Implementing Automated Prone Ventilation for Acute Respiratory Distress Syndrome via Simulation-Based Training

Prone position ventilation (PPV) improves survival in patients with severe acute respiratory distress syndrome (ARDS)^1–4  and is strongly recommended by consensus guidelines.^5,6  Nonetheless, PPV remains underused in intensive care units (ICUs) around the world.^7,8  Possible barriers to implementation include lack of perceived benefit, lack of preparation and protocols, and concern for patient safety and potential complications.^9–11 

The use of simulation-based training has grown in health care and has numerous benefits, including improved skill retention, interprofessional collaboration, and patient outcomes.^12,13  Simulation-based training is increasingly employed in the ICU and has been well received by critical care providers.¹⁴  Studies in critical care have used high-fidelity simulation-based training and interprofessional debriefings to identify unrecognized systems errors threatening patient safety, also known as latent safety threats (LSTs).^15,16 

Prone position ventilation is a complex procedure requiring collaboration among physicians, registered nurses, and respiratory therapists.¹⁷  The use of inter-professional simulation-based training before implementation of PPV has not been previously reported, with most studies focusing on training nurses.^18–20  Therefore, we sought to determine the impact of an interprofessional simulation-based training program on the perception of benefit and comfort with PPV among registered nurses, physicians, and respiratory therapists and to see whether such a program can help identify LSTs before implementation.

This prospective observational quality improvement study was conducted in the academic medical ICU (MICU) at Mount Sinai Hospital in New York City, which had no previous experience with PPV. The study was exempted by the institutional review board (IRB number 17-02608) and approved by the Mount Sinai Hospital Department of Medicine Quality Improvement Committee in July 2018.

After a review of ARDS guidelines⁵  and estimated prevalence of severe ARDS in the hospital’s MICU, the ICU leadership decided to implement PPV. An interprofessional PPV implementation task force was assembled. This group consisted of the director of the MICU (S.O.A.), the senior director of nursing (C.M.W.), the MICU nursing manager, the lead and senior authors of this article (A.D.P., S.J.H.), and the directors of respiratory therapy (G.G.O.), nursing education, wound care nursing (M.V.S.), physical therapy, and nutrition. At the initial meeting, it was decided to proceed with an automated PPV program. Although the vendor (Arjo Inc) provided the didactic session and a demonstration of routine placement (see “Training Initiative”), we helped tailor the content to topics identified in our needs assessment. The vendor had no role in the development of the simulations, debriefings, PPV protocol, or checklists. The vendor also had no input into the design of our study, data collection, data analysis, or preparation of the manuscript.

Over the course of 4 monthly interprofessional meetings, we developed a protocol and checklists (provided as a Supplement to this article) and made plans for initiating interprofessional training. Before training, participants completed anonymous surveys (provided as a Supplement to this article) assessing perception of and comfort with PPV using a 5-item Likert scale, in addition to preferences for training modalities. Latent safety threats were classified a priori into the following categories: equipment, procedure/protocol, personnel, and communication.

Study participants underwent a 2-hour interprofessional training session. Physician participants included practicing attending physicians with combined pulmonary and critical care medicine training and fellows participating in a pulmonary and critical care medicine fellowship accredited by the Accreditation Council for Graduate Medical Education; residents were not included. Training sessions consisted of a didactic session, simulated placement of volunteers with different body types in the prone position (Figure 1), simulated emergency scenarios (including cardiac arrest and bed malfunction), and a structured debriefing during which interprofessional input and LSTs were elicited (Figure 2). Training on how to speak with next of kin was not included. Checklists containing core competencies and essential steps guided the simulations (see Supplement). Sessions emphasized the importance of interprofessional audible communication, with use of read-back during routine placement and emergency scenarios. Physicians led cardiac arrest simulations and were given specific instruction on the differences between leading a code for a prone patient versus a standard ICU patient.

All sessions and debriefings were attended by the lead and/or senior author (A.D.P., S.J.H.), who recorded feedback about the training from the participants, including identification of LSTs and possible solutions. The structured debriefing format was adapted from quality improvement literature evaluating LSTs in simulation training.^15,16  Information gathered at debriefings was incorporated into the protocol and subsequent training sessions. Participants completed anonymous posttraining surveys.

