As clinicians became more familiar with how to treat patients with COVID-19, hospitals across the U.S. began to report that patients who were prone, or laid on their stomachs rather than on their backs, were recovering better. The why is still unclear, but it is thought that lying prone may distribute oxygen throughout the body better and relieve pressure on the lungs.

“For patients who are mobile, we can just ask them to turn over,” says Liza Rebello, nurse manager, critical care. “But for a critical patient, someone who is sedated and has breathing tubes, there’s more involved than you might think.”

The action of proning, or flipping onto their stomachs, a critically ill patient and all their life-supporting equipment, isn’t anything new in an intensive care unit, adds Jussara Gama, nurse manager of Sibley’s intensive care unit. The process has been used for severe acute respiratory distress syndrome patients, and many hospital units have one or two beds to assist. Otherwise, it takes six to eight people to safely complete the action. What was new with COVID-19 was the potential for needing to prone many seriously ill patients in the unit all at the same time.

“Initially, around the country, people were thinking, ‘Well, we need more proning beds,’” Gama says. “But it was nurses in the units most heavily impacted who said, ‘No, we’ll find a way to flip them safely ourselves without the extra equipment.’”

Building on lessons learned from nurses in heavily hit areas like New York, Rebello and the critical care nurses at Sibley began practicing proning before patients ever arrived—by practicing on each other. Collaborating with intensivists, respiratory therapists and physical rehabilitation staff, the team used empty rooms and volunteered themselves as “patients” to be moved to a prone position. They used the practice sessions to create a standard checklist and knowledge base that covered everything a proning team needed to manage, from securing the airway to monitoring invasive lines to checking skin for injuries.  

Since then, the intensive care team has cared for many real patients, and just like every other aspect of managing COVID-19, continues to update and refine the standard checklist as they gain experience and identify even better ways to accomplish this heavy, complicated task. Today, they stand ready for whatever comes next in this public health emergency.