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Prone Positioning in Awake Patients: Lessons From the Pandemic


By Jonah Zaretsky, MD

Placing patients on their stomach, known as ‘prone positioning,’ has been demonstrated as a successful intervention to improve outcomes in patients intubated with acute respiratory distress syndrome.1 During the initial wave of COVID-19, prone positioning in non-intubated patients outside the ICU was proposed as a safe way to help prevent progression to intubation and death. 

Prone Positioning Challenges 
Getting large numbers of people into the prone position is limited by patient and operational barriers. Evidence suggests prone positioning must be sustained for some time for it to have an effect.

For many patients, the position is uncomfortable or painful. It can put some at risk for pressure injuries. Some might be too weak to turn over on their own. It also can be interrupted by meals or other clinical interventions undertaken during the course of a hospitalization. All these are especially true in older and less mobile patients, who may stand the most to gain from prone positioning.  

“Owning the Prone”
While efforts were underway to develop prone positioning teams for intubated patients, we launched a multidisciplinary initiative to increase prone positioning among patients with respiratory failure, but who did not yet need intubation or ICU level care. Our initiative, detailed in the article, “Increasing Rates of Prone Positioning in Acute Care Patients with COVID-19,” from the January 2022 issue of The Joint Commission Journal on Quality and Patient Safety, consisted of four separate interventions:

1. Nursing, physical therapy, physician and patient education. This included a ‘one-pager’ handout with information for patients and nurses, as well as an instructional in-service video. The material we provided reviewed:

  • positioning tips
  • cushion or pillow placement
  • pressure injury prevention
  • precautions to insure comfort and safety

2. Optimization of supply management and operations. Led by a wound, ostomy and continence nursing team, we sought appropriate supplies to maximize comfort and reduce pressure injuries in the supply-limited setting of the pandemic peak.  

3. Acute care prone positioning team. To our knowledge, our effort represents the first instance of a prone positioning team for awake patients, although prone positioning teams have been described in patients intubated in the ICU setting. Our physical therapist-run team promoted prone positioning by assisting patients who were less mobile into the prone position – optimizing for safety and comfort.

4. Electric health record optimization. We developed note templates for prone positioning for the physical therapist prone positioning team. We also included fields on nursing flowsheets in the electronic medical record to indicate patient position.  

Continuous Learning 
During the course of this initiative, challenges and barriers arose, and modifications were made to address emerging challenges and barriers, including: 

  • Coughing fits and transient hypoxia were addressed by using a stepwise process of prone positioning.  
  • Anxiety (especially for patients who couldn’t return to an upright position on their own due to decreased mobility) was addressed by placing devices such as phones and call buttons within reach. Pharmacologic interventions for sleep or anxiety were also proposed in select cases.  

The expanding population of patients with COVID-19 led to the development of triage criteria for our prone positioning team to focus on patients who required moderate assist rather than maximal assist. Patients who were maximal assist typically took longer periods of time to reposition and usually did not tolerate the prone position well. 

We created a run chart showing the frequency of the prone position by week. The chart suggests improved frequency of prone positioning during the time of our initiative. We also compared the frequency of prone positioning to that of two other hospitals within our health system that did not have a similar initiative, and found our rates were significantly higher.3   

Prone Positioning Success

At the time our initiative began, evidence for awake prone positioning in general, or in COVID-19 specifically, was limited. Since then, a meta-trial of six randomized studies published in Lancet Respiratory Medicine showed evidence of improvement of composite primary outcome of intubation or death within 28 days.4  

Our intervention was undertaken in New York City during the initial wave of the pandemic. This was a monumental and unprecedented stress on our health system, which meant novel challenges for deploying a multidisciplinary quality initiative like this. We hope that our initiative can be used as a blueprint to implement similar interventions in the future.  
Jonah Zaretsky, MD, is a Clinical Assistant Professor in the Division of Hospital Medicine in the Department of Medicine at New York University’s Grossman School of Medicine.

1. Guerin, C., et al., Prone positioning in severe acute respiratory distress syndrome. N Engl J Med, 2013. 368(23): p. 2159-68.
2. Munshi, L., et al., Prone Position for Acute Respiratory Distress Syndrome. A Systematic Review and Meta-Analysis. Ann Am Thorac Soc, 2017. 14(Supplement_4): p. S280-S288.
3. Zaretsky, J., et al., Increasing Rates of Prone Positioning in Acute Care Patients with COVID-19. The Joint Commission Journal on Quality and Patient Safety, 2021.
4. Ehrmann, S., et al., Awake prone positioning for COVID-19 acute hypoxaemic respiratory failure: a randomised, controlled, multinational, open-label meta-trial. Lancet Respir Med, 2021. 9(12): p. 1387-1395.