AACN Advanced Critical Care

Volume 32, Number 2, pp. 159-168

© 2021 AACN

Development of a Prone Team

and Exploration of Staff Perceptions
During COVID-19
Karen Miguel, MM-H, RN, CPPS

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Colleen Snydeman, PhD, RN, NE-BC
Virginia Capasso, PhD, CNP, ACNS, CWS, FACCWS
Mary Ann Walsh, BSN, RN
John Murphy, DNP, RN
Xianghong Sean Wang, MS

ABSTRACT
Objective: As intensive care unit bed capac- turning-related adverse events.
ity doubled because of COVID-19 cases, Results: No adverse events occurred to
nursing leaders created a prone team to patients or members of the prone team.
support labor-intensive prone positioning of The prone team mitigated pressure injuries
patients with COVID-related acute respira- using prevention strategies. The prone team
tory distress syndrome. The goal of the and intensive care unit staff were highly
prone team was to reduce workload on satisfied with their experience.
intensive care teams, standardize the pron- Conclusion: The prone team provided sup-
ing process, mitigate pressure injuries and port for critically ill patients, and team mem-
turning-related adverse events, and ensure bers reported feeling supported and
prone team safety. empowered. Intensive care unit staff were
Methods: Staff were trained using a hybrid highly satisfied with the prone team.
learning model focused on prone-positioning Key words:  COVID-19, proning, prone posi-
techniques, pressure injury prevention, and tioning, prone team, SARS-CoV-2

O n January 30, 2020, the World Health Virginia Capasso is Advanced Practice Nurse, Nurse Scien-
tist, Patient Care Services Quality, Safety & Practice, Massa-
Organization declared the novel coro- chusetts General Hospital; and Instructor in Surgery, Harvard
navirus, subsequently named SARS-CoV-2, Medical School, Boston, Massachusetts.
a public health emergency.1 Within weeks,
Mary Ann Walsh is Staff Coordinator, Patient Care Services
the COVID-19 pandemic confronted the US Quality, Safety & Practice, Massachusetts General Hospital,
health care system with the unprecedented Boston, Massachusetts.
need to react in real time. This public health
John Murphy is Staff Specialist, Edward B. Lawrence Cen-
emergency was like no other. For the most ter for Quality and Safety, Massachusetts General Hospital,
Boston, Massachusetts.

Karen Miguel is Staff Specialist, Patient Care Services Qual- Xianghong Sean Wang is Senior Data Analyst, Patient Care
ity, Safety & Practice, Massachusetts General Hospital, 55 Services Quality, Safety & Practice, Massachusetts General
Fruit St, Boston, MA 02114 ([email protected]). Hospital, Boston, Massachusetts.

Colleen Snydeman is Executive Director, Patient Care Ser- The authors declare no conflicts of interest.
vices Quality, Safety & Practice, Massachusetts General
Hospital, Boston, Massachusetts. DOI: https://doi.org/10.4037/aacnacc2021848

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critically ill, there were devastating sequelae, legacy ICUs had the knowledge and clinical
yet a dearth of curative interventions. acumen to prone patients, but only 1 unit
In the early stage of the pandemic, the focus was using this therapy regularly. Despite the
was on treating symptoms associated with benefits of PP being well documented in the
acute respiratory distress syndrome (ARDS) research literature, studies show it is under-
caused by SARS-CoV-2, specifically the destruc- used.10-13 Likely reasons for aversion to the
tion of lung tissue and, most notably, the alve- practice may be misperceptions of the need
oli. SARS-CoV-2 infection causes mild disease for resource-intensive training, acquisition of
in most people but has led to severe disease specialty equipment, or provider-level mis-
with acute hypoxic respiratory failure (ie, conceptions of higher risk for adverse events
ARDS) in many. Nearly 25% of this popula- during the practice of turning that would
tion requires mechanical ventilatory support. outweigh the benefit of improved oxygen-
Usually within 1 week of exposure, patients ation.14 Given the benefit to patients and the

