Rapid adoption of the ICS/FICM guidance for prone positioning in adult critical care within mechanically ventilated patients: a single centre, retrospective evaluation

Introduction

The pandemic

COVID-19 became a global healthcare emergency in 2019 as the virus spread profoundly and rapidly. COVID-19 was a global pandemic that led to the death of 6,475,346 people to 2nd September 2022 (1). The virus spread from China, with Italy also being affected early on. The U.K. went into lockdown in March 2020 to try and stem the rapid increase in cases.

Acute respiratory failure is the cardinal clinical presentation of COVID-19 and is associated with considerable mortality (2). Treatments for patients hospitalised for COVID-19 developed rapidly, and relied on anecdotal evidence from other countries, or from more severely affected parts of the U.K. Early reports from Italy (3) and China indicated that mechanically ventilated patients who were prone positioned had associated improvements in their oxygenation and mortality (4).

Prior to the COVID-19 pandemic, prone positioning would be used as a treatment for severe acute respiratory distress syndrome (ARDS) characterised by non-cardiogenic pulmonary oedema and shunted related hypoxemia. Prone positioning improves ventilation and perfusion enabling improvements in oxygenation and is associated with decreased mortality (5). The patient is turned from supine into a prone position for a period of several hours which increases lung volume alongside dorsal lung recruitment, more homogenous ventilation distribution and redistribution of perfusion (6).

Locally, prior to the COVID-19 pandemic, fewer than 10 patients on the intensive care unit (ICU) were prone positioned annually. Usual practice at the time used seven to eight critical care staff members to support in this procedure, which was led by a senior intensivist (7). The anticipated high number of admissions, patient prone positioning requirement and staffing challenges (both numbers and skill mix) associated with the pandemic resulted in a rapid review of local practice.

To deliver the number of prone positioning procedures required in this situation, we changed local practice to five members of staff undertaking this procedure to comply with the recently published ICS/FICM guidelines for prone positioning in adult ICU (8). In March 2020 a local checklist was created along with a brief training programme in preparation for rapid adoption into daily practice.

The clinical effectiveness of prone positioning in COVID-19 and non-COVID-19 related ARDS has been well established (9). However, this change in the process of achieving prone positioning had not been evaluated prior to being instigated, therefore the feasibility and safety was unknown.

Aim

The aim of this single centre evaluation was to assess the safety and feasibility of the rapid adoption of the ICS/FICM guidance in mechanically ventilated patients with COVID-19.

Methods

Ethical consideration

This project was classified as a service evaluation by the NHS trust’s research and development office. It was subsequently registered (Ulysses 1705) and followed all local governance processes.

Setting and sample

This service evaluation was conducted in a single centre, U.K. tertiary, university teaching hospital from 1st March 2020 to 28th February 2021. Two ICUs were dedicated as COVID-19 ICUs, increasing the bed numbers from 30 to 52 ICU beds at the peak of the pandemic. Pre-pandemic, critical care physiotherapy was provided from 8am–8pm, seven days per week with staff working a variety of shift durations. During the pandemic this service was extended to provide critical care physiotherapy from 7am–8am with all staff working 13-hour shifts. A senior critical care physiotherapist was present on every shift. The decision to instigate prone positioning was ICU medical consultant/intensivist led.

All prone positioning episodes for all patients with COVID-19 who were mechanically ventilated across both intensive care units (ICU) were included in the service evaluation.

Intervention

The rapid adoption of the ICS/FICM guidelines were implemented through the development of a bedside prone checklist (Figure 1); multi-disciplinary team training through simulation and bedside teaching; and the creation of a YouTube video resource www.youtube.com/watch?v=U_FWLsBoorg (10).

See Figure 1: AICU HCID Proning Checklist v 1.3.

The prone checklist recommended the use of five staff members to complete the procedure. This included one airway trained doctor (who was not necessarily ICU based), a critical care physiotherapist and three additional staff members predominantly made up of redeployed staff from theatres, orthopaedics and paediatrics. The critical care physiotherapist led the procedure using the checklist and were available from 7am–8pm daily. At the end of each day the lead critical care physiotherapist ensured that the number of prone procedures undertaken and any adverse events were accurately recorded.

Patients were positioned in prone for 16 hours (5) and aimed to be in the prone position overnight. Therefore, positioning patients into prone and back to supine was undertaken during two ‘proning rounds’ in the morning and evening. Outside of these hours, procedures were kept to a minimum and led by either an ICU doctor or nurse with the team made up of ICU staff on the night shift.

Data collection

A retrospective review of prospectively collected data recorded in clinical records and the incident reporting system was completed for all included patients.

Each patient reposition was considered to be one procedure (supine to prone, or prone to supine). As the purpose of the evaluation was to assess the safety of the prone procedure and not the effect of prone positioning, an adverse event was defined as an iatrogenic injury occurring during the procedure (for example, endotracheal tube (ETT) or line dislodgement).