The primary outcomes of interest were perception of benefit and comfort related to PPV, including comfort caring for patients receiving PPV, managing cardiac arrest in PPV patients, and speaking to next of kin about PPV. Nurses were asked about comfort levels with routine nursing care such as cleaning, feeding, and administering medications. Before training, providers were also surveyed about preferences for further training modalities. Novel and total LSTs identified during training were recorded during debriefings.

Descriptive statistical analyses were used to compare providers’ experience, perception, and comfort related to PPV before and after training, in addition to preferred training modalities. Kruskal-Wallis 1-way analysis of variance was used to compare provider groups with each other before training. The χ² test was used to evaluate for pre-post changes within each provider group. A priori responses consisting of “Agree” and “Strongly agree” were grouped together as “Agree,” and responses consisting of “Disagree” and “Strongly disagree” were grouped together as “Disagree.” Statistical significance was defined as a P less than .05. The references to LSTs were counted and categorized; the mean number of novel LSTs also was calculated. Analyses were performed by using STATA/MP version 13 (StataCorp).

A total of 82 providers underwent training, and 73 (89%) completed posttraining surveys (37 nurses, 18 physicians, 18 respiratory therapists; Table 1). Training occurred over the course of 12 separate 2-hour sessions in 3 days in June 2018. Providers had minimal previous PPV experience, with most having proned 5 or fewer patients. No significant differences were found in the characteristics of providers surveyed before and after training.

Before training, only 39% of nurses agreed that PPV would be beneficial to their patients with severe ARDS, compared with 96% of physicians and 70% of respiratory therapists (P < .001; Figure 3A). Less than half of nurses (35%) and physicians (27%) felt comfortable taking care of prone patients, compared with 70% of respiratory therapists (P = .04; Figure 3B). Less than 30% of providers across all disciplines were comfortable managing cardiac arrest in prone patients (P = .43; Figure 3C). Providers identified simulation and in-person demonstrations as the training methods that would be most helpful, with no significant differences found between the provider groups.

After training, the perceived benefit of PPV increased among all providers, with the largest increase (50 percentage points) occurring in nurses (P < .001 for before vs after training), compared with 30 percentage points for respiratory therapists (P = .008) and 4 percentage points for physicians (P = .046; Figure 3A). The group with the greatest improvement in comfort with taking care of proned patients was physicians (increase of 51 percentage points from before to after training; P = .005), followed by nurses (28 percentage points; P = .002) and respiratory therapists (19 percentage points; P = .48; Figure 3B). In addition, physicians, who played the role of code leader, demonstrated the greatest improvement (increase of 70 percentage points from before to after training; P < .001) in comfort with managing cardiac arrest, followed by respiratory therapists (61 percentage points; P = .01) and nurses (30 percentage points; P = .02; Figure 3C). Nurses reported significantly increased comfort with routine nursing care, with increases of 27 percentage points for administering medications, 31 percentage points for feeding, and 17 percentage points for cleaning (P < .05 for each). Comfort with speaking to next of kin did not change significantly after training in any discipline (Figure 3D).

Twenty novel LSTs were identified (mean of 1.67 per session, range 0-4). Of the total, 42% were related to equipment, 39% to procedure/protocol, 12% to personnel, and 7% to communication. Solutions included generation of new checklists, creation of bundles for equipment, and clarification of protocol (Table 2). Areas for training modification identified during debriefings included shortening the didactic component, using volunteers with different body types, and limiting the number of participants per session to 6 in order to maximize active participation. Coaching for physicians before running code simulations was also added to the training initiative, with corresponding checklists included in the protocol. Participants noted the following benefits of interdisciplinary training: increased interprofessional communication and team building and identification of patient-centered, discipline-specific LSTs by providers who volunteered to be proned (eg, identification of potential sites of pressure injury by a proned wound care nurse).

In this study, a novel interprofessional simulation-based training program at a hospital with minimal previous PPV experience improved providers’ perception of benefit and comfort levels with the procedure. The study highlights the importance of aligning providers’ understanding of the utility of PPV in severe ARDS in order to achieve the interprofessional collaboration required. Perception of the benefit of PPV and comfort levels with both routine care and emergency scenarios improved for all 3 categories of providers. In addition, the training helped identify LSTs, allowing incorporation of solutions into the protocol to facilitate safe implementation.