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present with dyspnea, increased pulmonary critical juncture of the facility with patient
edema, and bilateral opacities like ground load, it was determined by nursing and
glass on chest imaging.2,3 hospital leadership that a proning program
should be implemented.
Background A search for evidence on the benefits of
Reports from China and Italy, 2 countries proning resulted in little information on a
hit early with the illness, noted that the prac- dedicated proning team (PT). Operational
tice of proning, a known but often last-ditch questions emerged: How many staff would
effort, could improve oxygenation for many be required on a team? How many patients
patients.4,5 First proposed in the 1970s, prone would need to be turned? How often? Would
positioning (PP) in patients with moderate to turns be planned or emergent? The objectives
severe ARDS considerably improves oxygen- of our program included (1) creating a team
ation and significantly reduces both mortality separate from but in tandem with critical
and ventilator-associated pneumonia.6 Prone care staff, thereby reducing the workload on
positioning increases lung volume and decreases ICU teams caring for patients with severe
atelectasis by recruiting alveoli, improving ARDS due to COVID-19; (2) standardizing
dependent aeration, and mobilizing secretions. the PP process to minimize turning-related
Prone positioning also reduces ventilator- adverse events throughout all ICUs; and (3)
related lung injury due to overdistention that ensuring PT members’ personal safety.
occurs with higher positive end-expiratory As the institution targeted a greater than
pressure. Simply put, in normal supine posi- 100% increase in ICU bed capacity (from
tion, the heart, diaphragm, and liver cause 109 to 235 beds) to manage the predicted
pressure on alveoli, collapsing them. In the surge of patients with COVID-19 who would
prone position, where the heart, diaphragm, need intensive care, several hundred additional
and liver are not compressing lung tissue, traveling nurses and former ICU nurses from
there are more available alveoli to recruit, the organization were rapidly trained and
thereby improving oxygen–carbon dioxide redeployed to the ICU environment. With
exchange. Ultimately, oxygenation improves.7-9 limited PP experience, these newly trained
In this article, we share how 1 large academic staff nurses and newly formed care teams
institution addressed the oxygenation needs would greatly benefit from a dedicated PT
of patients with COVID-19 by developing that could offset the enormous resource bur-
and implementing a proning program. den and allow the nurses to better serve these
patients with COVID-19.
Methods After the closure of ambulatory care set-
Development and Planning tings and elective surgical and interventional
As COVID-19 cases began to inundate this procedures, a labor pool of staff was formed.
large academic medical center, critical care These staff members were available to meet
stakeholders and patient care services safety any institutional needs. Our focus was selec-
leaders recognized the need to create a best- tion of staff with expertise in positioning and
practice resource to support PP for the highest- mobility. We chose a total of 75 operating
acuity patients in the 6 legacy and 5 pop-up room nurses, operating room assistants, and
intensive care units (ICUs). Staff in 3 of the outpatient physical therapists from the labor

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pool for their knowledge of PP and strong board that they began to own and popu-
understanding of safe mobilization and posi- late themselves.
tioning.15 Review of admitting volume data A resource-nurse role was created to better
and forecasting from ICU leadership aided us triage ICU team requests. To maximize effi-
in determining the size of the team to meet ciency and minimize wait time, the resource
patient demand. In 1 week, the PT concept nurse carried the pager and made initial con-
was approved and implemented. tact with the requesting unit, communicating
steps that needed to be in place before the
Training and Education team’s arrival. The resource nurse also dis-
Prone positioning is a complex procedure patched new incoming requests to the PTs as
requiring careful, synchronized coordination. they were on an assignment, expediting the
It also has many potential complications.16 care of the next patient. A checklist was used
Using the procedure developed by this insti- by the team to ensure safety steps were taken