Analysis was undertaken using descriptive statistics.

Results

Two hundred and eighty two patients were admitted to the two ICUs with COVID-19 during the evaluation period. Of these, 123 patients were prone positioned while mechanically ventilated on a median of four (IQR 2–6) occasions during this 12-month time period. There were 1,258 procedures of which 27 (2%) occurred out of hours (after 8pm). There were four adverse events recorded (adverse event rate 0.32%) during the prone procedures: two peripheral cannula removals, one nasogastric tube dislodgement and one accidental extubation (Table 1). The accidental extubation occurred out of hours.

Less than five prone procedures (0.4%) occurred with more than five members of staff during the two ‘proning rounds’. Of the 27 prone procedures that occurred out-of-hours, the number of times more than five members of staff undertook a procedure is unknown.

Table 1: Patient and prone positioning characteristics.

IQR = interquartile range; BMI = body mass index; NGT = nasogastric tube.

* = Unless stated otherwise.

** = % of total prone procedure n = 1,258.

*** = occurred outside the 7am–8pm time frame.

Discussion

This retrospective single centre evaluation demonstrated very low adverse event rates, and the rapid and safe adoption of the ICS/FICM guidelines for prone positioning in adult critical care within mechanically ventilated adults. It is hard to place our very low proportion of adverse rates during the procedure in context as the literature base including a scoping review tends to focus on physiological adverse events related to prone positioning, such as barotrauma or pressure sores (11), as opposed to the process of achieving the position.

The rationale of the allocation of a critical care physiotherapist to the team lead role was to enable the airway trained doctor (who may not have been familiar with the ICU environment) to solely focus on the airway and afforded a consistent leader to support the high proportion of redeployed staff who were less familiar with the environment. It is beyond the scope of this evaluation to assess the contribution of the physiotherapist in this lead role, however this approach developed a pool of expert staff to lead the vast majority of the procedures. Undertaking the procedures during two ‘proning rounds’ maximised the use of this expert resource and minimised the number of procedures undertaken overnight when there were additional staffing challenges.

Despite 48% of patients in the evaluation being classified as obese with a BMI over 30 (12), prone positioning could still be safely undertaken with five staff members. Less than five prone procedures occurred with between five to eight members of staff; this was anecdotally due staff confidence due to patients with higher body hiatus during shifts of marked stress levels. Additionally, there were no incidences of staff injury during a prone procedure however, this is only recorded for the two ‘proning rounds’ whilst it is unknown for the 27 prone procedures out of hours.

Limitations

A limitation during this time period is that the documentation was not as comprehensive as compared to pre-pandemic and therefore some adverse events (for example, peripheral cannula dislodgement) may not have been recorded overnight, however, this is unlikely for more substantial adverse events (for example, ETT dislodgement). This might not be generalisable for other services due to our model that allowed a senior critical care physiotherapist to lead all prone procedures between 7am–8pm. As the purpose of this review was to evaluate the process of positioning a patient into prone, no information was collected on the physiological consequences of prone, or the long-term patient outcomes.

Conclusion

In this service evaluation, it was deemed safe and feasible to undertake prone procedures in mechanically ventilated patients with COVID-19 following the rapid adoption of the ICS/FICM guidance. It was feasible with five members of staff, and led during the two ‘proning rounds’ by a critical care physiotherapist aiming to provide consistency in the delivery. There was a low rate of adverse rates during the prone procedures, and no recorded staff injury during the two ‘proning rounds’.

Acknowledgement

Thank you to all the members of staff within ICU and especially to all the members of staff who were redeployed who supported with the proning procedures. The authors would like to recognise the remarkable teamwork during this period.

Key points

1. Prone positioning with five members was feasible in mechanically ventilated patients following ICS/FICM guidelines.

2. Critical care physiotherapist led prone positioning using a MDT developed checklist resulted in a low rate of adverse events.

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7 Oxford University Hospitals NHS Foundation Trust. OUH adult intensive care unit/cardiovascular intensive care unit guidelines. http://ouh.oxnet.nhs.uk/AdultIntensiveCareUnit/Document%20Library/Respiratory/Proning/Proning%20Guidelines.pdf [Accessed 18th December 2021].

8 Intensive Care Society. Guidance for: Prone positioning in adult critical Care, 2019. https://www.ics.ac.uk/ICU/Guidance/PDFs/Prone_Position_Guidance_in_Adult_Critical_Care [Accessed 10th November 2021].

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10 Oxford University Hospitals NHS Foundation Trust. AICU HCID proning procedure – video v4 (checklist v1.3) [video file]. Available from: https//www.youtube.com/watch?v=U_FWLsBoorg.

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