EHC Critical Care/ED Edited 4/28/2020 Version: 4/28/2020v8

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EHC Critical Care/EDCOVID19 Self-Proning and Repositioning Protocol for Non-Ventilator Patients (ICU)Version: 4/28/2020v8Edited 4/28/2020Background: Patients with novel coronavirus pneumonia (NCP) can present with hypoxemiaand acute respiratory distress syndrome (ARDS). Proning is an evidence-based interventionrecommended for intubated patients with severe ARDS. Proning improves ventilation-perfusionmatching in the lung and increases the number of alveoli available to participate in gasexchange. Anecdotal evidence suggests that non-intubated patients with NCP may benefit fromself-proning.Purpose: To avoid intubation and improve oxygen saturation in COVID-19 patients and highrisk PUIs on high flow nasal cannula.Inclusion Criteria: (Must meet all criteria) Confirmed COVID-19 disease and High Risk PUIsHypoxemia requiring high flow nasal cannulaIncreasing high flow nasal cannula requirementAble to understand their situation and communicate and cooperate with procedureAble to independently repositionExclusion Criteria: (TF) Trauma: unstable cervical, thoracic, lumbar, pelvic, skull, or facial fracturesNeurologic: uncontrolled intracranial pressure, cerebral edema, frequentseizures, or altered mental statusHematologic: Active bleedingENT: raised intraocular pressure or recent ophthalmic surgery, facial trauma, or recentoral maxillofacial surgery in last 15 daysCardiac: severe hemodynamic instability, SBP less than 90mm Hg, unstable cardiacrhythms, ventricular assist device, intra-aortic balloon pump, sternotomy on presentadmission, open chest, new pacemaker in last 48 hoursPulmonary: hemoptysis, unstable airway, new tracheostomy 7 days or failure totolerate finger occlusion, bronchopleural fistula, lung transplantAbdomen: second or third trimester pregnancy, grossly distended abdomen, ischemicbowel, abdominal compartment syndrome, extensive inguinal or abdominal soft tissueinjuryMusculoskeletal: chest wall abnormalities, kyphoscoliosis, or advanced arthritisSkin: Acute burns on more than 20% body surfaceOther: inability to independently turnThe materials are intended solely for general educational and information purposes, are made available in the context of the public health emergency related to thecoronavirus (COVID-19) and have not been subject to review that typically would occur in a non-emergent situation. The materials do not constitute the provision ofmedical, legal or other professional advice. EMORY UNIVERSITY AND EMORY HEALTHCARE MAKE NO WARRANTIES, EXPRESS OR IMPLIED AS TO THEMATERIALS, INCLUDING, WITHOUT LIMITATION, COMPLIANCE WITH QUALITY, REGULATORY, ACCREDITATION OR STANDARDS OF CARE. EMORYEXPRESSLY DISCLAIMS ANY WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE.Copyright 2020, Emory University and Emory HealthcarePage 1 of 6

Self-proning protocol (SPP): Primary nurse will screen all NCP patients for self-proning eligibility once a shift. If apatient meets criteria, the primary nurse will notify the primary team for providerassessment. Primary team will assess the patient and determine the eligibility of patient for SPP andplace a communication order. Notify Respiratory Therapist (RT) once order is placed.Prior to Repositioning Perform anterior body wound care and dressing changes, as needed.Patients should consider using the rest room prior to start of therapyRelocate ECG electrodes to avoid placement over any potential pressure points, or causingdiscomfort.Empty ileostomy or colostomy drainage bags, as neededPlace draw sheet or pad under patient.Consider timing and size of last meal. If patient ate 75% of a meal, consider delaying proningfor 30 minutes to one hour.Engage side rails as safety mechanism or to assist with independent repositioningEnsure the bed brake is engagedEducate patient that they can readjust while in prone position to increase comfort.Gather supplies needed prior to entering the roomSupplieso Personal protective equipmento Pillow(s)o Foam or gel positioning devices, foam dressings, or rolled towels to protectpressure pointso Supplemental Oxygeno Sp02 monitoring equipmento Suction equipment set upo Extra ECG electrodeso Wound and ostomy care supplies, skin care supplieso Draw sheet or padRepositioningThe materials are intended solely for general educational and information purposes, are made available in the context of the public health emergency related to thecoronavirus (COVID-19) and have not been subject to review that typically would occur in a non-emergent situation. The materials do not constitute the provision ofmedical, legal or other professional advice. EMORY UNIVERSITY AND EMORY HEALTHCARE MAKE NO WARRANTIES, EXPRESS OR IMPLIED AS TO THEMATERIALS, INCLUDING, WITHOUT LIMITATION, COMPLIANCE WITH QUALITY, REGULATORY, ACCREDITATION OR STANDARDS OF CARE. EMORYEXPRESSLY DISCLAIMS ANY WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE.Copyright 2020, Emory University and Emory HealthcarePage 2 of 6