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tution’s ICU clinical nurse specialists, a new before the team arrived, during the maneuver,
curriculum titled “Proning Intubated Patients and before leaving the room (Figure 1). These
in the Intensive Care Unit” was developed steps included ensuring a physician order was
for the core group selected for redeployment written to prone the patient, enteral feedings
to the PT. Training included a review of the were turned off, necessary supplies were gath-
purpose, indications, expected outcomes, and ered, and the respiratory therapist assigned
potential complications of PP, a step-by-step to the unit was available. A PT lead, also a
video of the procedure,6,17 and a refresher nurse, held a huddle briefing with the ICU
on proper technique for donning and doffing nurse, and the respiratory therapist when
personal protective equipment. A 60-minute available, before the team entered the room.
simulation, led by the critical care clinical Critical elements such as clinical concerns
nurse specialist, allowed trainees to practice and known physical limitations of the patient
the basic safety steps for manually turning were discussed.
a patient receiving ventilatory support to The respiratory therapist and the ICU
prone position and back to supine position. nurse caring for the patient led the call out
The highest priority was placed on staff for maneuvers for the PT during the turn
safety and awareness of the risk for possi- (Figure 1). Sterile caps were placed on dis-
ble adverse patient events. Scenarios included connected catheters. Oxygen saturation mon-
managing adverse events such as inadvertent itoring remained in place for the entire turn.
endotracheal tube or central access catheter When the turn was completed and after con-
removal. The use of pressure-relieving posi- firmation that the airway was secure, the
tioning equipment to help mitigate develop- monitoring devices were reconnected and
ment of pressure injuries due to long proning pressure-relieving strategies individualized for
intervals was also a focused priority.18-21 the patient were implemented. The PT dis-
cussed with the ICU team anything they could
Team Structure and Team Roles do differently for next time. After each assign-
The PT was available 24/7. There were 2 ment, in support of a constant state of learn-
teams of 4 on both the day and evening shifts, ing, the PT debriefed at the home base with
and 1 team of 3 on the night shift. Each PT the other members to share the multiple posi-
consisted of a minimum of 1 operating room tioning challenges they faced due to habitus
registered nurse and 1 physical therapist. and body mobility, and the creative position-
A home base for this team was established ing techniques and devices they used to maxi-
in a vacant space of a hospital department. mize skin integrity. This sharing of real-time
Within 24 hours, the space was converted information honed the team’s skills quickly.
to a PT office suite, complete with computers,
telephones, and a break area with essentials Implementation
such as a refrigerator, microwave, and coffee The determination of when to prone and
machines. Assignment boards and communi- supine the patient was decided by the ICU
cation boards were used for answering fre- teams monitoring the patient’s clinical status,
quently asked questions and information particularly hemodynamic and ventilatory
sharing in real time. Staff were met with a daily criteria. Proning time ranged from 16 hours
inspirational message on the communication to longer than 8 days. The PT’s needs were

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Before Team Arrival Team Arrival After Turning

Coordinate time with RT Prone team leader/RN huddle Check ETT positioning,
airway stability (RT)
Tube feeds off 1 hour before RT: Lead counter for all position changes
1 through 3 Reconnect A-line and
Assure orders for turn and
other vital signs (RN)
premedications Primary RN monitors catheters, gives OK
to RT before all moves Pull sheet taut
Obtain proning supplies
Ensure bed locked, at appropriate height, Recheck pressure points,
Perform eye care
mattress inflated (ICU) confirm eyes covered
Apply skin moisture barrier
Side rails down Reapply restraints,
Empty drains/bags SCDs, etc
Disconnect and cap A-line, and any other
Disconnect nonessential lines (ECG leads/stickers, BP cuff, etc) Put up side rails

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catheters, tubing, restraints
Leave oxygen saturation probe ON Remind RN to turn head
during turn every 2 hours; prone
Page Prone Team
team available to assist

Figure 1: Prone/supine safety checklist. BP indicates blood pressure; ECG, electrocardiogram; ETT, endotra-
cheal tube; ICU, intensive care unit; RN, registered nurse; RT, respiratory therapist; SCD, sequential compres-
sion device.

quickly identified and supporting tools were musculoskeletal injury during proning (ie,
developed in the early days of the program, pushing, pulling, and lifting the patient)22
including: daily report sheets for rounding to was compounded by the challenges of main-
all ICUs; real-time reports from the electronic taining emotional and moral equilibrium in
medical record identifying all patients with unprecedented circumstances that was com-
COVID-19 who were receiving ventilatory pletely out of their sphere of control. Leaders
support and their basic demographics (ie, age, acknowledged this fear of exposure to self
sex, and weight); and an enhanced checklist and loved ones and contraction of the poten-
for preproning, proning, and postproning tially lethal COVID-19.23
needs. A wound care specialist reviewed a The team was led by a former ICU nurse
series of safety reports related to development with a Master’s degree and 2 staff specialists
of pressure injuries in patients who were with nursing leadership experience. The PT
proned, which led to several pressure-relieving leadership focused on enculturating team-
products being added to an existing formu- work and psychological safety into the work-
lary to enhance pressure redistribution. The place and continuous process assessment and
newly added products were shared with the improvement. This leadership team was com-
PT so they could learn when and how to use mitted to workforce safety as a core value.
them. Additionally, a new procedure for tap- Physical and psychosocial resiliency required
ing endotracheal tubes was determined and strong leadership to cultivate teamwork and
shared with the PT, who reminded teams to cohesion among team members who were
do it prior to proning a patient. Along with unfamiliar with each other and the care of
the unit-based clinical nurse specialist, the PT critically ill patients in the ICU. In accordance
supported diffusion of pressure-injury preven- with the tenets of Alcoa CEO Paul O’Neill,24
tion products and consistently communicated the team was treated with dignity and respect
best practices in pressure-injury prevention by staff, received the resources they needed to
strategies across the 11 ICUs. do their job, and were recognized and thanked
regularly for their work. To create a “habit of
Leadership and PT Cohesiveness excellence”24 and support an environment for
Personal safety of the PT members was a constant state of learning, the PT carried
1 of the 3 objectives of the program and a out huddles at shift change in which staff
focus of PT leaders. For members of the were empowered to share highlights and
team, managing the known and perceived changes for improvements. These changes
risks of physical stressors associated with were made in real time and communicated

