Self-Proning in Non-Intubated
Patients with COVID-19: A Strategy
to Avoid Intubation
Jan Powers
Sue Chubinski
Michele Kadenko-Monirian
rone positioning has become
an accepted part of medical
treatment for mechanically
ventilated patients with acute respiratory distress syndrome (ARDS)
(Gattinoni et al., 2010; Guérin et al.,
2013; Mancebo et al., 2006; Taccone
et al., 2009). Most current literature
has focused on the critical care setting. Previous studies demonstrated
proning in ventilated critical care
patients improved oxygenation by
reducing lung ventilation/perfusion
mismatch and promoting recruitment of non-aerated dorsal lung
regions to optimize oxygenation
(Gattinoni et al., 2010; Guérin et al.,
2013; Mancebo et al., 2006; Marini,
2016; Taccone et al., 2009). To
achieve best results in critically ill
patients with ARDS, a pivotal study
by Guérin and coauthors (2013)
found proning should occur for at
least 16 hours/day.
Recently, large numbers of patients with coronavirus disease
(COVID-19) experiencing oxygenation compromise have been admitted to medical units. Conserving
the use of critical care beds and ven-
P
Patients with coronavirus disease (COVID-19) experiencing
oxygenation compromise often are admitted to medical units.
Assessment of the impact of self-proning on oxygenation in patients
with COVID-19 suggested early self-proning is a viable, nursedriven option to improve oxygenation, prevent transfer to intensive
care, and decrease need for invasive mechanical ventilation.
tilators also has been a concern.
Subsequently, nurses have looked
for interventions to decrease or prevent patient deterioration, preventing the need for intubation and
transfer to critical care. One intervention identified by nursing staff
was prone position for awake, nonintubated patients with COVID-19
in an attempt to improve oxygenation and prevent intubation.
Purpose
The purpose of this study was to
evaluate the impact of self-proning
for awake, non-intubated patients
with or suspected to have COVID-
19 on medical units. Patients were
encouraged to self-prone twice a
day for at least 30 minutes, but up
to 2 hours.
Review of the Literature
A literature search was performed
in Ovid MEDLINE for 2015-2020
using the search terms prone position, proning, and prone. These terms
were combined with awake, self,
conscious, or non-intubated; 53
unique articles were identified with
17 relevant for this study. A search
also was completed in CINAHL
(EBSCO) but yielded no additional
articles. Evidence is lacking for the
Jan Powers, PhD, RN, CCNS, CCRN, NE-BC, FCCM, is Director for Nursing Research and
Professional Practice, Parkview Health, Fort Wayne, IN.
Sue Chubinski, PhD, RN, NPD-BC, CMSRN®, is Educator, Nursing Education and Clinical
Excellence, Parkview Health, Fort Wayne, IN.
Instructions for
Contact Hours
MSN J2105
Nursing Continuing Professional
Development (NCPD) contact hours can
be earned for completing the evaluation
associated with this article. Instructions
are available at amsn.org/journalNCPD
Deadline for submission:
April 30, 2023
1.3 contact hours
Stephani Schultz
Christina Lung
Tammy Carman
Michele Kadenko-Monirian, MS, RN, AGCNS-BC, ACCNS-AG, CCRN, CNRN, is Clinical
Nurse Specialist, Parkview Health, Fort Wayne, IN.
Stephani Schultz, BSN, RN, CMSRN®, is Educator, Nursing Education and Clinical
Excellence, Parkview Health, Fort Wayne, IN.
Christina Lung, MSN, RN, CMSRN®, NE-BC, is Nursing Services Manager, Parkview Regional
Medical Center, Fort Wayne, IN.
Tammy Carman, AD, RN, is Clinical Nurse, Parkview Randallia Hospital, Fort Wayne, IN.
Acknowledgment: Authors acknowledge all clinical nurses on the COVID-19-designated medical units who tirelessly assure patients receive the best possible evidence-based care.
March-April 2021 • Vol. 30/No. 2
77
Background
Prone positioning improves oxygenation in patients experiencing respiratory distress. It is used to decrease mortality in mechanically ventilated
patients diagnosed with acute respiratory distress syndrome. However,
very little evidence has addressed use of prone positioning in non-intubated patients.