Instruct the patient to switch between the following positions listed below every 2hours. For each position change, be vigilant in monitoring patient vital signs andresponse to the intervention. Assess and document position change. If tolerated,prone position should be maintained for at least 1- 2 hours twice daily.a) Left lateral recumbentb) Right lateral recumbentc) Sitting upright 60-90 degreesd) Laying prone in bed (laying on the abdomen) Assess for oxygenation improvement with the position change. Document patientresponse as listed below. If oxygen saturation deteriorates within 15 mins, perform the following:o Try another positiono Ensure oxygen connected to wall and patient.o Increase oxygen flow rate.o Change patient position and consider return to supine position with HOB 30-60degrees.o Call primary team MD/APP and RT for consideration of intubation.o If patient rapidly deteriorates, follow the process for emergency response. Assist patient with repositioning into the prone position, support their arms, head, andchest with a pillow (swimmer’s position).Saunders, Elsevier Inc. 2014 Position tubing and lines to prevent kinking or obstructionPlace pillows under hips or legs, as needed, for comfortSpecial Considerations: Patient must have the call light within reach. Have patient’s phone or device within reach if patient requests. Utilize music or television as a distraction. Consider using reverse Trendelenburg bed position (helpful for patients with largeabdomens, prevention of aspiration, continuation of tube feedings)The materials are intended solely for general educational and information purposes, are made available in the context of the public health emergency related to thecoronavirus (COVID-19) and have not been subject to review that typically would occur in a non-emergent situation. The materials do not constitute the provision ofmedical, legal or other professional advice. EMORY UNIVERSITY AND EMORY HEALTHCARE MAKE NO WARRANTIES, EXPRESS OR IMPLIED AS TO THEMATERIALS, INCLUDING, WITHOUT LIMITATION, COMPLIANCE WITH QUALITY, REGULATORY, ACCREDITATION OR STANDARDS OF CARE. EMORYEXPRESSLY DISCLAIMS ANY WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE.Copyright 2020, Emory University and Emory HealthcarePage 3 of 6

Saunders, Elsevier Inc. 2014 Consider lateral position if patient is unable to tolerate prone position Maintain positions for 1-2 hours in each position as tolerated When not prone, consider sitting upright at 60-90 degrees Do not titrate down oxygen requirements while in prone position. May titrate up ifindicated according to oxygen saturations.Self-proning protocol termination criteria: Cardiac arrest AHA recommendations:“For Suspected or confirmed COVID-19 patients who are in proneposition without an advanced airway, attempt to place patient in thesupine position for continued resuscitation.” Respiratory rate greater than 30 breaths/minute with increased work of breathing oraccessory muscle use MAP 65 mmHg on maximum dose of norepinephrine of 0.05 ug/kg/min Heart rate 50 beats per minute or greater than 120 SpO2 90% or PaO2 55 mm Hg despite increasing FiO2 Patient inability to tolerate prone positionCompletion of therapy Patient can notify nursing staff and reposition out of prone position. Ensure tubing is not tangled. Change bed position out of the reverse Trendelenburg position if applicable. Complete VS as stated under monitoring. Instructions on how to properly use incentive spirometry q2 while awake per providerorders. Document education provided.Documentation Document the following in electronic medical record. If electronic medical record notavailable, utilize downtime form.The materials are intended solely for general educational and information purposes, are made available in the context of the public health emergency related to thecoronavirus (COVID-19) and have not been subject to review that typically would occur in a non-emergent situation. The materials do not constitute the provision ofmedical, legal or other professional advice. EMORY UNIVERSITY AND EMORY HEALTHCARE MAKE NO WARRANTIES, EXPRESS OR IMPLIED AS TO THEMATERIALS, INCLUDING, WITHOUT LIMITATION, COMPLIANCE WITH QUALITY, REGULATORY, ACCREDITATION OR STANDARDS OF CARE. EMORYEXPRESSLY DISCLAIMS ANY WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE.Copyright 2020, Emory University and Emory HealthcarePage 4 of 6