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in a daily email update. Positive comments ICU Survey

from the ICU staff and team members was The second survey targeted care teams
captured on a unit communication board. from the 11 ICUs (6 legacy and 7 pop-up)
Team members were celebrated regularly. caring for patients requiring PP. A scannable
QR code to access the questionnaire was
Project Evaluation provided in a flyer and an email invitation
To better prepare for possible mobiliza- was sent to leaders in the ICUs with a request
tion of a PT in the event of a second surge to post and distribute to staff. Participation
or another pandemic, we felt it was impor- was voluntary and anonymous. The survey
tant to understand the perception of the was an 11-item instrument with 2 open-ended
process both from the perspective of PT questions. Respondents answered using the
members as well as the ICU staff using the described 7-point Likert scale, with a focus
resource. Two surveys were created and dis- on timely and efficient response of the PT

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tributed in the final weeks of the PT pro- and their knowledge of the procedure and
gram. Survey data were collected and managed pressure-relieving devices. The open-ended
using Research Electronic Data Capture questions were (1) What was the most satis-
(REDCap) electronic data capture tools.25,26 fying aspect of working with the prone team?
REDCap is a secure, web-based software and (2) Was there anything we could have
platform designed to support data capture done to improve your experience with the
for research studies. prone team?
The surveys received exempt status from
the hospital’s institutional review board. Results
The study posed no risk to participants The PT was operational for 8 weeks (Fig-
because all information recorded was deiden- ure 2). The PT successfully turned 147 patients
tified to ensure patient and staff anonymity. 450 times without loss of any oral or endo-
Survey participants were verbally informed tracheal airways; arterial, venous, or central
of the purpose of the survey, the redaction catheters; or any tubes and drains (Table 1).
of their personal information, and that The PT completed 228 prone and 211 supine
their participation in the survey reflected maneuvers. There were 11 requests for assis-
implied consent. tance moving challenging, nonintubated patients
to prone position and head turns on patients
PT Survey with mobility restrictions who were receiving
The PT survey was designed to gather infor- ventilatory support. No team member sustained
mation on PT members’ experience while par- physical injuries or COVID-19–positive con-
ticipating on the team. It was an 11-item versions. The size of the team was adjusted
instrument. Respondents answered using a as turn demand decreased.
7-point Likert scale (1, strongly disagree; 2,
disagree; 3, somewhat disagree; 4, neutral; 5, PT Results
somewhat agree; 6, agree; 7, strongly agree). Of 72 PT members, 54 (75%) responded to
The questions focused on preparedness for the survey (Table 2 and Table 3). Prone team
the role, leadership support, team-member members overwhelmingly reported a positive
decision-making and empowerment, personal experience (> 94% agreed or strongly agreed)
satisfaction, and overall value of the PT to being a member of the team (eg, safe, empow-
the ICU staff. There were 3 open-ended ques- ered, valued, supported by leadership, per-
tions: (1) Describe your personal perspective sonal satisfaction, overall experience). These
of this redeployment, before and after prac- responses validated leaderships’ effort to encul-
ticing on the prone team; 2) Describe the turate teamwork and psychological safety
most satisfying aspect(s) of your role; and 3) within the team. Most survey takers (80%)
Was there anything we could have done to responded positively (ie, agreed or strongly
improve your experience with the prone team? agreed) that they felt adequately prepared for
We emailed an invitation flyer with a scan- the role. There were areas of opportunity as
nable QR code to access the questionnaire to well. Suggestions included a greater focus on
PT members and also posted the flyer in the familiarizing the team with the intensive care
PT’s home base. Participation was voluntary environment; more time simulating the pron-
and anonymous. ing maneuver; practicing the maneuver on a

