COVID-19 October 02

Prone positioning benefits for the COVID-19 patient

How one action is clearly saving lives

The influx of ICU patients due to COVID-19 over the last few months has put a strain on bedside nurses. They’re typically the first and last healthcare professionals to see a patient when they come into a facility and when they leave, not to mention the around-the-clock care they provide. And there’s one thing nurses know how to do that’s absolutely critical to COVID-19 patient care: moving patients from their backs to their stomachs.

The evidence is in—proning COVID-19 patients saves lives

While many nurses know how to prone a patient, as this is done often in operating rooms and recovery rooms, some ICU nurses have not acquired the same skill. So, in a time when nursing staff is already stretched too thin, it can be difficult to provide training on the fly. This is why facilities such as The John Hopkins Hospital have implemented a designated “prone team,” like a code team that goes to units to help manage patients in crisis.1

We’re saving lives with this [proning], one hundred percent. It’s such a simple thing to do, and we’ve seen remarkable improvement. We can see it for every single patient.2

— Dr. Narasimhan, regional director for critical care at Northwell Health

As more evidence supports its effectiveness, the technique is catching on, and more and more hospitals are placing patients with COVID-19 on their stomachs—proning them—as a way to increase the amount of oxygen to the bottom and back portions of the lungs.3 This practice relieves some of the pressure on the heart and diaphragm when lying on the back, and it can help clear respiratory secretions.

How proning came about

Beyond the pressure on the heart and lungs, when patients in critical conditions are ventilated, the risk of ventilator-associated events increases. Early mobility and safe patient handling are mission-critical for helping patients return to their baseline level of health. Since the outbreak of COVID-19, physicians and researchers have been seeking the most effective treatment options. Based on established treatments for related respiratory diseases such as ARDS (Acute Respiratory Distress Syndrome), some hospitals began “proning” patients for extended periods of time in hopes it would improve COVID-19 outcomes.

Although ARDS and COVID-19 work through different mechanisms and require different treatments, proning is effective for both. Up to this point, hospitals justified proning COVID-19 patients based on limited direct evidence and anecdotal evidence from the field. Now, as more data becomes available, there is enough peer-reviewed evidence to support proning as a part of COVID-19 protocols for ventilated patients.4

We’re hearing from healthcare providers that they are seeing improvement in oxygenation in COVID-19 patients when practicing prolonged proning.5 Medline is dedicated to partnering with healthcare systems to create solutions that improve patient care. This has led to the introduction of proning product bundles to help make early mobility more intuitive for bedside caregivers and safer for patients.

— Barb Pusateri, clinical specialist at Medline who designs and implements evidence-based best practice safe patient handling education

Ultimately, it is critical to get patients with respiratory illnesses moving to help lung expansion and keep secretions moving. As patients are mechanically ventilated, prolonged immobility often leads to delirium and generalized weakness, and proning, as a crucial part of early mobility, plays a significant role in reducing these affects and can even reduce the time spent on mechanical ventilation by improving strength and endurance.6

How proning works

Proning can be done manually or by using a patient lift. However, given the need to limit the interactions and exposure between healthcare professionals and COVID-19 patients, the increased use of lifts in patient care is something most hospitals should consider. Whereas it may take up to six nurses to prone a patient manually, using a patient lift requires less staff (usually around three) and helps reduce the physical strain on caregivers. Whether or not you have a prone team in place to train your staff, there are handy resources that take nurses through the process. Click here for instructions on how to prone a patient using a patient lift.

Instructions on how to prone a patient using a lift from Medline on Vimeo.

Lifts and friction-reducing equipment used for proning*

*Utilizing the proper equipment can help reduce the number of staff needed and reduce the risk of injury

Lifts and friction-reducing devices help reduce the amount of physical exertion required by staff to perform the task. Many ICUs and other departments have lifts, but they often are underutilized because bedside nurses worry about dislodging tubes or IV lines. However, a lift is an incredible tool because when used properly, it is safer for the nurse and the patient than moving them manually. When using a lift, it is recommended to have two to three caregivers available to assist.

Once the patient is in the prone position, where they may typically remain for up to a full day, nurses must also be sensitive to preventing pressure injuries to the skin from remaining in one position. Our skin health team has developed a helpful article outlining the process and steps for decreasing the risk of pressure injuries.

What about the cost?

Some may ask whether the labor or equipment utilized in proning patients is cost effective in light of the budget constraints facing most healthcare facilities. We don’t have the studies yet on the cost analysis for COVID-19 patients and hospitals using proning techniques; however, a study was conducted a year ago on the cost effectiveness of prone positioning for patients with severe ARDS. The findings were that with cases such as those with ARDS or COVID, prone positioning has been shown to be both cost and clinically effective and that “applying a similar analytic framework to other ICU interventions would help improve the overall cost-effectiveness of critical care in diverse settings.”7

All in all, most facilities are eager to implement techniques that will ultimately save lives, and it seems clear that the simple act of proning a patient and increasing early mobility is clearly making an impact on the positive recovery of many COVID-19 patients.

Learn more about how Medline is empowering healthcare providers with lifts and other tools to help in the fight against COVID deaths by speaking to your Medline representative today or calling 1 800 MEDLINE for more information.

References:

  1. https://www.hopkinsmedicine.org/coronavirus/articles/prone-team.html
  2. https://www.cnn.com/2020/04/14/health/coronavirus-prone-positioning/index.html
  3. https://www.uptodate.com/contents/coronavirus-disease-2019-covid-19-critical-care-and-airway-management-issues
  4. Roesthuis, L., van den Berg, M., & van der Hoeven, H. Advanced respiratory monitoring in COVID19 patients: use less PEEP! Critical Care24(230), 2-4. doi:10.1186/s13054-020-02953-z
  5. N Engl J Med 2013 (2013) Prone Positioning in Severe Acute Respiratory Distress Syndrome https://www.nejm.org/doi/full/10.1056/NEJMoa1214103
  6. Knight J., Nugam Y., & Jones A. (2018) Effects of bedrest series. Nursing Times
  7. Baston, C., Coe, N., Guerin, C., Halpern, S., & Mancebo, J. (2019). The Cost-Effectiveness of Interventions to Increase Utilization of Prone Positioning for Severe Acute Respiratory Distress Syndrome. Critical Care Medicine47(3), 198-205. doi: 10.1097/CCM.0000000000003617, https://pubmed.ncbi.nlm.nih.gov/30779719/