Cardiff Critical Care SOP 024

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s Prone Position SOP

Author(s): Karla Hobbs

Internal reviewer: Judith Burnett

External reviewer:

Version: 1.0 Issue Date: 30/09/2019 Review Date: October 2022

Contents

Prone Kit List..............................................................................................Pg 2 Prone Sizing Guide.............................................................................Pg 3 Turning the patient from Prone to Supine....................................................Pg 4 Turning the patient from Supine to Prone..............................................................................Pg 5 Care and positioning after Prone position...........................................Pg 6 - 7

Cardiff Critical Care SOP 001

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9/30/2019 KH / Prone Team

1.Prone kit list and Size Guide

Prone kit

Prone sheet

3 yellow slide sheets

2 wide for SUPINE to PRONE

PLUS 1 standard for PRONE to SUPINE

3 florescent prone straps (non disposable)

3 -4 pillows

2 flat sheets

ECG stickers (consider placing defibrillator pads

Lateral Head Support Memory Foam Pad

Silicone Wedge

Insight ET tapes

SOP document and Careplan

Kept in the A3N Linen room top shelf

All spare equipment stored in the A3

corridor store room

Cardiff Critical Care SOP 001

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Prone Checklist

Ensure sufficient staffs are available

1 individual with Advanced Airway skills

5 additional staff

Collect the Prone kit

Airway

□ Check the grade of intubation, current length of the Endotracheal (ETT) tube at

the teeth

□ Oral and deep suction

□ Change Anchorfast to Insight secure the ETT/Trache tube

Breathing

□ Note End tidal CO2 trace and value

□ FiO2 to 100%

□ Consider the position of any intercostal drains, any temporary clamping of the

chest drains should only done by a senior doctor

Circulation

□ Ensure CVS stability

□ Ensure all vasoactive drugs have sufficient volumes – change as indicated

□ Disconnect non-essential intravenous infusions – position all IV lines to the top

and bottom of the bed. Check that all IV lines are clean and secure

Disability

□ Ensure the patient is fully sedated and paralysed

Environment / Equipment

□ Position al lines / drains etc towards the head end of the bed or towards the feet

end of the patient

□ Consider the position of the urinary catheter

□ CVVHDF should be put on saline re-circulation

Pressure and Hygiene care

□ Assess the visible pressure areas; aim not to prone on a hard mattress

□ Oral assessment and mouth care should be performed

□ Eye care- clean and lubricate with simple ointment place a gauze pad and

tape the eyes closed

□ Aspirate the nasogastric tube and disconnect the feed

□ Remove the patient gown – maintaining patient dignity

□ Assemble the staff

□ Delegate specific tasks to individuals

Cardiff Critical Care SOP 001

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TURNING PRONE NB: PLACE THE STRAPS AND EXCESS SLIDE SHEET ON THE SIDE THE PATIENT IS BEING TURNED TOWARDS

Fig 1. Placement of the prone sheet level

with the top of the shoulder

Fig 2. Placement of the pillows

Fig 3. Placement of the straps over the pillows

1. Review the checklist

2. Increase the FiO2 to 100%

3. Decide in which direction to turn (Consider the position

of Arterial & CVC lines)

4. Brief the team and decide actions in the event of an

adverse event during the procedure

5. Place the arms to the side (palms facing thighs)

6. Roll the patient to:

a. Change the bottom sheet

b. Insert the slide sheet (excess slide sheet on the side

the patient is being turned towards)

c. Then the prone sheet (On top of the slide sheets top

edge level with the shoulder Fig 1.)

d. Roll the patient back onto their back

7. Centre the patient on the prone sheet (adjust the

patient’s position if indicated)

8. Remove the ECG leads and stickers or any other

monitoring if required

9. Place the 3 pillows horizontally across (Fig 2.).

Chest (level with the shoulder clear of the airway)

Pelvis

Knees

10. Position straps – Lock the loop of the strap (Cilp facing

out), onto the handle of the prone sheet on the side the

patient is turning to face, place straps through the

handle on the other side and lay them over the patient

(1 strap over chest, pelvis and knees Fig 3.).

11. Slide the patient so their head is off the bed and slide to

the opposite corner of the bed

12. Position the staff - 3 nurses on the side the patient is

turning to face, 2 nurses on the other side.

13. How to use the straps and slide sheets

- Staff on the turn side should pull the strap tight

with one hand, and brace the patient with the

other hand

- Nurses on the on the other side pull the top slide sheet

downwards (ensure the excess slide sheets are free)

- Adjust the patient to ensure they will be positioned in the

middle of the bed.