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25 5 Teams
450 Total Turn Events
(2 day, 2 evening, 1 night)
21 21
228 Prone
211 Supine
20 19 4 Teams
11 Other
(2 day, 1 evening, 1 night)
17 17
16 16 16
3 Teams
15 14 14 (2 day, 1 evening) 1 Team
13 13 13
12
(11 am to 7 pm)
11 12 11 11 11 11
1111 10 11
10 10 10 10 9 9
9 9 9 9 8 8 8
8 8 7
7 7 6 6 6 6 6 6 6 6
6 5 6 6 5 6
5 5 5 5 5 5 5 54 5 4

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4 4 4 4 4 4 4 4 4 4 4 4 3 43 3 3 3 3
43 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 2 2 2 2 3
2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 21 2 21 21 2 2 2 2 1 1 1 1
1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 0 1 1 10 1 10
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 00
4/9
4/10
4/11
4/12
4/13
4/14
4/15
4/16
4/17
4/18
4/19
4/20
4/21
4/22
4/23
4/24
4/25
4/26
4/27
4/28
4/29
4/30
5/1
5/2
5/3
5/4
5/5
5/6
5/7
5/8
5/9
5/10
5/11
5/12
5/13
5/14
5/15
5/16
5/17
5/18
5/19
5/20
5/21
5/22
5/23
5/24
5/25
5/26
5/27
5/28
5/29
5/30
6/1
6/2
6/3
6/4
6/5
6/6
6/7
6/8
Day Evening Night Total

Figure 2: Prone team volume and decommissioning plan.

Table 1: Characteristics of Patients Table 2: Prone Team Member Survey

Proned by the Prone Team (N = 147) Demographics
Characteristic Valuea Member Title No. of Responses (%)
Age, mean (SD), range, y 61 (14.3), 27-89 Registered nurse 37 (68.5)
Sex Operating room assistant 13 (24.1)
Male 104 (71)
Female 43 (29) Physical therapist 4 (7.4)

Ethnic background Total 54

Hispanic or Latino 60 (41)
Other 87 (59) worried about my personal health as well as those in
Admitting diagnosis my family. However, after the first few days I felt very
Respiratory failure 137 (95) comfortable and was so glad to be a member of this
outstanding team and proud of the work we did. We
Secondary diagnoses
Hypertension 63 (43) were provided with all the resources needed to do our
Obesity 59 (40) job safely. I felt leadership went above and beyond. …
They were always available to answer questions, listen
Obesityb
to our concerns and always open to suggestions. I
Mild 29 (49)
would be proud to be on this team again if necessary.
Moderate 16 (27)
Severe 14 (24) (PT member, operating room registered nurse)
a
b
 Values are no. (%) unless otherwise indicated. I still remember the first time I got in the elevator
 Determined from body mass index.
going to prone my first [patient with] COVID. … I
was trying to keep my hand from shaking as I held
human (vs a mannequin); and scheduling the my face shield. After the initial nervousness went
PT working schedule in a more transparent, away and I started learning more about the process
fair, and timely manner. and what we could do to make a difference. … I will
The following examples highlight the PT always remember the people I met, the impact I made,
responses to their experience being redeployed and the lives I helped save due to my role on the pro-
and level of satisfaction being a member of ning team. What started as one of the most terrifying
the team: transitions I’ve ever had to make, ended as one of
I was nervous to be in a role [on the PT] that came the most rewarding experiences of my life. (PT mem-
directly in contact with patients with COVID and was ber, physical therapist)

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Table 3: Prone Team Member Experience During the COVID-19 Pandemic

No. of Responses Positive

Survey Item (N = 54) Responses, %a
1. I was adequately prepared for my role as a prone team member 54 79.60
(eg, training: HealthStream and simulation).
2. I had what I needed to safely perform the role (eg, supplies, personal 54 94.40
protective equipment review, adequate staffing).
3. I was included in decision-making about changes to improve the team. 54 98.20
4. I felt supported in this role by the prone team coordinators/leaders. 54 100.00
5. I found personal satisfaction with the role. 53 94

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6. I felt that I made a difference in the care of patients with COVID-19. 53 100
7. I felt the prone team was valued by the staff on the critical care units. 54 98.10
8. Overall, I would rate my experience as a member of the prone team 54 98.20
as positive.
a
 Positive responses include both strongly agree and agree responses.

