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.