Simulation Training Could Boost Interdisciplinary Staff Comfort With Prone Ventilation

By Marilynn Larkin

May 14, 2020

NEW YORK (Reuters Health) — A simulation-based educational program on prone position ventilation (PPV) to manage acute respiratory distress syndrome (ARDS) increased comfort with the procedure among physicians, nurses, and physical therapists.

"While we are learning more about COVID-19 every day, it remains to be seen whether there is anything unique about how PPV would change the outcome of patients critically ill with COVID-19 as compared to other causes of ARDS," Dr. Armeen Poor of NYC Health and Hospitals/Metropolitan in New York City noted in an email to Reuters Health. "Anecdotally, these patients' oxygen levels respond dramatically with PPV, and some patients do seem to improve overall with it, but we don't have data from large studies to know for sure."

"I think most hospitals and medical centers have the resources necessary to implement PPV, especially as an automated bed is not required to perform this maneuver," he said. "What I believe is essential is that, as in our study, an interprofessional team work closely together to identify and address any hospital-specific barriers to implementation."

"By simulating the maneuver and responses to emergency scenarios," he added, "providers can develop their own protocols, identify safety issues early, and hopefully ease the implementation process."

As reported in the American Journal of Critical Care, 73 providers - 37 nurses, 18 physicians, 18 respiratory therapists - participated in the two-hour training and completed surveys. The training consisted of a didactic session, simulated placement of volunteers with different body types in the prone position, simulated emergency scenarios (including cardiac arrest and bed malfunction), and a structured debriefing.

Before training, only 39% of nurses agreed that PPV would be beneficial to patients with severe ARDS, compared with 96% of physicians and 70% of respiratory therapists. After training, recognition of perceived benefit increased to 89% of nurses and to 100% of physicians and respiratory therapists.

Before training, fewer than a third of nurses (29%) and physicians (24%) felt comfortable taking care of prone patients. Post-training, the proportion of providers who felt they could comfortably care for prone patients and manage cardiac arrest increased significantly among nurses (63% and 59%, respectively) and physicians. (78% and 94%).

Twenty latent safety threats were identified, as well: 42% related to equipment (e.g., bed too high); 39% to procedure/protocol (e.g., lack of role assignment); 12% to personnel (inadequate nurse staffing); and 7% to communication (e.g., lack of standardized communication with family). Solutions included developing new checklists, creating bundles for equipment, and clarifying protocols.

Dr. Anthony Lubinsky, medical director of respiratory care at NYU Langone Tisch Hospital in New York City, commented in an email to Reuters Health, "The prone position has been shown to improve survival in patients with moderate and severe ARDS. It is likely that (it) may have a similar benefit in patients with severe acute respiratory failure due to COVID-19, although high quality data is needed to confirm this hypothesis."

"Complications of proning include misplacement of life support devices such as IV catheters and the endotracheal tube, and risk for pressure injuries on the anterior surface of the body, especially the face," said Dr. Lubinsky, who was not involved in the study. "Barriers to implementation include limited experience in some centers, and the large number of patients meeting criteria for proning during the COVID-19 pandemic."

"Our experience has been that an evidence-based, protocol-driven, multidisciplinary approach can safely deliver proning treatment to large numbers of patients across a diverse health care system," he concluded.

The American Association of Critical-Care Nurses provides a free self-paced course, "COVID-19 Pulmonary, ARDS and Ventilator Resources," at Additional COVID-19 resources are available at

SOURCE: American Journal of Critical Care, online May 1, 2020.