ICU Survey Results

Table 4: Intensive Care Unit Staff Use of
Although a response rate could not be cal-
Prone Team During the COVID-19 Pandemic
culated because of unclear methodology of
survey distribution, more than 200 responses ICU Staff Demographics No. of
were received from the 11 ICUs. Forty-eight and PT Use Responders (%)
percent of responders used the PT 1 to 3 times Role
(Table 4). Nearly 200 respondents (> 90%) Registered nurse 156 (78)
agreed or strongly agreed that the PT was an Respiratory therapist 20 (10)
asset for care teams in the ICU (eg, knowledge- MD and NP/PA/CRNA 23 (11)
able about turning procedure, timely and efficient Other 2 (1)
with responses to requests, knowledgeable Total 201
about positioning and pressure-relieving How many times did you engage
devices). The majority of ordering providers with the prone team for a turn
(74%) were more likely to order PP knowing prone/supine?
there was a PT (N = 201 responses)(Table 5). 1-3 96 (48)
This finding was encouraging given reports in 4-6 62 (31)
the literature of underuse of PP because of mis- ≥ 7 43 (21)
conceptions of higher risk for adverse events
Abbreviations: CRNA, certified registered nurse anesthetist; ICU,
during turning that would outweigh the bene- intensive care unit; MD, medical doctor; NP, nurse practitioner; PA,
fit of improved oxygenation.14 physician assistant; PT, prone team.

The following excerpts highlight the ICU As a respiratory therapist [RT], it was greatly appre-
team responses to open-ended questions: ciated that everyone was respectful of the RTs’ main
They [PT] relieved a huge work load burden that goal to keep that OET [oral endotracheal tube] in…
had been pulling already busy ICU staff. I was and they ensured that I was comfortable with my
deployed to a pop-up ICU working with other hold [on the OET] when we turned on my count …
ICU nurses who did not have a comfort level with they listened when we needed to stop at different
proning, and many general care nurses who were points, switching of [electrocardiogram] leads and
unfamiliar with proning. Prior to the prone team, [defibrillation] pads, staying after turns assuring [the
we had a shift where we proned 8 patients in 10 patient] remained stable. (ICU respiratory therapist)
hours! Having a cohesive team come in to prone/
supine was a huge asset. (ICU nurse) Wow, that was everyday bravery and clutch help at
its best, early or late in the day, always enthusiastic,
Everyone on the multiple different prone team mem- expert, and collegial. I am grateful for the chance to
bers were fantastic, receptive, listened and worked give this perspective in writing, because I would be
together … and had it down to a science of efficiency! hard-pressed to carry it off in person. I have

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Table 5: Intensive Care Unit Staff Perceptions of a Prone Team During COVID-19 Pandemic

No. of Positive
Staff Perception Item Responses Responses, %a

1. Did you find the prone team program an asset for care teams caring for 201 99.5
patients with COVID-19 (as a clinician, as a unit, for the organization)?
2. The prone team response was timely and efficient. 201 94.0

3. The prone team members were knowledgeable about the turning procedure. 201 90.0

4. The prone team members were knowledgeable about positioning and 201 91.0
pressure-relieving devices.
5. Were you more apt to place an order for proning as a recruitment effort 23 74.0

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knowing there was a prone team? (for MD and NP/PA/CRNA only)
Abbreviations: CRNA, certified registered nurse anesthetist; MD, medical doctor; NP, nurse practitioner; PA, physician assistant.
a
 Positive responses include both strongly agree and agree responses.

