key: cord-285202-aiap6z9u
authors: Short, Briana; Parekh, Madhavi; Ryan, Patrick; Chiu, Maggie; Fine, Cynthia; Scala, Peter; Moses, Shirah; Jackson, Emily; Brodie, Daniel; Yip, Natalie H.
title: Rapid implementation of a mobile prone team during the COVID-19 pandemic
date: 2020-08-25
journal: J Crit Care
DOI: 10.1016/j.jcrc.2020.08.020
sha: 
doc_id: 285202
cord_uid: aiap6z9u

PURPOSE: The coronavirus disease 2019 (COVID-19) is associated with high rates of acute respiratory distress syndrome (ARDS). Prone positioning improves mortality in moderate-to-severe ARDS. Strategies to increase prone positioning under crisis conditions are needed. MATERIAL AND METHODS: We describe the development of a mobile prone team during the height of the crisis in New York City and describe characteristics and outcomes of mechanically ventilated patients who received prone positioning between April 2, 2020 and April 30, 2020. RESULTS: Ninety patients underwent prone positioning for moderate-to-severe ARDS. Sixty-six patients (73.3%) were men, with a median age of 64 years (IQR 53–71), and the median PaO(2):FiO(2) ratio was 107 (IQR 85–140) prior to prone positioning. Patients required an average of 3 ± 2.2 prone sessions and the median time of each prone session was 19 h (IQR 17.5–20.75). By the end of the study period, proning was discontinued in sixty-seven (65.1%) cases due to clinical improvement, twenty (19.4%) cases due to lack of clinical improvement, six (5.8%) cases for clinical worsening, and ten (9.7%) cases due to a contraindication. CONCLUSION: The rapid development of a mobile prone team safely provided prone positioning to a large number of COVID-19 patients with moderate-to-severe ARDS.

During the coronavirus disease 2019 (COVID-19) pandemic, an overwhelming majority of those requiring ICU level of care had acute hypoxemic respiratory failure requiring mechanical ventilation for acute respiratory distress syndrome (ARDS) (1). ARDS is common. In one large observational study, 23.4% of patients requiring mechanical ventilation for acute respiratory failure met criteria for ARDS. Mortality from ARDS depends on severity, and ranges from 35-46% (2) . Prone positioning, when used in conjunction with low tidal volume ventilation, has been shown to significantly reduce mortality in moderate-to-severe ARDS (3) (4) (5) . Despite the evidence, the use of prone positioning in moderate-to-severe ARDS remains low (2, 6) . Barriers to implementation of prone positioning include lack of provider recognition of ARDS, uncertainty of evidence, and resource utilization (2, 3) .

Our medical intensive care unit (MICU) instituted a prone positioning program in 2014 for the management of moderate-to-severe ARDS. The MICU Prone Program was a nursing-led initiative that trained MICU nurses in safe manual placement of patients with ARDS in the prone position. Indications for proning were based on prior evidence (4), including patients with The COVID-19 Prone Team at NewYork-Presbyterian -Columbia University Irving Medical Center was developed as a dedicated mobile team comprised of a MICU clinical nurse specialist (CNS), occupational therapists (OTs), and physical therapists (PTs), who were redeployed to this role from their usual clinical jobs. Twelve OTs and twelve PTs were trained to be part of the team during the height of the pandemic. They all had cardiopulmonary rehabilitation experience, and most have worked with ICU patients as part of our early mobilization program.

In addition to knowledge of body mechanics and positioning critically ill patients, they had experience in securing airways, lines, drains, and monitoring devices in an ICU setting. The COVID-19 Prone Team covered 14 separate ICUs, a combined total of 240 COVID ICU beds.

