Name: an educational video demonstration of how to prone a critically ill intubated patient
Uploaded: 2022-11-30T12:30:00
Description: Watch this Scientific Journal Video about An Educational Video Demonstration of How to Prone a Critically Ill Intubated Patient at JoVE.com

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 i...

<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 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>
</table>

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 ...

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