Clinician collaboration key to proning ARDS patients

May 7, 2020

Two years ago, before acute respiratory distress syndrome (ARDS) became one of the most serious complications of COVID-19, Mount Sinai Hospital in New York City developed an interprofessional educational program related to prone position ventilation (PPV), which provides relief for lungs ravaged by the disease. 

Prior to the novel coronavirus, PPV was an underused intervention in most intensive care units. It’s a complex procedure requiring collaboration among physicians, nurses and respiratory therapists, and barriers to its use include lack of preparation and protocols. 

The study was conducted in the academic medical intensive care unit (MICU) at Mount Sinai, as part of its implementation of PPV for patients with ARDS. “Implementing Automated Prone Ventilation for Acute Respiratory Distress Syndrome via Simulation-Based Training” is published in the May issue of American Journal of Critical Care (AJCC). 

The two-hour interprofessional training sessions consisted of a didactic session, simulated placement of volunteers in prone position and simulated emergency scenarios followed by a structured debriefing. A total of 82 providers with minimal previous PPV experience participated in 12 separate sessions conducted over three days in June 2018. 

The simulation-based program allowed Mount Sinai to train nearly 90% of the MICU staff to care for patients in prone position, as well as practice placement of volunteers with different body types. The PPV implementation task force included the MICU director, the senior director of nursing, the MICU nursing manager and the directors of respiratory therapy, nursing education, wound care nursing, physical therapy and nutrition. 

Lead author Ameen Poor, MD, is now an attending physician in the Division of Pulmonary & Critical Care at NYC Health + Hospitals/Metropolitan in New York City, and an assistant professor of medicine at New York Medical College. 

“Much like many other healthcare centers around the world, we were initially hesitant to implement PPV at Mount Sinai,” he said. “The successful use of PPV requires collaboration and teamwork, and our training program focused on the interprofessional nature of PPV from the start, with nurses, physicians and respiratory therapists working closely together. All participants were able to voice concerns and develop a sense of ownership of the protocol as it was being developed.” 

Pre- and post-surveys of participants found the perceived benefit of PPV increased among all providers, with the largest increase (50%) occurring in nurses. Physicians reported the greatest improvement in comfort with taking care of proned patients (an increase of 51%. The training also improved providers’ comfort in managing cardiac arrest in prone patients. 

According to the authors, the significant improvements in comfort levels with PPV across all disciplines in the unit may reflect enhanced teamwork and improved communication achieved during the simulation.

The training also identified 20 latent safety threats that led to changes in the PPV protocol. In addition to addressing equipment needs and staffing concerns, the team created checklists for providers and developed tools to improve communication with patients and families. 

The study is part of AACN’s growing library of clinical resources related to ARDS and other complications of COVID-19, including a free self-paced course, “COVID-19 Pulmonary, ARDS and Ventilator Resources,”. The COVID-19 resources also include free pocket cards, webinars, procedure manual excerpts and journal articles. 

AACN has the story

More COVID-19 coverage HERE.