1st Movement to

Turn the patient through 90 degrees on their side

2nd Movement

Lower the patient to the prone position

14. Slide the patient down the bed and turn the head to

face the ventilator

15. Unclip and remove the straps and the prone sheet

16. Reattach ECG and any other monitoring

17. Adjust the pillows – ensure the pillows are under the

chest, pelvis and knees ) not under the abdomen

18. Brace the patient remove the slide sheets

19. Position the arms in the swimmers position (head facing

arm up)

20. Refer to aftercare checklist.

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s TURNING FROM PRONE TO SUPINE NB: PLACE THE STRAPS AND EXCESS SLIDE SHEET ON THE SIDE THE PATIENT IS BEING TURNED TOWARD

Fig 1. Placement of the prone sheet on the slide

sheets

Fig 4. Patient in the Prone position. Narrow (3rd) slide

sheet over the patient’s back.

1. Review the pre turn checklist

2. Increase the FiO2 to 100%

3. Decide in which direction to turn (Consider the

position of Arterial & CVC lines)

Do not roll the patient face into the bed.

4. Brief the team and decide actions in the event of

an adverse event during the procedure

5. Place the arms by their side palms facing thighs.

6. Roll the patient to

a. Insert the slide sheets (excess slide sheet on the

side the patient is being turned towards (patients

back)),

b. Place the prone sheet (on top the of the slide

sheets, the top edge level with the shoulders (Fig

1.)

c. Roll the patient back

d. Brace the patient and unravel to slide sheets

and prone sheet

7. Centre the patient on the prone sheet (adjust the

patient’s position if indicated).

8. Remove the ECG leads, stickers and any other

monitoring.

9. Place a 3rd slide sheet folded in half, length ways

over the patient’s back (Fig 4.)

10. Position straps

– Lock the loop of the straps (clip facing out) onto

the handle of the prone sheet on the side the

patient is turning towards

- Loop the straps through the handle on the

opposite side and lay them over the patient (1 strap

over chest, pelvis and knees).

11. Slide the patient so the head is off the bed, and

slide to the opposite corner away from the direction

of the turn

12. Position staff - 3 nurses at the on the side the patient

is turning towards and 2 nurses on the other side.

13. How to use the straps and the slide sheets

-Staff behind the patient should pull the strap tight

with one hand and brace the patient with the other

hand.

-Nurses on the other side should pull the top slide

sheet downwards.

-Adjust the position of the patient to ensure they will

be positioned in the middle of the bed.

1st Movement to

Turn the patient through 90 degrees onto their side

2nd Movement

Lower the patient into the supine position.

14. Slide the patient down so their head is on the bed

15. Unclip and remove the straps, prone sheet, and

pillows.

16. Reattach ECG and other monitoring.

17. Brace the patient and remove the slide sheets

(bracing the patient)

18. Refer to the aftercare checklist

Cardiff Critical Care SOP 001

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s Immediate care after Prone

Airway

□ Check the ETT/Trache is safe and secure

□ Note End tidal CO2 trace and value Breathing

□ Check the patient is ventilating

□ Check SaO2

□ Return FiO2 to original value

□ Carryout an ABG 10minutes after prone positioning Circulation

□ Ensure CVS stability

□ Check that all IV lines are secure Disability

□ Check sedation Environment / Equipment

□ Re-connect and reposition al lines / drains /feed / treatments

□ Consider the position of any intercostal drains, any temporary clamping of the chest drains should only done by a senior doctor

Pressure care

□ Place the silicone wedge and Lateral Head memory foam pad under the cheek

□ Ensure there is no pressure on the globe of the eye and that the eyes are closed and protected

□ Check that limbs are not resting infusions/ monitoring lines

□ Ensure the arms are placed in the swimmers position when flat (see above)

□ Check that the arms not > 90 degrees above the shoulder

Care during Prone

□ Reposition the head and arms 2-4 hourly and document

□ Check and document the pressure area 2-4 hourly

□ Oral suction 1 - 2 hourly (or as indicated)

□ Check there is no pressure on the eye globe hourly

Date: Addressograph:

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s Reposition the head and arms 2 – 4 hourly

1 airway trained person

2 additional members of staff

Place the arms by the side palms facing inward

Roll the patient and insert the slide sheet

Slide the patient so their head is off the bed

Turn the head to the opposite direction

Slide the patient back down the bed

Reposition the arm

Turning the patient side to side

Place the arms by their side palms facing inward

Roll the patient (Do not to turn the patient’s face into the bed

Place a 4th pillow length ways under the 3 pillows already

Head facing the reaching arm knee is slightly bent

Time

Position

change

Pressure

area check

Cheeks

Eyes

Ears

Breasts

Ulnar Nerve

Ulnar Nerve

Genital area

Knees