Adaptation and Uncertainty: A Qualitative Examination of Provider Experiences With Prone Positioning for Intubated Patients With COVID-19 ARDS.
COVID-19
acute respiratory distress syndrome
implementation science
prone position
Journal
CHEST critical care
ISSN: 2949-7884
Titre abrégé: CHEST Crit Care
Pays: United States
ID NLM: 9918681585806676
Informations de publication
Date de publication:
Sep 2023
Sep 2023
Historique:
medline:
9
10
2023
pubmed:
9
10
2023
entrez:
9
10
2023
Statut:
ppublish
Résumé
Prone positioning was widely adopted for use in patients with ARDS from COVID-19. However, proning was also delivered in ways that differed from historical evidence and practice. In implementation research, these changes are referred to as adaptations, and they occur constantly as evidence-based interventions are used in real-world practice. Adaptations can alter the delivered intervention, impacting patient and implementation outcomes. How have clinicians adapted prone positioning to COVID-19 ARDS, and what uncertainties remain regarding optimal proning use? We conducted a qualitative study using semi-structured interviews with ICU clinicians from two hospitals in Baltimore, MD, from February to July 2021. We interviewed physicians (MDs), registered nurses (RNs), respiratory therapists (RTs), advanced practice providers (APPs), and physical therapists (PTs) involved with proning mechanically ventilated patients with COVID-19 ARDS. We used thematic analysis of interviews to classify proning adaptations and clinician uncertainties about best practice for prone positioning. Forty ICU clinicians (12 MDs, 4 APPs, 12 RNs, 7 RTs, and 5 PTs) were interviewed. Clinicians described several adaptations to the practice of prone positioning, including earlier proning initiation, extended duration of proning sessions, and less use of concomitant neuromuscular blockade. Clinicians expressed uncertainty regarding the optimal timing of initiation and duration of prone positioning. This uncertainty was viewed as a driver of practice variation. Although prescribers intended to use less deep sedation and paralysis in proned patients compared with historical evidence and practice, this raised concerns regarding patient comfort and safety amongst RNs and RTs. Prone positioning in patients with COVID-19 ARDS has been adapted from historically described practice. Understanding the impact of these adaptations on patient and implementation outcomes and addressing clinician uncertainties are priority areas for future research to optimize the use of prone positioning.
Sections du résumé
BACKGROUND
BACKGROUND
Prone positioning was widely adopted for use in patients with ARDS from COVID-19. However, proning was also delivered in ways that differed from historical evidence and practice. In implementation research, these changes are referred to as adaptations, and they occur constantly as evidence-based interventions are used in real-world practice. Adaptations can alter the delivered intervention, impacting patient and implementation outcomes.
RESEARCH QUESTION
OBJECTIVE
How have clinicians adapted prone positioning to COVID-19 ARDS, and what uncertainties remain regarding optimal proning use?
STUDY DESIGN AND METHODS
METHODS
We conducted a qualitative study using semi-structured interviews with ICU clinicians from two hospitals in Baltimore, MD, from February to July 2021. We interviewed physicians (MDs), registered nurses (RNs), respiratory therapists (RTs), advanced practice providers (APPs), and physical therapists (PTs) involved with proning mechanically ventilated patients with COVID-19 ARDS. We used thematic analysis of interviews to classify proning adaptations and clinician uncertainties about best practice for prone positioning.
RESULTS
RESULTS
Forty ICU clinicians (12 MDs, 4 APPs, 12 RNs, 7 RTs, and 5 PTs) were interviewed. Clinicians described several adaptations to the practice of prone positioning, including earlier proning initiation, extended duration of proning sessions, and less use of concomitant neuromuscular blockade. Clinicians expressed uncertainty regarding the optimal timing of initiation and duration of prone positioning. This uncertainty was viewed as a driver of practice variation. Although prescribers intended to use less deep sedation and paralysis in proned patients compared with historical evidence and practice, this raised concerns regarding patient comfort and safety amongst RNs and RTs.
INTERPRETATION
CONCLUSIONS
Prone positioning in patients with COVID-19 ARDS has been adapted from historically described practice. Understanding the impact of these adaptations on patient and implementation outcomes and addressing clinician uncertainties are priority areas for future research to optimize the use of prone positioning.
Identifiants
pubmed: 37810258
doi: 10.1016/j.chstcc.2023.100008
pmc: PMC10560392
mid: NIHMS1933150
pii:
doi:
Types de publication
Journal Article
Langues
eng
Subventions
Organisme : NHLBI NIH HHS
ID : F32 HL160039
Pays : United States
Organisme : NHLBI NIH HHS
ID : T32 HL007534
Pays : United States
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