By Maggie Chiu, PT, DPT, GCS, Assistant Supervisor Cardiopulmonary Physical Therapy, New York-Presbyterian Hospital
This blog post highlights the study “Developing and Implementing a Dedicated Prone Positioning Team for Mechanically Ventilated ARDS Patients During the COVID-19 Crisis” in the June 2021 issue of The Joint Commission Journal on Quality and Patient Safety. The study details the strategies that successfully allowed 400+ prone positioning (PP) interventions in 6 weeks during the initial wave of the COVID-19 pandemic in March 2020.
There we were, standing in the corridors of our familiar medical intensive care unit (ICU) as the first of many COVID-19 patients were being transported to their room. You could palpate the tension and uncertainty lingering in the air. As a university medical center and research facility, we are adapted to change and embracing the unknown. This felt different.
Within the course of weeks, 7 of our 8 ICUs filled to the brim with COVID-19 patients. There were talks of converting step down floors, operating rooms and catheterization labs to handle the influx. ICU rooms began housing two patient beds, and trials of splitting ventilators began to brace for a ventilator shortage. Our hospital paused surgeries, internships, visitors and volunteers to minimize risk and conserve precious personal protective equipment (PPE).
While a small percentage of patients were awake and needed physical and occupational therapies for rehabilitation, the majority of COVID-19 patients suffered severe acute respiratory distress syndrome (ARDS) and laid sedated, intubated and paralyzed.
As one of a handful of physical therapists with critical care competency, I watched helplessly as our ICU team marched on, wishing there was a way to help. Their dedication carried them shift after shift, as exhaustion covered their faces like war paint. It was around this time that we received the call to help with prone positioning (PP) or lying patients on their stomach.
It was something out of an Avengers movie. Twenty-four occupational and physical therapists (OT/PT) and three critical care nurses (CCRN) volunteered to form the “Prone Team.” We were led and trained by a single clinical nurse specialist (CNS) and his mannequin sidekick, Sam.
Training commenced at 8:00 a.m. with 8-10 members and lasted for several hours prior to initial bedside PP. Training of the entire team lasted a few days until each member reported confidence and comfort with the technique. We reviewed pertinent skills such as:
- breaking down each positioning to several coordinated lateral and quarter turns
- proper placement of turning device, continence pads and linen
- ensuring endotracheal tube (ETT) stability and documenting levels
- securing central venous lines, arterial lines, chest tubes and catheters
- communicating and cross checking each member’s tasks and upcoming steps
- coordinating timing of each step with team members and airway manager
A Hero’s Welcome
With that, we began our 6-week tour. Every day, a mobile unit of 4-5 PT/OT/CCRNs traveled across the hospital, responding to calls via our “Prone Phone.” In new units where redeployed staff have never encountered PP (such as the OR-ICU and children’s hospital that started housing adult COVID-19 patients), we were welcomed with sighs of relief and cheers of gratitude.
In units accustomed to PP (such as the medical ICU), we helped shoulder the physical strain and mental stress, allowing CCRNs to focus on their gravely ill and tenuous patients. As the weeks passed, patients began waking up and desperately needed rehabilitation services. We juggled our redeployed and original jobs simultaneously – proning one day, early mobilization another, in addition to orienting floor PT/OT staff to ventilators.
I can’t recall exactly what got us through those 6 weeks. Perhaps it was...
- the hospital meals our coworkers left for us
- the songs of hope that played after every successful extubation (my favorite was “Here Comes the Sun” by The Beatles)
- the look of relief on our colleagues’ exhausted faces
- the neighborhoods cheering for health care workers at 7 p.m.
- every time a PP patient woke up and gained mobility
- the time we were tricked into receiving the “2020 Friends of Nursing Award” by our CNS leader
Reminiscing now over a year past and heading into summer, with another wave down, millions dead and millions vaccinated, I still get teary eyed when I hear:
“Little darling, it seems like years since it's been clear...
Here comes the sun, and I say It's all right...” –The Beatles
Maggie Chiu, PT, DPT, GCS, is the Assistant Supervisor of Cardiopulmonary Physical Therapy at New York-Presbyterian Hospital, New York.