Many COVID-19 patients admitted for critical care may be periodically placed on their stomachs, a potentially life-saving course of treatment called “proning.”
As shown by decades of proning patients with acute respiratory distress syndrome (ARDS), the position improves oxygen flow as gravity animates lung secretions, improving ventilator performance and blood oxygenation.
“We’ve used it extensively during the pandemic with COVID-19, as it increases the likelihood of survival in these patients,” said Kelley Knapek, MPH, BSN, RN, CIC, an infection preventionist at Good Samaritan Medical Center in Lafayette, CO. “The risk of death in these patients, if initiated early, was decreased compared to patients who are not put in the prone position.”
But proning makes intravenous (IV) lines difficult to access, drains patient oral secretions onto line sites, and increases the risk of some healthcare-associated infections (HAIs). Knapek described how she and colleagues overcame these challenges at the 2022 conference of the Association for Professionals in Infection Control and Epidemiology (APIC).
“There are many considerations for the patient when placing them in the prone position,” she explained. “We worry about endotracheal tube dislodgment, hemodynamic compromise, disconnecting lines, eye injuries, [and] pressure injuries, as well as maintaining access to chest central lines, arterial lines, and urinary catheters. Your external catheters aren’t going to work in patients like this. You need more sedation and more paralytics.”
Proning patients typically is done using manual techniques, requiring multiple healthcare workers at the bedside who are trained in the movement procedure.
“Gathering trained staff in an ICU (intensive care unit) is very challenging and these manual techniques include pushing, pulling, and lifting the patient,” Knapek said. “It also places more staff at risk of exposure.”
The primary HAIs that increased in proned patients at Good Samaritan were catheter-associated urinary tract infections (CAUTIs) and central line-associated bloodstream infections (CLABSIs).
“When we looked into our CAUTIs, we saw that there were frequent fluctuations between constipation and diarrhea,” she said. “We saw that Foley [catheters] were in for a longer period of time, and we saw that peri care [cleaning genitals and anus] was documented, but nurses reporting it were saying that they couldn’t do it very well.”
Looking at the CLABSIs, the infection preventionist saw an increased frequency of internal jugular (IJ) line changes because they were wet. “That’s anecdotal at this point, but the lines needed to stay in longer —without an option for midlines or peripheral IVs,” she said. “We needed to start looking for new solutions in HAI prevention. Our bundles were being followed but they just weren’t enough.”
Interventions
Knapek and colleagues then formed a team, seeking input from all manner of clinical and ancillary departments, including pharmacy and vascular access.
“In these patients, there’s a need for heavy sedation, which leads to increased narcotics use,” she said. “That leads to constipation. If we give them a bunch of pro-motility agents, they get diarrhea. Gravity pulls that diarrhea down, it frequently contaminates the Foley [catheter] and we get a CAUTI. Even with this diarrhea, there’s not enough liquid for a rectal tube, so we can’t really solve the problem that way. We really wanted to stop the problem right before the constipation started. Nursing identified the problem and pharmacy identified a solution.”
The intervention included adding an osmotic laxative to the management of the ventilated patient order set. “We preselected it to encourage use and we made it scheduled so we could prevent constipation before it became a problem,” she said.
The team also agreed to switch to silver-impregnated Foley catheters for ICU patents, which have been shown to reduce CAUTIs because of the inherent antimicrobial properties of the metal.
“It was a one-on-one replacement, so we didn’t need any additional education,” Knapek said. “We specifically chose to use a little bit of a higher-cost intervention because we didn’t want to put additional work on our nurses, who were already stretched thin.”
With the CAUTI problem addressed, the team looked at reducing CLABSIs.
“When infection prevention looked into these cases, we saw that most of our CLABSIs were in patients who were proned and had IJ lines,” she said. “All had bacteria that commonly colonize the mouth and all of them had documented increased frequency of central line dressing changes.”
Nursing reported that IJ lines are hard to maintain and keep dry in prone patients. Knapek did a chart review and found that IJ dressings were changed, on average, every three days, whereas peripherally inserted central catheter (PICC) lines were changed about every six days.
“Our standard is seven days or when wet or soiled, so you see that’s a big difference between our standard seven days and what we were seeing for IJs,” she said. “We saw that oral secretions were just challenging to manage, so we decided to avoid our IJ lines altogether.”
Physicians, nursing, and the vascular access team all came together to develop a decision tree to avoid IJs in these patients. A PICC line was used in some cases as an alternative.
“Our new decision tree was this — if a COVID-positive patient or patient under investigation needed a central line, we first decided was this urgent or not urgent,” she said. “If it wasn’t urgent, we’d place an order for a vascular access team to insert this when possible. If it was urgent, we had to ask the vascular access team if they could respond quickly. We do have them here seven days a week with extended hours, so a lot of times they could come and insert that PICC line right away.”
If not, clinicians in the ICU would insert an IJ line, using a sticky dressing that was more resistant to secretions and soilage. “We would replace that with a PICC line within 48 hours,” she said. We wanted to remove any of our central lines as soon as possible.”
With these and other interventions, Knapek and colleagues reduced the CLABSI rate by 15% and the CAUTI rate by 22%.
