Improving Prone Positioning for Severe Acute Respiratory Distress Syndrome during the COVID-19 Pandemic. An Implementation-Mapping Approach.

Rationale: Prone positioning reduces mortality in patients with severe acute respiratory distress syndrome (ARDS), a feature of severe coronavirus disease 2019 (COVID-19). Despite this, most patients with ARDS do not receive this lifesaving therapy.Objectives: To identify determinants of prone-positioning use, to develop specific implementation strategies, and to incorporate strategies into an overarching response to the COVID-19 crisis.Methods: We used an implementation-mapping approach guided by implementation-science frameworks. We conducted semistructured interviews with 30 intensive care unit (ICU) clinicians who staffed 12 ICUs within the Penn Medicine Health System and the University of Michigan Medical Center. We performed thematic analysis using the Consolidated Framework for Implementation Research. We then conducted three focus groups with a task force of ICU leaders to develop an implementation menu, using the Expert Recommendations for Implementing Change framework. The implementation strategies were adapted as part of the Penn Medicine COVID-19 pandemic response.Results: We identified five broad themes of determinants of prone positioning, including knowledge, resources, alternative therapies, team culture, and patient factors, which collectively spanned all five Consolidated Framework for Implementation Research domains. The task force developed five specific implementation strategies, including educational outreach, learning collaborative, clinical protocol, prone-positioning team, and automated alerting, elements of which were rapidly implemented at Penn Medicine.Conclusions: We identified five broad themes of determinants of evidence-based use of prone positioning for severe ARDS and several specific strategies to address these themes. These strategies may be feasible for rapid implementation to increase use of prone positioning for severe ARDS with COVID-19.

Nurses' Perceptions of In-Hospital Versus Telephone Availability of an Intensivist at Night in an Intensive Care Unit.

BACKGROUND: Evidence suggests that in-person management by nighttime intensivists does not change patients' mortality rates in high-intensity intensive care units. OBJECTIVE: To better understand domains affected by nighttime intensivist staffing not previously measured. METHODS: Semistructured interviews of 13 night-shift nurses in an academic medical intensive care unit to elicit perceptions of nighttime staffing with attending intensivists versus residents with attending intensivists on call remotely. Interviews were done during the final months of a randomized trial comparing the same staffing models. Qualitative analysis was done by using a grounded theory approach. Three investigators independently reviewed interview transcripts to identify key domains. RESULTS: In addition to 5 themes probed during interviews (efficiency, communication, job place comfort, quality of patient care, and procedures), participants identified 3 other themes (supervision, systems issues, and experience). Most participants thought that nighttime intensivists improved clinical care, procedures, efficiency, communication, and job place comfort. Two thought that the quality of patient care, efficiency, or communication was the same with both arrangements. Three reported no effect on their job place comfort. Twelve mentioned improved supervision of trainees, and all thought systems issues improved. CONCLUSIONS: Nurses perceive improvements with nighttime intensivists in several domains. Future work is needed to determine whether such perceptions translate into improved outcomes for staff or patients.