Much like many other health care centers around the world, our hospital was initially hesitant to implement PPV. Michie et al²¹  described a novel framework for behavior change interventions represented by a behavior change wheel. The hub of the wheel is a behavior system involving 3 essential conditions: motivation, capability, and opportunity. Our interprofessional simulation-based training fits into this framework by emphasizing motivation through improved perception of benefit of this lifesaving modality, capability through the didactic session and demonstration, and opportunity through real-time simulation.

The existing literature on education about and implementation of PPV reflects the traditional nursing-oriented approach to PPV.^18–20  In addition, many aspects of routine nursing care and quality metrics (eg, feeding) are directly affected by prone positioning. Our findings before training are consistent with previous studies that identified lack of perceived benefit and safety concerns as potential barriers to implementation of PPV.^9–11  Most nurses did not believe that PPV would be beneficial to patients with severe ARDS and were not comfortable with providing routine nursing care to patients in the prone position. Identifying and addressing discrepancies in perception of benefit with training before implementation may facilitate interprofessional buy-in and enhance collaboration among providers.

An enhanced sense of teamwork may have contributed to the improved perception of and comfort with PPV after training, as reflected in debriefings across all 3 disciplines. Historically, providers from different disciplines have held discrepant attitudes about teamwork in the ICU, possibly affecting the quality of collaboration and delivery of care.²²  The significant improvements in comfort levels with PPV across all disciplines in our unit may reflect enhanced teamwork resulting from improved communication achieved during the simulations. The emphasis on read-back, which can improve information transfer during simulated crises,²³  provided an opportunity to practice the form of communication that would be essential during such scenarios. Furthermore, physician presence at simulated cardiac arrests may have facilitated cohesion and a sense of “shared leadership,” which has been described as a promising method in simulation training for improving interprofessional collaboration.¹² 

The ability to identify LSTs before implementation is probably another important factor in the improved comfort with PPV after training. Our center focused on the interprofessional nature of PPV from the start, with leadership representing nurses, physicians, and respiratory therapists working closely together in initial protocol development. Even so, our interprofessional debriefings elicited 20 additional LSTs from the 3 categories of providers. Proposed solutions to these unrecognized systems errors were incorporated into the protocol. We also applied an iterative learning process to our implementation, allowing staff members and trainers to continuously learn from the simulation training and subsequently improve the protocol.²⁴  Giving providers a voice during debriefings allowed all participants to develop a sense of ownership of the protocol that was being implemented. The open forum for voicing concerns may have provided reassurance, improving overall comfort with the procedure.

This study has several strengths. The novel simulation-based training for PPV, emphasizing an interprofessional approach to emergency scenarios such as cardiac arrest and bed malfunction, has not been previously described in the literature. In addition, the program allowed us to train nearly 90% of our MICU staff and practice placement of volunteers with different body types. Limitations include the single-center nature of the study and the lack of survey matching due to anonymity, which precluded measurement of the training initiative’s intrapersonal impact and reduced the overall power for detecting differences. The simulations were not performed in the ICU but rather in a simulation center, which may not reflect the nuances of a real PPV experience. Not all providers who received training completed surveys, making respondent bias a possibility. In addition, providers were aware that they were being evaluated, giving rise to a possible Hawthorne effect. Nonetheless, no significant changes were found after training in comfort with speaking to next of kin about PPV, which was not addressed by our program; the comfort level not addressed by our training may serve as a control for the study. In addition, we did not use qualitative research methods when conducting debriefings and collecting qualitative data. We used automated beds in our training, which may limit generalizability. However, key principles of our design and implementation, including the interprofessional focus and emergency simulations, may extend to the implementation of a manual PPV program.

Although automated PPV is a popular option in many centers, future researchers will need to evaluate the impact of interprofessional simulation-based training on implementing a manual PPV program. Furthermore, in our study, we evaluated the initial training session before implementation. Further research is needed to assess the long-term effects of training on perception of and comfort with PPV, as well as the optimal timing of retraining to maximize knowledge retention and comfort.

Interprofessional simulation-based training can improve perception of benefit and comfort with providing PPV and is an effective method of identifying LSTs before implementing a PPV program for severe ARDS. By enhancing interprofessional collaboration, such simulation-based training may facilitate buy-in and implementation of this essential and underused intervention.

Arjo Inc provided equipment and assistance with the didactic sessions and demonstration. The authors are grateful to the Mount Sinai Hospital MICU staff of nurses, respiratory therapists, physicians, and wound care experts, without whose enthusiasm, commitment, and collaboration this study and the implementation of PPV at our center would not have been possible.