Their day-to-day availability increased based on demand, up to 7 days a week, from 7am to 7pm at the peak, for 22 days. If a patient needed to be emergently repositioned outside of the COVID-19 Prone Team hours, they were repositioned by MICU nurses. In the event of cardiac arrest, if a patient could not be safely placed in the supine position, the protocol specified the prone position should be maintained for cardiopulmonary resuscitation in an effort to minimize risk of ventilator circuit disconnect with the associated risk of aerosolization of viral particles (7, prone positioning. All patients requiring proning during this time were proned by this team, including within the MICUs. During this same period, 314 patients were admitted to our hospital with COVID-19 requiring invasive mechanical ventilation. Baseline characteristics of these patients are shown in Table 1 . The majority of patients who required prone positioning were men (73.3%), with a median age of 64 years (range 53-71). There was a high prevalence of comorbid hypertension (55.6%) and diabetes (46.7%). All of the ICUs, including those newly created during the COVID-19 pandemic, had patients treated by the COVID-19 Prone Team. By the end of the study period, proning was discontinued in sixty-seven (65.1%) cases due to improvement in gas exchange, in twenty (19.4%) cases due to lack of clinical improvement, in six (5.8%) cases for clinical worsening and in ten (9.7%) cases due to the development of a contraindication. Thirty-six patients died and 54 remained alive ( Table 2) 

The rapid implementation of the mobile COVID-19 Prone Team that travelled to multiple ICUs at our institution during the height of the COVID-19 pandemic, increased the ability to prone patients with moderate-to-severe ARDS. In a 28-day period, 90 patients were proned by this team with 244 individual proning sessions. After implementation of the COVID-19 Prone Team, more patients who met criteria for prone positioning were actually proned, as 12 patients intubated were proned between March 2, 2020 and March 31, 2020 (1) compared to 90 during the study period. By utilizing OTs and PTs who were familiar with critical illness and positioning patients, and by developing a careful but efficient training program, the COVID-19 Prone Team was able to safely provide an evidence-based intervention to critically ill patients with ARDS in a variety of ICU settings.

Prone positioning has been shown to have a mortality benefit in patients with moderate-tosevere ARDS, but has been underutilized due to provider under-recognition of ARDS, frequent misunderstanding of its indications, disbelief in quality of evidence, and resource utilization, which during times of crisis is more pronounced (2, 12) . During the COVID-19 pandemic, the concentration of patients with moderate-to-severe ARDS increased considerably. This increase This study has several limitations. While we are able to describe the characteristics of the patients treated, we have limited data to define the overall population of moderate-to-severe ARDS patients in our hospital during the study period. It is unclear what proportion of patients with moderate-to-severe ARDS received this therapy when indicated. Also, with limited data on the incidence of moderate-severe ARDS in our hospital prior to the COVID-19 pandemic, it is unclear if our proning rate changed with this implementation. However, prior to COVID-19, proning was only available to patients in the MICUs therefore limiting this treatment to the capacity of the MICU. Lastly, our outcomes data is limited by the study duration. At the end of the study, forty-five patients were still hospitalized, therefore the outcome of these treated patients is yet to be determined. However, of the fifty-four patients whose hospital survival is yet to be determined, thirty-six (80%) patients had prone therapy stopped due to clinical improvement.

The feasibility and success of the COVID-19 Prone Team has created the possibility of sustaining and even expanding prone positioning capabilities across our hospital network in case of a future crisis. Further education and training can be disseminated to nurses and clinicians working in non-medical ICUs, utilizing some of the training materials and personnel in the COVID-19 Prone Team.

During the COVID-19 pandemic, the rapid development and implementation of a mobile prone team allowed for increased capacity to prone patients with moderate-to-severe ARDS in ICUs beyond the MICUs to meet the surge of critically ill patients during the height of the pandemic.

This was done effectively and with tolerable adverse outcomes. 6 (IQR 2-11) BMI= body mass index; SOFA = sequential organ failure assessment; ICU=intensive care unit; cc/kg=centimeters per kilogram; cm H 2 0 = centimeters of water; PEEP=positive end expiratory pressure; FiO 2 =fraction of inspired oxygen; PaO 2 = partial pressure or arterial oxygen 

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Figure 1: Number of interventions per day: Daily number of interventions completed by the prone team. Includes placing in both the supine and prone position. X axis represents dates in

We would like to acknowledge the physical therapist, occupational therapists and nurses who worked tirelessly on the COVID-19 Prone Team for their extraordinary efforts throughout this pandemic. We would also like to acknowledge our fellow healthcare workers for their dedication to outstanding patient care during this unprecedented pandemic and express our profound sympathy to our patients, their families and the community for all those who suffered during the pandemic.

J o u r n a l P r e -p r o o f