A Mixed Methods Evaluation of the Implementation of Prone Positioning in COVID-19 ARDS

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Project Summary/Abstract Despite decades of research, mortality from the acute respiratory distress syndrome (ARDS) remains high. Recently, ARDS has received increased attention during the coronavirus disease 19 (COVID-19) pandemic, as the majority of patients with COVID-19 requiring intensive care unit (ICU) admission develop ARDS. The resulting increases in patients with this syndrome has highlighted the need to ensure broad and sustained implementation of existing evidence-based interventions (EBIs) for ARDS. One such lifesaving ARDS intervention is prone positioning. While prone position is supported by randomized controlled trials and recommended in ARDS guidelines, historically it has been underutilized. As healthcare delivery has changed rapidly and dramatically during COVID-19, the critical care practice of prone positioning has also evolved. Prior to the pandemic, prone positioning was utilized in 10-15% of appropriate patients, and now during the pandemic is being used in 40-80% of patients depending on the setting. Understanding the mechanisms behind this rapid practice change is key to more broadly implementing prone positioning and other EBIs for ARDS care during the COVID-19 pandemic and beyond. The main objective of this project is to evaluate the factors influencing the increased use of prone positioning during COVID-19. We hypothesize that factors related to organizational changes (e.g., proning teams, proning protocols and staffing levels), provider characteristics (e.g., belief in efficacy, recognition of ARDS) and patient factors (e.g., higher disease severity) led to the marked increases in use of prone positioning during the COVID-19 pandemic. We will use implementation science tools including the Consolidated Framework for Implementation Research (CFIR) to provide a comprehensive mixed methods evaluation of prone positioning during the pandemic. Using a retrospective cohort study of mechanically ventilated patients with COVID-19 ARDS, we will define the frequency of prone positioning in different settings within our health system and evaluate the patient and ICU factors that predict proning use. Using qualitative methods, we will conduct semi- structured interviews with ICU team members to explore the facilitators of and barriers to prone positioning in COVID-19. Finally, we will survey ICU team members across our health system to evaluate the CFIR implementation determinants associated with the implementation outcomes of acceptability, appropriateness, fidelity and sustainability of prone positioning. This work has the potential to inform a broader and sustained implementation of prone positioning as well as increase our understanding of how to rapidly translate therapeutic advances to the bedside of critically ill patients. This research will provide the applicant with the necessary training to develop the skills needed to pursue a career as an independently funded researcher working in the field of implementation science and critical care.