Primary nurse will ensure documentation of mobility, RASS, CAM-ICU, prior to eachtherapy. Document the following prior to repositioning, 15 minutes after each position change,hourly, and end of each position change:a. Vital signs (including BP, HR, RR, Sp02, oxygen device, L/min of supplemental 02).b. Range of motion.c. Patient’s response and tolerance under activity/mobility. End of each position change, documenta. Duration in activity section under medical record.b. New onset pain or paresthesia.c. Patient’s response to the intervention in progress note once a shift. Document date and time of notification to provider for any adverse effects to interventions.REFERENCES:1. Bamford, P., Bentley, A., Dean, J., Whitemore, D., Wilson-Baig, N. 2020. ICS Guidance forProne Positioning of the Conscious COVID Patient. Intensive Care Society, /2020-04-12-Guidance-for-conscious-proning.pdf2. Ding, L., Wang, L., Ma, W. et al. Efficacy and safety of early prone positioning combined withHFNC or NIV in moderate to severe ARDS: a multi-center prospective cohort study. Crit Care24, 28 (2020). https://doi.org/10.1186/s13054-020-2738-53. Farkas, Josh. Proning the non-intubated patient. Published on September 21, 2016.Emergency Department Critical Care (EMCrit). 2016. Retrieved d/ on April 7th, 20204. Feltracco P, Serra E, Barbieri S, et al. Noninvasive high-frequency percussive ventilation in theprone position after lung transplantation. Transplantation proceedings. 2012;44(7):2016-2021.5. Feltracco P, Serra E, Barbieri S, et al. Non-invasive ventilation in prone position for refractoryhypoxemia after bilateral lung transplantation. Clin Transplant. 2009;23(5):748-750.6. Gattinoni L, Taccone P, Carlesso E, Marini JJ. Prone position in acute respiratory distresssyndrome. Rationale, indications, and limits. American journal of respiratory and critical caremedicine. 2013;188(11):1286-1293.7. Guérin, Claude Ventilation in the prone position in patients with acute lung injury/acuterespiratory distress syndrome, Current Opinion in Critical Care: February 2006 - Volume 12 Issue 1 - p 50-54 doi: 10.1097/01.ccx.0000198999.11770.588. Guérin C, Reignier J, Richard JC, et al. Prone positioning in severe acute respiratory distresssyndrome. The New England journal of medicine. 2013;368(23):2159-2168.The materials are intended solely for general educational and information purposes, are made available in the context of the public health emergency related to thecoronavirus (COVID-19) and have not been subject to review that typically would occur in a non-emergent situation. The materials do not constitute the provision ofmedical, legal or other professional advice. EMORY UNIVERSITY AND EMORY HEALTHCARE MAKE NO WARRANTIES, EXPRESS OR IMPLIED AS TO THEMATERIALS, INCLUDING, WITHOUT LIMITATION, COMPLIANCE WITH QUALITY, REGULATORY, ACCREDITATION OR STANDARDS OF CARE. EMORYEXPRESSLY DISCLAIMS ANY WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE.Copyright 2020, Emory University and Emory HealthcarePage 5 of 6

9. Pérez-Nieto, O.R., Guerrero-Gutiérrez, M.A., Deloya-Tomas, E. et al. Prone positioningcombined with high-flow nasal cannula in severe noninfectious ARDS. Crit Care 24, 114(2020). https://doi.org/10.1186/s13054-020-2821-y10. Riedel T, Richards T, Schibler A. The value of electrical impedance tomography in assessingthe effect of body position and positive airway pressures on regional lung ventilation inspontaneously breathing subjects. Intensive care medicine. 2005;31(11):1522-1528.11. Riera J, Pérez P, Cortés J, Roca O, Masclans JR, Rello J. Effect of High-Flow Nasal Cannulaand Body Position on End-Expiratory Lung Volume: A Cohort Study Using ElectricalImpedance Tomography. Respiratory care. 2013;58(4):589-596.12. Scaravilli V, Grasselli G, Castagna L, et al. Prone positioning improves oxygenation inspontaneously breathing nonintubated patients with hypoxemic acute respiratory failure: Aretrospective study. J Crit Care. c.2015.07.00813. Scott Weingart. COVID19 – Awake Pronation – A guest write-up by David Gordon, MD. EMCritBlog. Published on April 6, 2020. Emergency Department (Embeds). 2020. COVID-19 (AwakeSelf-Proning). Retrieved from https://www.embeds.co.uk/2020/04/08/ covid-19-awake-selfproning/ on April 8th, 202014. Sun, Q., Qiu, H., Huang, M. et al. Lower mortality of COVID-19 by early recognition andintervention: experience from Jiangsu Province. Ann. Intensive Care 10, 33 5. Valter C, Christensen AM, Tollund C, Schønemann NK. Response to the prone position inspontaneously breathing patients with hypoxemic respiratory failure. Acta Anaesthesiol Scand.2003;47(4):416-418. . Abroug, F., Ouanes-Besbes, L., Elatrous, S. et al. The effect of prone positioning in acuterespiratory distress syndrome or acute lung injury: a meta-analysis. Areas of uncertainty andrecommendations for research. Intensive Care Med 34, 1002 e materials are intended solely for general educational and information purposes, are made available in the context of the public health emergency related to thecoronavirus (COVID-19) and have not been subject to review that typically would occur in a non-emergent situation. The materials do not constitute the provision ofmedical, legal or other professional advice. EMORY UNIVERSITY AND EMORY HEALTHCARE MAKE NO WARRANTIES, EXPRESS OR IMPLIED AS TO THEMATERIALS, INCLUDING, WITHOUT LIMITATION, COMPLIANCE WITH QUALITY, REGULATORY, ACCREDITATION OR STANDARDS OF CARE. EMORYEXPRESSLY DISCLAIMS ANY WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE.Copyright 2020, Emory University and Emory HealthcarePage 6 of 6

COVID19 Self-Proning and Repositioning Protocol for Non-Ventilator Patients (ICU) Edited 4/28/2020 Version: 4/28/2020v8 Background: Patients with novel coronavirus pneumonia (NCP) can present with hypoxemia and acute respiratory distress syndrome (ARDS). Proning is an evidence-based intervention recommended for intubated patients with severe ARDS.