Aims
Assess the impact of early self-proning on oxygenation in patients who
had or were suspected of having coronavirus disease (COVID-19). The
goal was to improve oxygenation to avoid escalation to the intensive care
unit (ICU) and the need for invasive mechanical ventilation.
Methods
This descriptive study consisted of a patient cohort from medical units in
two hospitals. Data collected were limited to medical record reviews.
Identified patients were able to reposition themselves.
Results
This study enrolled 46 patients who self-proned a total of 180 times (average 4 times per patient). Patients experienced an increase in oxygenation
97% of the time.
Limitations and Implications
Only patients with the ability to self-prone were included. This was an
observational study with no comparison group. Self-proning of awake,
non-intubated patients is a nurse-driven practice that may lead to
improved patient outcomes.
Conclusion
In this study, early self-proning was identified as a viable option to
improve oxygenation, prevent transfer to ICU, and decrease the need for
invasive mechanical ventilation.
flow nasal cannula (HFNC) with
prone patients, HFNC in patients
not prone, noninvasive ventilation
(NIV) prone, and NIV without
prone positioning. The primary outcome was a decreased rate of intubation. Patients receiving oxygen by
HFNC with prone positioning had a
significantly greater improvement
in oxygenation (p=0.043). The application of prone positioning with
HFNC was well tolerated and efficacious. Other researchers also identified feasibility of early prone positioning with similar improvements
in oxygenation, avoidance of intubation, improved survival, and
reduced patient transfer to ICU
(Caputo et al., 2020; Dong et al.,
2020; Elharrar et al., 2020; PérezNieto et al., 2020; Sartini et al.,
2020).
Despite low-quality published
reports with small samples, most
published studies demonstrated
improvements in oxygenation with
prone positioning in awake patients. Based on the limited evidence, some support exists for
prone positioning in non-ICU
patients. Additionally, the Intensive
Care Society released guidelines for
prone positioning of awake, nonintubated patients (Bamford et al.,
2020).
Ethics
application of prone positioning as
a nursing intervention outside the
intensive care unit (ICU).
Of the identified literature in the
search, four articles were procedural
reviews of mechanism of action or
commentary. Multiple publications
consisted of letters reporting small
case series (Pérez-Nieto et al., 2020;
Sartini et al., 2020; Sun et al., 2020;
Thompson et al., 2020; Xu et al.,
2020). Eight additional papers presented retrospective or prospective
case series or cohort studies (Caputo
et al., 2020; Despres et al., 2020;
Ding et al., 2020; Dong et al., 2020;
Elharrar et al., 2020; GolestaniEraghi & Mahmoodpoor, 2020; Paul
et al., 2020; Scaravilli et al., 2015).
Before 2019, only one study was
completed on awake proning in
patients without COVID-19. The
78
study included a patient population
with mixed diagnoses. In a retrospective chart review of 15 nonintubated patients with hypoxemic
respiratory failure treated with
prone positioning, Scaravelli and
colleagues (2015) found prone positioning to be feasible and to
improve oxygenation. Other published studies on awake prone positioning as a treatment modality
with patients with COVID-19 are
limited by small samples.
A prospective observational cohort study in two teaching hospitals
enrolled 20 non-intubated patients
with moderate-to-severe ARDS who
were placed in the prone position
(Ding et al., 2020). Blood gas analysis was used to evaluate oxygenation
with four treatment modalities. The
four methods included use of high-
The study was submitted to the
hospital’s Institutional Review
Board and, due to low-risk for human subjects, was deemed exempt.
A waiver of informed consent also
was granted.
Sample Selection
Study participants were admitted
to one of four designated COVID-19
medical units at two hospitals
(regional medical center, high-capacity community hospital) which are
part of the same hospital system.
Non-intubated patients who could
turn themselves in the prone position were included. Patients were
excluded if they were under age 18,
pregnant, or mechanically ventilated in an ICU during the current
hospitalization.
March-April 2021 • Vol. 30/No. 2
Self-Proning in Non-Intubated Patients with COVID-19: A Strategy to Avoid Intubation
FIGURE 1.
