious process that is rapidly evolving to a critical illness might prompt a quicker and more intensive treatment, thereby potentially leading to better patient outcomes. The Endotoxin Activity (EA) assay can be used at the bedside as a reliable biomarker of systemic endotoxemia. The detection of elevated endotoxin activity levels has been repeatedly shown to be associated with an increased disease severity in patients with sepsis and septic shock. The assay is quick and easy to perform. Briefly, after sampling, an aliquot of whole blood is mixed with an anti-endotoxin antibody and with added LPS. Endotoxin activity is measured as the relative oxidative burst of primed neutrophils as detected by chemioluminescence. The assay&#39;s output is expressed on a scale from 0 (absent) to 1 (maximal) and categorized as &#8220;low&#8221; (&#60;0.4 units), &#8220;intermediate&#8221; (0.4&#8211;0.59 units), or &#8220;high&#8221; (&#8805;0.6 units). The detailed methodology and rationale for the implementation of the EA assay are reported in this manuscript.

We hereby present a protocol to measure at the bedside the endotoxin activity of human whole blood samples. The Endotoxin Activity assay is a simple test to perform and may be a useful biomarker in critically ill patients with sepsis.

Lipopolysaccharide, also known as endotoxin, is a fundamental component of gram-negative bacteria and plays a crucial role in the development of sepsis ...

The Dyspepsia Educational Tool As a Novel Aid in Dyspepsia Management

Digital educational tools have a well-established role in current healthcare. In particular, disorders that are managed non-pharmacologically benefit from this development, as it enables patient engagement in self-management. Dyspepsia is a condition thought to arise from gastric and duodenal perturbations, brain-gut axis disturbances, and dietary factors. Behavioral interventions are a major part of dyspepsia treatment, hence patient engagement and motivation through education is essential. Protocols that describe the development process of such educational tools are scarce. We provide a methodology describing development of a dyspepsia educational tool. Assessment of users' needs is the first step, followed by a literature search. The content is developed based on the main themes and entered into a content management system, to build the program. Final adjustments are made after a pilot test of the tool. The presented protocol can be used as a guide for development of a digital dyspepsia educational tool or as a tool for similar situations.

This protocol describes the development process of a digital dyspepsia educational tool. Assessment of unmet needs and literature, content development, and building of the tool are presented. The methodology can be used as a guide for future development of digital educational tools.

Digital educational tools have a well-established role in current healthcare. In particular, disorders that are managed non-pharmacologically benefit from ...

An Educational Video Demonstration of How to Prone a Critically Ill Intubated Patient

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Manual Muscle Testing: A Method of Measuring Extremity Muscle Strength Applied to Critically Ill Patients