self-diagnosed PTSG—posttraumatic sincere grati- with COVID-19 continue to be developed,

tude. The proning team was one of many big and the optimal PT size has yet to be deter-
small innovations of [patient care services], never on mined.28,29 Teams of 4 with at least 1 nurse
national TV or in the [New York] Times, but unforget- and 1 physical therapist supporting the unit-
table and always much appreciated. (ICU physician) based nurse and respiratory therapist were
appropriate for our purposes.
They provided positioning supplies [pressure- When performing this evidence-based inter-
relieving] and the manpower to easily go prone. … vention, the PT successfully completed 450
They also had the knowledge of things that worked/ maneuvers without physical harm to any team
things that didn’t work. … They answered pages member. No unnecessary harm to patients by
quickly and had an extremely helpful attitude no way of dislodgement of endotracheal airway
matter what time of day or night you called them. tubes, arterial and central venous monitoring
(ICU advanced practice nurse) catheters, and drainage catheters occurred.
Doussot et al28 reported 8.8% position-related
Discussion complications and Short et al27 reported cath-
This rapid deployment of a PT served mul- eter dislodgement in 1 patient. Our outcomes
tiple ICUs in our institution during the local stand out from those of other colleagues at
peak of the COVID-19 pandemic to help over- facilities with dedicated PTs, in part because
come the increasing workload on our ICU of the comprehensive training and post-turn
staff. Multiple factors led to the success of debriefings that were conducted, as well as
this multidisciplinary team, including execu- leadership enculturation of a habit of excel-
tive nursing and hospital leadership’s support lence24; staff were treated with respect, given
and a hybrid training model that included adequate resources, and shown regular appre-
simulation, the use of standard checklists, ciation for their efforts. Hodgson et al15 deter-
and a model for team cohesion adopted by a mined programmatic success hinged on leader-
dedicated leadership team with a focus on con- ship support to enculturate a team behavior.
tinuous process assessment and improvement. The value of this program was fully appre-
Composed of operating room nurses, ciated through survey feedback. The ICU staff
assistants, and physical therapists who were overwhelmingly expressed appreciation for
familiar with critically ill patients and posi- the PT having implemented this lifesaving
tioning maneuvers, the PT ensured that no maneuver for our most acute patients. Prone
additional strain was added to clinical nurs- team members articulated the deep personal
ing and other bedside clinicians who were value of being part of this inaugural team.
already overburdened with the surge. In a Initial fear for self and family transformed into
recent article, Short et al27 supported the feelings of pride and satisfaction in being a
importance of familiarity with these skills. part of something bigger than the individual,
As new prone positioning techniques and to be a part of something so impactful to their
other complex care requirements for patients patients, their peers, and their community. The

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experience brought a level of camaraderie that concept of a dedicated team could be extrapo-
had not been felt before. The American Asso- lated for such well-known needs as a mobility
ciation of Critical-Care Nurses asserts that team. Hospital-wide, dedicated team members
institutions must implement resources to mit- and frontline caregivers can feel supported
igate the harmful effect of emotional unease and valued with this model.
during a crisis.23 The role of strong leadership
is a primary component of the success of the Conclusion
team and was important for the team’s emo- The implementation of a PT demonstrated
tional and psychological health during this novel support for critically ill patients and
challenging time. their caregivers during the initial surge of
We hope the findings of this study provide the COVID-19 pandemic. Access to an effi-
a framework for institutions considering the cient and standardized process for manag-
implementation of a PT by highlighting the ing proning improved predictability and

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importance of balancing the needs of patients safety for patients being turned. A trained,
with the overall psychosocial health of the dedicated PT ensured safety of patients and
staff caring for them. In emerging literature staff. Staff felt supported, empowered, and
on patients with moderate to severe ARDS valued for their roles as members of the PT.
due to COVID-19, researchers report an asso- Intensive care unit staff were satisfied with
ciation between PP and improved physiologic using the PT.
parameters and reduced mortality rate.30 More
ACKNOWLEDGMENTS
research is needed to examine the long-term The authors thank the Massachusetts General Hospital
benefits of PP for patients with COVID-19. (MGH) Nursing and Patient Care Services Executive
Leadership Team for its sponsorship of the program
Practice Implications and all the members of the MGH prone team for
We felt that with the possibility of a sec- their commitment to making this program one of
the great success stories of the 2020 pandemic. The
ond surge, it was critical for us to review authors specially thank Sandra Thomas and Melanie
the program and identify opportunities for Roth for their administrative and editing support and
improvement. In accordance with the insti- Lisa Liang Philpotts, Treadwell Library Knowledge
tution’s predictive modeling, consideration Specialist, for sharing her guidance and expansive
knowledge about researching pertinent articles in
should be given to deploy the PT sooner, using the literature.
the decommissioning plan our institution used
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