Awake Prone Algorithm and Procedure
Patient not intubated
receiving supplemental
oxygen
Always continue
program on PUM
protocol as able
Patient alert,
awake, cooperative,
and able to
move self
Patient on
2-6L/O2
Yes
Explain procedure and
assist patient in prone
position per nursing
protocol
Follow Procedure Below for Placing Patient in Prone Position
Procedure for Patient Preparation Prior to Positioning Prone
1. Assemble supplies before entering room.
2. Follow appropriate precautions.
3. Explain to patient the purpose of prone position and planned
length of time that patient will be prone.
Goal: Minimum 30 minutes to maximum 2 hours BID
4. Verify patient has not eaten within the last 30 minutes.
5. Assess patient for actual or potential skin breakdown; pad with
Mepilex® (bilateral shoulders, chest iliac crest, knees).
6. Evaluate patient’s ability to turn head side to side (in prone
position, patient will be asked to turn head to best ROM side).
7. Remove fitted sheet; place flat sheet under patient’s shoulders
and Covidien pad at hips.
8. Obtain, document vital signs, including SpO2. If on telemetry,
remove EKG electrodes from front and place on back.
9. Remove stat lock from Foley; verify securement of feeding tube,
chest tube(s), and IV (if applicable).
10. Correctly position all tubes, taking into account the direction of the
turn (tubes in the lower torso aligned with either leg and extended
off the bed). Adjust IV pump position close to head of bed; verify
tubing has generous length for the turn.
Procedure of Manual Pronation
1. Verify position of all tubes, taking into
account the direction of the tubes.
2. Instruct patient to raise affected arm with IV
overhead.
3. Have patient roll over to prone position;
adjust gown-tubing.
4. Place patient in swimmer’s pose (one side
slightly off bed, adjust with pillows and
position to avoid traction on the brachial
plexus and lift diaphragm off bed. Assist
patient to best position of comfort.
5. Place patient on continuous SpO2
monitoring.
6. Replace EKG leads on telemetry patients.
7. Assess patient’s response, noting if patient
is having any respiratory distress. If patient
not tolerating, assist patient to supine
position, HOB raised. Use two flat sheet
method if patient unable to turn supine.
Notify provider and document.
HOB = head of bed, IV = intravenous, PUM = persons under monitoring, ROM = range of motion
March-April 2021 • Vol. 30/No. 2
79
TABLE 1.
Self-Proning Algorithm and Criteria
Inclusion
Exclusion
Alert
Documented aspiration risk
Awake
Patient nauseated/vomiting
Cooperative
Tracheostomy/laryngectomy
>30 minutes from last meal
Severe reflux
Able to reposition independently from supine to prone and
vice versa
Continuous gastric tube feedings
Hemodynamically stable:
Combative
HR 50-120
Restraints
SBP 90-180
Morbid obesity
MAP ≥65
Pregnancy ≥ second trimester
No new arrhythmia on EKG
Unstable spinal cord
Limited neck ROM
Respiratory
RR <40
Specific surgical and/or trauma precautions per provider order
Special Considerations (clarify with provider)
Continuous j-feedings (low-no aspiration risk)
CPAP/BiPAP (may improve ventilation)
Skin breakdown
Recent pacemaker implantation (no arm movement on pacemaker side above shoulder x 4 weeks)
Recent surgeries to the chest (no proning ≤6 weeks post-CAB)
Recent surgical and/or trauma (especially facial, thoracic, cervical and/or spinal, abdominal)
CAB = coronary artery bypass, CPAP/BiPAP = continuous positive airway pressure/bilevel positive airway pressure, HR = heart
rate, MAP = mean arterial pressure, ROM = range of motion, RR = respiratory rate, SBP = systolic blood pressure
Design and Method
This retrospective descriptive
study evaluated the impact of a
nurse-driven protocol for self-prone
positioning. The main outcome of
interest was oxygenation. Other
outcome variables included need
for ICU admission, need for intubation/mechanical ventilation, and
length of stay.
Given the low risk versus high
potential for improvement, a small
group of clinical nurses, clinical
nurse specialists (CNSs), educators,
and medical staff at the study institution developed a protocol for selfproning. A simple algorithm was
developed to identify patients who
could be proned safely while awake
(see Figure 1). Instructions were
written on how to prone a patient
and monitor after proning. The protocol was approved through the
site’s COVID Incident Command
Center (ICC), which was estab80
lished early in the pandemic to help
clinical staff remain current on rapidly changing procedures (see Table
1). As part of the ICC structure, a
COVID Commander role was developed and filled by a charge nurse
from the primary acute care unit
housing affected patients.
