Strategies to increase utilization of prone positioning for severe ARDS with COVID-19
A new study published in the Annals of the American Thoracic Society identified strategies that may be feasible to increase utilization of prone positioning for patients with severe acute respiratory distress syndrome with COVID-19.
Prone positioning has been shown to reduce mortality in severe ARDS, but up to 85% of these patients do not receive this therapy, according to a press release issued by the American Thoracic Society.
Researchers conducted semi-structured interviews with a diverse group of 30 clinicians from ICUs in the University of Pennsylvania Health System and the University of Michigan Medical Center to address barriers to prone positioning as an initial therapeutic strategy in this patient population.
The researchers identified five broad themes that determined the use of prone positioning in patients with severe ARDS with COVID-19: knowledge, resources, alternative therapies, team culture and patient factors.
The researchers then presented their findings to focus groups of ICU leaders at Penn. Input from the focus groups were used to develop strategies to promote implementation of prone positioning using the Expert Recommendations for Implementing Change (ERIC) framework. The implementation strategies identified through this research were adopted as part of Penn Medicine’s COVID-19 response, according to the release.
“Just as we use evidence-based approaches to care for patients, we sought to use evidence-based approaches to conduct this project. The advantage of all of these frameworks and the implementation mapping approach are that they provide guides for a complex process that help us to be robust and complete in identifying and assessing barriers and facilitators and in developing strategies with a stakeholder group,” Meeta Prasad Kerlin, MD, MSCE, associate professor of medicine in the Perelman School of Medicine at the University of Pennsylvania and the Palliative and Advanced Illness Research Center at Penn Medicine, said in the release.
Based on identification of the five broad themes that determine the use of prone positioning, the researchers developed implementation trategies to address barriers, such as educating clinicians about prone positioning, establishing protocols and guidelines as educational programs, and supporting team coordination and creating a culture of collaboration and teamwork in the ICU to promote team-based intervention.
During the clinician interview process, 27% of clinicians reported frequent use of prone positioning in their ICU, 46% reported occasional use and 27% reported rare or never use. Knowledge about prone positioning was integrate to its use as an initial therapeutic strategy. Researchers noted that some clinicians believed prone positioning was a salvage therapy and not an initial therapy of choice for severe ARDS. Many clinicians also reported a lack of staffing adequate for prone positioning, which created a barrier to implementation, and the culture of the ICU team influenced the use or lack of use of prone positioning.
“Prior to a large, randomized trial that demonstrated a benefit to early prone positioning, several studies had evaluated it as a late intervention. These early studies were largely negative, and people became aware of this as a therapy that one tries at the end, as a salvage. Many people may still rely on that older belief and culture,” Kerlin said.
Early in the pandemic, the urgent need to increase prone positioning implementation became evident and those with little to no experience with this intervention needed to become comfortable quickly, Kerlin said. Due to the urgent need, health systems quickly adopted some of Kerlin and colleagues’ implementation strategies.
“As the COVID-19 census has waned, some of the resources put towards their care, such as some of these strategies, have faded with time,” Kerlin said in the release. “In our next phase of research, we hope to conduct studies to test the effectiveness of some of these specific strategies in improving the utilization of prone positioning.”