Hospital-Level Availability of Prone Positioning, 2019 vs 2021

Abstract

Rationale. Prone positioning (PP) of patients with moderate-severe acute respiratory distress syndrome (ARDS) is an evidence-based and guideline-recommended practice, but our 2019 survey found that fewer than half of Massachusetts ICUs could routinely offer PP. As studies have described rapid adoption of evidence- and nonevidence- based practices alike during COVID-19, we re-surveyed Massachusetts ICUs in 2021 to determine if institutional-level adoption of PP among intubated patients had changed during the COVID-19 pandemic;we additionally ascertained adoption of awake PP. Methods. In follow-up to our 2019 survey, we surveyed intensive care units (ICUs) at all acute-care hospitals in Massachusetts, June-October 2021. The survey asked: “Does your ICU have the ability to prone intubated patients?” (“Yes, routinely,” “Case-by-case,” or “No”). Follow-up questions inquired if ICUs had protocols/guidelines on intubated PP, trained nurses in intubated PP, and whether awake PP had been adopted. We collected descriptive hospital data (number of ICU and hospital beds, nonprofit status, teaching status, case-mix index) and tested for associations with chi-square tests. Results. Of the 57 acute care hospitals in Massachusetts with ICUs, 47 responded to the survey (82% response;compared to 54/60 [90%] in 2019;three hospitals surveyed in 2019 had closed ICUs in 2021). The number of hospitals able to routinely perform PP in intubated patients increased from 24 (44%) to 39 (83%);hospitals able to perform PP among intubated patients on a case-by-case basis or not at all decreased from 15 (28%) to 5 (11%) and 15 (28%) to 3 (6%), respectively (p<0.001) (Figure 1). ICUs with a protocol/guideline for intubated PP increased from 27 (50%) to 43 (92%) (p< 0.001);ICUs that had trained some or all nurses in intubated PP increased from 34 (63%) to 45 (96%) (p<0.001). In contrast to 2019, in 2021 there were no associations between availability of intubated PP and hospital/ICU bed number, teaching status, nonprofit status, or case-mix index. In 2021, 43 (92%) of Massachusetts ICUs had adopted awake PP, 19 of whom had not adopted routine PP of intubated patients in 2019, and 4 of whom had not adopted intubated PP in 2021. Conclusions. There was a significant increase in the proportion of Massachusetts ICUs that had adopted evidence-based, guideline-recommended PP in intubated patients by 2021. At the same time, almost all ICUs also adopted non-evidence-based PP in awake patients. Our results illustrate that factors other than available evidence play a large role in practice adoption.