All nurses and patient care technicians on medical units admitting
patients with COVID-19 were instructed on inclusion criteria for
implementation and the process for
self-proning. Further distribution of
the protocol focused on charge
nurses, who then introduced the
procedure to clinical staff at daily
shift huddles. Informal demonstrations of positioning and scripted
encouragement to patients were
reviewed with staff. The information was reinforced by email and
handouts posted at the nurses’ stations and in staff bathrooms. In
addition, computer-based educa-
tion modules were assigned to all
nursing staff. Educators and CNSs
provided one-on-one just-in-time
education on all shifts, including
weekends. Ongoing bedside reinforcement and follow up were provided by charge nurses, educators,
CNSs, managers, and COVID Commander. Clinical nurses were very
receptive and quickly became advocates of the self-proning practice.
Before the study, patient positioning fields were added to the electronic health record to document selfproning. For data collection and
study inclusion, a report was built to
identify any patient who had documentation turned self-prone to identify patients for inclusion. Patient
charts were reviewed based on inclusion criteria. The study was conducted April 1-May 31, 2020.
Data were collected on all patients who had at least one episode
of self-proning and were not intu-
March-April 2021 • Vol. 30/No. 2
Self-Proning in Non-Intubated Patients with COVID-19: A Strategy to Avoid Intubation
bated. Few or no arterial blood gases
were available for the sample. As a
result, the key indicator for oxygenation was oxygen saturation
(SpO2) using pulse oximetry.
Information on patient age, oxygenation support, date/time of selfproning, length of prone episode,
and length of stay was collected.
Patient transfer to the ICU or intubation also was documented.
Findings
During the data collection period, 46 participants had 180 selfproning episodes. Average prone
episodes per patient was four (range
1-42), with average time in the
prone position 136 minutes (range
20-360). Patients’ average age was
57 (range 26-100). Thirty participants had confirmed COVID-19
and 16 were presumed to have
COVID-19. However, none of the
suspected cases had positive results
at further evaluation.
The average SpO2 for participants
before prone positioning was 93%
(84%-100%), and the average after
returning supine was 96% (90%100%). Patients experienced an
increase in SpO2 with prone position in 175 (97%) episodes. Participants who did not experience an
increase in SpO2 or had oxygenation that remained the same or
slightly decreased, represented 1%2%. Only five episodes (3%) of selfproning required an increase in
oxygen delivery. No complications
or adverse events were documented
during any self-prone episode.
Of 46 participants, three (6.5%)
were transferred to ICU but only
one required intubation and
mechanical ventilation. The average hospital length of stay was 7.1
days (range 2-14). Almost all participants were discharged to home
(n=41; 89.1%); only 4 (8.7%) went
to an extended care or rehabilitation facility. One older patient was
transitioned to palliative care at the
family’s request and expired.
Discussion
This study is one of the largest
cohorts published to date and the
only one implemented by nurses.
Results of this study demonstrated
positive outcomes with improved
oxygenation for non-intubated, selfproning medical patients. Nurses
initiated this protocol with interprofessional collaboration for patients
with or suspected of having COVID19. The interprofessional collaboration created an energized atmosphere on the units as successes were
shared and celebrated. Self-proning
may prevent deterioration, and conserve use of ICU beds and ventilators. The process was feasible, safe,
and required no additional equipment for independent self-proning.
Findings demonstrated higher
rates of improved oxygenation
(97%) after self-proning compared
to other studies reporting 13%-20%
improvement (Elharrar et al., 2020;
Scaravelli et al., 2015). However,
this study differed from prior
research in that arterial blood gas
results were not available, so SpO2
was used to determine outcome
(Ding et al., 2020; Dong et al., 2020;
Scaravilli et al., 2015). Other studies
also consistently reported improved
avoidance of intubation; in the current study, only one (2%) patient
subsequently required intubation.
This is a notable finding compared
to other studies with higher reported intubation rates. In studies by
Pérez-Nieto and coauthors (2020)
and Ding and colleagues (2020),
intubation rates were cited as 33%
and 45% respectively. Data from the
current study are similar to the
report by Sun (2020), who also
found notable improvements in
oxygenation.
