Tips for Setting Up a Proning Program

By Karen Miguel, RN, MM-H, CPPS Feb 09, 2021

Added to Collection

As a trauma clinical nurse specialist (CNS) at a high-volume level II trauma center, my daily practice usually consists of handoffs and rounds, research coordination, literature searches and generally supporting the trauma and acute care surgery teams.

Is your unit proning many patients? I’d like to share my organization’s approach, including how we set up a proning team and what we learned.

Research supports that the prone position improves oxygenation in many patients. There is no good evidence-based data to tell us how long or how frequently patients should be proned. Prior to the COVID-19 pandemic, studies showed that proning is an underutilized therapy. The reasons for lack of use include:

  • Inadequate resources for intensive training
  • Need for acquisition of specialty equipment
  • Provider-level misconception of higher risk for adverse events during turning

Our Proning Program

During the first wave of the pandemic our organization was inundated with patients who had COVID-19. We quickly took action and opened additional ICUs. Patient care service line leaders realized that we needed to create a team to help nurses learn and adopt the best practices for proning patients. Our organization implemented a proning program with the following objectives:

  • Reduce the workload of the ICU teams
  • Standardize the proning process
  • Mitigate pressure injuries and other adverse events
  • Ensure staff and patient safety

The Proning Team

Our proning team members were staff from ambulatory care settings, the operating room and other interventional areas that were closed or had a decrease in volume due to COVID-19. These staff included operating room nurses who are RNs, operating room assistants (ORAs) and outpatient physical therapists (PTs). Each team had a nurse as team lead. In addition, a resource nurse was included to:

  • Triage requests to the proning teams that were mobilized
  • Ensure there was a physician’s order for the procedure
  • Instruct the units on how to prepare for the proning team’s arrival to improve efficiency
  • Activate the scheduled on-call proning team member to cover sick calls of other team members

Teams were composed of four healthcare personnel, including at least one RN and one PT. Since our organization has 235 ICU beds, we implemented two teams on day and evening shifts and one team on night shift. The proning team hours of operation and contact information were communicated to nursing and hospital leadership. This information was also posted to an internal webpage with COVID-19-related resources.

Team Member Education

Team member training included a review of the following:

  • Purpose of proning
  • Indications for proning
  • Expected outcomes
  • Potential complications
  • Step-by-step video of the proning procedure
  • Refresher on proper technique for donning and doffing personal protective equipment
  • Use of pressure-relieving equipment
  • Pressure injury prevention
  • Head and body positioning
  • Education regarding the clinical environment and the condition of a patient with COVID-19

In addition, the training included a 60-minute simulation led by critical care clinical nurse specialists. The simulation allowed staff to practice turning a ventilated patient and also how to manage an adverse event such as inadvertent extubation or arterial line loss.

The Process

Once the proning team arrived on the unit (and before entering the room), the team lead consulted with the ICU nurse caring for the patient regarding any clinical concerns and the patient’s physical limitations. The team ensured there was a physician’s order for the procedure and obtained the needed supplies. The ICU RN and the unit respiratory therapist led the turning maneuvers.

Supportive Tools

Our team identified the following tools and resources needed to support their work:

  • Daily rounding sheets
  • Real-time reports from the electronic health record identifying all ventilated patients with COVID-19 and their demographics
  • Checklist for pre-proning, proning and post-procedure needs
  • New pressure-relieving products

Implementing a proning team provides support to both the ICU staff and critically ill patients. Using a designated team and a standardized process can improve patient outcomes and staff satisfaction.

What strategies are you using to prone your patients?