Repositioning Patients in Respiratory Distress Recommended

Marcia Frellick

February 01, 2019

SAN DIEGO — A new protocol for turning patients with severe acute respiratory distress syndrome (ARDS) on their stomachs for at least 12 hours a day has made the procedure faster and easier to implement in hospitals, according to two critical care clinical nurse specialists.

Before the protocol was in place, it was, "I need 1 hour, I need 2 hours, I can't find the head cushion," said Maureen Seckel, MSN, RN, from the Christiana Care Health System in Newark, Delaware.

Now, the whole process — prepping the room, gathering the staff, and turning the patient — takes 15 to 30 minutes at Christiana.

In fact, "we have done it in 5 to 10 minutes when we need to move fast," Seckel added.

Family members like the prone positioning, she said, often saying, "They look so comfortable. This is how they sleep usually."

The benefits of the prone position for patients with ARDS — better ventilation of the lungs and decreased mortality rates — have been understood for 40 years, and the procedure is recommended in current practice guidelines (Am J Respir Crit Care Med. 2017;195:1253-1263).

However, misinformation or poor training of hospital staff can mean that patients do not receive the recommended treatment. A 2016 study showed that less than 16% of qualified patients were being put in this position (JAMA. 2016;315:788-800).

The latest evidence on ARDS will be a central topic when the Society of Critical Care Medicine (SCCM) 2019 Congress meets next month.

Nurse Specialists Share Strategies

To address the underuse of the prone position, Seckel and Dannette Mitchell, MSN, also from the Christiana Care Health System, led the process to develop a protocol that details the role that each physician, nurse, and respiratory therapist performs before, during, and after placing the patient in the prone position (AACN Adv Crit Care. 2018;29:415-425).

First, the pair had to get buy-in from physicians, nurses, and respiratory therapists and agreement on the evidence used to draft the protocol.

Traditionally, doctors have given the order to prone and nurses have carried it out, but there has been no standardization of the procedure across intensive care units (ICUs), Seckel told Medscape Medical News.

The protocol includes a side-lying step — a halfway point during the lateral rotation when the team pauses to evaluate how the patient is doing and check that all lines and tubes are in the right positions.

"Some patients don't do well when you flip them and you have to flip them back," Mitchell explained.

The intermediate side position prevents some of the jarring movement, she told Medscape Medical News.

Different parts of the proned patient's body have to be cushioned. The team at Christiana uses gel cushions, as opposed to foam or a face cradle, because they can be reused, are easy to clean, and effectively relieve pressure, Seckel said.

No Special Beds Needed

There is often a misconception that special mechanical beds are needed to rotate patients, but manual turning in a standard ICU bed is just as effective, less expensive, and eliminates the delay related to having a special bed delivered, Mitchell explained.

Some clinicians at different hospitals have reported being unable to perform the procedure because they have been unable to pull enough nurses together in the middle of the night to turn a patient safely, Seckel noted.

But the people don't have to be nurses, she said. The team can include physicians, nurse's aides, escorts — anyone who is capable and understands the role. It helps to practice the flipping procedure periodically with staff members, she added.

In theory, the turning can be done with four people, but the general recommendation is to enlist one person for every 35 pounds of patient, Mitchell said.

Because patients who need proning are connected to ventilators and tubes, each line must be inspected before and after the turning to make sure it is clean and properly positioned. At Christiana, each tube is assigned to a clinician.

Team Huddle Important

Proning presents challenges for physicians because they can no longer see the chest of these very sick patients and don't have a clear view of the tubes and lines, said Michelle Ng Gong, MD, from the Montefiore Medical Center in Bronx, New York.

If cardiopulmonary resuscitation is necessary, the patient needs to be quickly turned, she noted. Physicians less confident about proning can opt for extracorporeal membrane oxygenation, but that is invasive and more expensive.

This protocol is a valuable tool for those already proning or moving toward that, and it emphasizes the necessity of the preproning team huddle, Gong said.

Even at Montefiore, where severe ARDS patients are proned routinely, a team meeting is conducted before each procedure because there can be new people on the team or, depending on the time of day, different people serving in the traditional roles.

The meeting is also a helpful refresher because proning patients is not something clinicians at Montefiore do every day, Gong noted, although the procedure is more common during flu season.

Gong, who will speak about barriers to evidence-based practice for ARDS patients at the SCCM congress, said that in off-peak times, clinicians might prone a patient just once every 3 to 4 weeks.

Every year, nearly 200,000 patients in the United States are diagnosed with ARDS, Seckel writes in her report. And globally, it is the cause of 10% of all ICU admissions and affects 23% of patients on ventilators.

Seckel, Mitchell, and Gong have disclosed no relevant financial relationships.

Follow Medscape on Twitter @Medscape and Marcia Frellick @mfrellick

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