Most participants in this study
were discharged to home (89%).
Some were discharged to rehabilitation or skilled nursing facilities
(8.7%). The death of a centenarian
patient resulted in this study’s 2%
mortality compared to 5%-20%
mortality in previously published
studies (Ding et al., 2020; PérezNieto et al., 2020; Scaravilli et al.,
2015). This one death in the current
study resulted from a change to a
palliative care focus for this patient.
Duration of prone time varied in
this study, which is similar to other
studies (range 30 minutes-12 hours,
March-April 2021 • Vol. 30/No. 2
mean 2.5 hours). Frequency of
proning in previous studies ranged
from twice a day with variable duration times based on patient’s ability
to tolerate prone positioning (Ding
et al., 2020; Dong et al., 2020;
Elharrar et al., 2020). Results of this
study are consistent with other
studies in finding self-proning safe
and effective for patients with suspected or positive COVID-19.
Limitations
Because there are limited reported data on self-proning in a nonICU setting, an initial descriptive
study design was an appropriate
beginning approach. However,
there are limitations in drawing
conclusions, relationships, or inferences. In addition, retrieving data
from the electronic medical record
was dependent on consistency in
charting and accurate application of
charting choices in the patient position section. A limited time was
selected for study, resulting in a
small convenience sample from two
sites that may not be representative.
However, this study recruited a
greater number of participants than
prior research and provides preliminary data for designing the next
study. Finally, there was no comparison group to determine if outcomes improved as a result of proning interventions.
Recommendations for
Future Research
Future studies are needed to
determine optimal frequency and
duration of proning within a 24hour period. Future research also
should include a control group and
comparison (pre/post) to delineate
the benefits of self-proning in these
lower-risk patients. A longer collection period, with data collected
prospectively during proning,
should be considered to reduce
challenges associated with retrospective data collection. Identification of potential confounders, such
as mobility progression, medications, or other respiratory therapies,
should be considered. Expanding
application of this preventive nurs81
ing intervention to patients in
the Emergency Department with
COVID-19, community patients
positive for COVID-19 recovering at
home, and patients with other diagnoses (e.g., pneumonia) also should
be explored. Expanding awake
proning to include adults and children with acute and chronic respiratory disease should be considered,
as the intervention may prove useful. Future research also should
explore nurses’ experience through
a qualitative approach.
Nursing Implications
Patient positioning is within the
autonomous scope of nursing practice; self-proning also can be completed independently by the patient. The self-proning procedure is
low-risk and can be implemented
easily on any medical unit with no
additional resources. Nurses should
be empowered and encouraged to
implement this practice for their
patients. This study suggested the
use of nurse-driven proning protocols can help prevent further respiratory deterioration in medical
patients.
Throughout the global pandemic, nurses were able to ask clinical
practice questions, review available
evidence, and implement nurse-driven interventions to prevent and
improve patient outcomes. During
this study, nurses reported excitement over having a powerful intervention they could initiate independently that often resulted in
rapid improvement in patients’
oxygenation. This intervention also
decreased patients’ anxiety about
their difficulty in breathing. Before
this study, medical nurses viewed
proning as a physician-driven ICU
intervention that required a team to
implement for critically ill patients.
Medical nurses quickly adopted the
practice as a safe and effective tool
to improve their patients’ respiratory condition, preventing escalation
of care and conserving critical care
beds within the facility. With more
experience, nurses may be able to
recruit participants as they report
positive outcomes.
With the initial prone session,
nurses must be present to supervise
and guide the patient proning procedure to assure safety and establish
patients’ baseline response. Further
nursing assessment should focus on
how patients tolerate the position,
including monitoring oxygen saturation and vital signs. In this study,
some patients initially desaturated
and required time to adjust to the
position change. Recovery time was
dependent on patient condition.
Ongoing nursing assessments of
proning effectiveness may provide
data to improve proning practices.
Conclusion
Even though this observational
study had a small sample, benefits
were positive. No additional risk to
patients was identified. This study
confirmed use of nurse-driven
proning protocols can assist with
preventing further respiratory deterioration in medical patients. Additionally, nurses were able to use the
intervention of self-proning with
no additional resources. Nurses
empowered through evidencebased practice were able to provide
positive clinical outcomes for
patients during a pandemic.
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