Factors Influencing the Implementation of Prone Positioning during the COVID-19 Pandemic: A Qualitative Study

Abstract

Rationale: The adoption of prone positioning for patients with acute respiratory distress syndrome (ARDS) has historically been poor. However, in mechanically ventilated patients with coronavirus disease (COVID-19) ARDS, proning has increased. Understanding the factors influencing this change is important for further expanding and sustaining the use of prone positioning in appropriate clinical settings. Objectives: To characterize factors influencing the implementation of prone positioning in mechanically ventilated patients with COVID-19 ARDS. Methods: We conducted a qualitative study using semistructured interviews with 40 intensive care unit (ICU) team members (physicians, nurses, advanced practice providers, respiratory therapists, and physical therapists) working at two academic hospitals. We used the Consolidated Framework for Implementation Research, a widely used implementation science framework outlining important features of implementation, to structure the interview guide and thematic analysis of interviews. Results: ICU clinicians reported that during the COVID-19 pandemic, proning was viewed as standard early therapy for COVID-19 ARDS rather than salvage therapy for refractory hypoxemia. By caring for large volumes of proned patients, clinicians gained increased comfort with proning and now view proning as a low-risk, high-benefit intervention. Within ICUs, adequate numbers of trained staff members, increased team agreement around proning, and the availability of specific equipment (e.g., to limit pressure injuries) facilitated greater proning use. Hospital-level supports included proning teams, centralized educational resources specific to the management of COVID-19 (including a recommendation for prone positioning), and an electronic medical record proning order. Important implementation processes included informal dissemination of best practices through on-the-job learning and team interactions during routine bedside care. Conclusions: The implementation of prone positioning for COVID-19 ARDS took place in the context of evolving clinician viewpoints and ICU team cultures. Proning was facilitated by hospital support and buy-in and leadership from bedside clinicians. The successful implementation of prone positioning during the COVID-19 pandemic may serve as a model for the implementation of other evidence-based therapies in critical care.

Keywords: acute respiratory distress syndrome; coronavirus disease; implementation science; prone positioning.

Figure 1.

Consolidated Framework for Implementation Research (CFIR) domains with study-specific definitions. The CFIR consists of five domains to organize the study of factors that are important for effective implementation. The intervention (intervention domain), in this case, prone positioning, is introduced into a context that consists of individual clinicians (individuals) working in ICUs (inner setting) that exist within the broader hospital and societal context (outer setting). The intervention has core features necessary for efficacy and efficiency but is also adapted and refined by the context in which it is introduced (double arrow to individuals, inner setting, and outer setting). Implementation processes are the strategies that can improve implementation (increased adoption, penetration, and sustainability) of the intervention being implemented. COVID-19 = coronavirus disease; ICU = intensive care unit.