IMPLEMENTATION OF PRONE PROTOCOL IN THE MEDICAL ICU Shozab Ahmed Katelyn Thompson Ross Davidson

Background ARDS (Acute Respiratory Distress Syndrome) Inflammatory lung condition that leads to multi-organ failure Mortality 40-60% Mortality benefit with Timely diagnosis Low Tidal Volume ventilation (LTV) Paralysis within 48 hours of diagnosis Prone positioning within 48 hours of diagnosis PROSEVA trial Improved mortality in patients with severe ARDS with prone positioning Short and long term complications Skilled team and training

Multicenter, prospective, RCT 466 patients with severe ARDS 26 ICUs in France & 1 in Spain 237 prone/229 supine Inclusion Criteria Pao2/Fio2 of <150, FIO2 - 0.6, PEEP -5 Proned after the first 12-24 hrs of stabilization 16 hours prone Controlled Mechanical Ventilation TV of 6cc/kg Primary outcome Died from any cause within 28 day after inclusion

Koulouras, 2016

UNMH Diagnosis was not made timely Attending dependent care (LTV, paralysis) Prone positioning was not done

Pre-Prone training survey Attendings Nurses training, staff training Nurses 68 nurses responded to the survey 28 nurses have never done it before 22 did it once before 1 said yes but not at UNMH 1 said yes but in 1992 1 said yes more than 10 years ago

Pre-Prone survey How did you feel about the prone process? Uneasy, uncoordinated, anxious, disorganized, nerve wrecking, unconfident, apprehensive and the list goes on and on. Only 3 nurses reported being comfortable What do you need to feel more comfortable with proning? Protocol, checklist, presentation/education, guidelines, equipment, staffing and practice, practice and some more practice

Intervention Something needs to be done Education about the importance of early diagnosis so appropriate actions could be taken Door sign Generate adult ARDS order set (diagnosis criteria, ventilator settings, paralysis with sedation, and Prone order with link to the guideline and checklist)

Intervention Guidelines Checklist Simulation using a mannequin Video Indications Contraindications Preparation Prone positioning Maintenance Termination Checklist Simulation using a mannequin Video

Goals and Objectives Medical ICU nurses who have completed the simulation training will be able to perform the proning procedure accurately as measured by using a checklist. Medical ICU nurses who have completed the simulation training will feel comfortable (at least 4 out of 5 on a Likert scale) with their skills to prone a patient.

METHODS Simulation model Mannequin, IV poles, CVC, ETT, arterial lines 90 MICU nurses, Respiratory therapists, several sessions Mandatory training Brief introduction Pre session survey Showed one, made them do one Post session survey

Assessment After the training session, each group will be asked to prone the mannequin. A check list will be used to make sure that all the steps were followed and in the correct order. Medical ICU nurses who have completed the simulation training will be able to perform the proning procedure accurately as measured by using a checklist. Medical ICU nurses who have completed the simulation training will feel comfortable (at least 4 out of 5 on a Likert scale) with their skills to prone a patient. The number of patients proned over the year after August 1, 2016 will be tracked and compared to historical controls over the prior two years.

I feel able to prepare the patient for prone positioning

I feel able to gather appropriate equipment and staff for prone positioning

I feel competent in performing the actual proning process

I feel able to care for patient in the prone position

I feel competent in the process of returning the patient to supine position

I feel that, with the appropriate number of people present , I am able to ensure my own personal safety during the process of proning

Average Responses

Future Plans Application submitted to collect data as to the number of the patients proned since August 2016 Poster presented at Society of Critical Care Medicine

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