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. 2023 Dec 28;18(12):e0296379. doi: 10.1371/journal.pone.0296379

Organisation and delivery of a dedicated multidisciplinary prone ventilation team in the intensive care unit: Strategies and lessons from COVID-19

Luke Bracegirdle 1,2,3,4,*, Matthew Stubbs 1, Rezaur Rahman 1,4, Alexander I R Jackson 1,2,3,4, Helmi C Burton-Papp 4, Robert Chambers 1,4, Sanjay Gupta 1,4, Michael P W Grocott 1,2,3,4, Ahilanandan Dushianthan 2,3,4
Editor: Tommaso Tonetti5
PMCID: PMC10754430  PMID: 38153940

Abstract

Background

COVID-19 placed immense strain on healthcare systems, necessitating innovative responses to the surge of critically ill patients, particularly those requiring mechanical ventilation. In this report, we detail the establishment of a dedicated critical care prone positioning team at University Hospital Southampton in response to escalating demand for prone positioning during the initial wave of the pandemic.

Methods

The formation of a prone positioning team involved meticulous planning and collaboration across disciplines to ensure safe and efficient manoeuvrers. A comprehensive training strategy, aligned with national guidelines, was implemented for approximately 550 staff members from a diverse background. We surveyed team members to gain insight to the lived experience.

Results

A total of 78 full-time team members were recruited and successfully executed over 1200 manoeuvres over an eight-week period. Our survey suggests the majority felt valued and expressed pride and willingness to participate again should the need arise.

Conclusion

The rapid establishment and deployment of a dedicated prone positioning team may have contributed to both patient care and staff well-being. We provide insight and lessons that may be of value for future respiratory pandemics. Future work should explore objective clinical outcomes and long-term sustainability of such services.

Background

In January 2020, the global pandemic of Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) viral infection, posed a significant threat to healthcare in the United Kingdom (UK). It became evident that a subset of COVID-19 patients would experience critical illness, manifesting as acute respiratory distress syndrome (ARDS) and subsequent acute hypoxic respiratory failure (AHRF). The majority of these patients necessitated invasive mechanical ventilation, which has a substantial associated risk of mortality [1]. Initial reports from China and Italy highlighted the strain that COVID-19 placed on critical care resources, with mounting demand for mechanical ventilation and a substantial unmet need for additional qualified intensive care personnel.

Prone position ventilation has long been employed in managing ARDS patients and early evidence suggested potential benefits for COVID-19 patients with severe lung disease [2]. However, the process of proning critically ill, mechanically ventilated patients is time-consuming and labour-intensive. Early in the COVID-19 pandemic, it became evident that existing intensive care staff were unable to perform the required multiple prone cycles without compromising bedside care. Consequently, we determined the need for a dedicated, specialised prone team to address the growing service demands, whilst ensuring patient and staff safety. By late March 2020, in response to the increasing number of patients in the General Intensive Care Unit (GICU) at University Hospital Southampton (UHS), a dedicated critical care prone team was established. UHS is a large teaching hospital with approximately 1200 inpatient beds. GICU is a 32-bed unit. Notably, early Intensive Care National Audit and Research Centre (ICNARC) data indicated UHS GICU as a positive (low mortality) outlier for risk-adjusted 28-day mortality from COVID-19 until August 31st, 2020 [3]. Our group has recently demonstrated that prone positioning in our cohort improved oxygenation indices [4]. We attribute these positive outcomes, at least in part, to the swift implementation of the dedicated prone service.

This report outlines our experience in establishing a critical care prone service at UHS, sharing valuable insights and proposing a blueprint for its rapid reactivation in response to further COVID-19 outbreaks or the emergence of novel respiratory illnesses in the future.

Methods

Design and conception

The establishment of a prone positioning team to safely reposition mechanically ventilated patients in GICU required meticulous planning, preparation, and multidisciplinary collaboration. This work was discussed with our research and development department, and as a quality improvement project with participant involvement being purely voluntary, ethical approval was deemed not to be required. We assembled a team of senior clinical leaders and training personnel to oversee the development and implementation. This was completed within a two-week period. Fig 1. outlines the key components of our local process for setting up the service.

Fig 1. The stages of development of the prone positioning team during the COVID-19 pandemic.

Fig 1

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Based on staffing requirements, we identified three categories of personnel crucial for successful prone manoeuvres.

  1. Airway-Trained Personnel

    These clinicians possess the skills to promptly identify and manage airway emergencies that may occur during prone positioning. They are prepared to perform rapid endotracheal intubation if accidental extubation of a critically hypoxic patient occurs. An experienced anaesthetist, intensivist, or advanced critical care practitioner (ACCP) is suited for this role.

  2. Team Members for Patient Turn

    These individuals possess expertise in manual handling and are responsible for assisting in the physical turning of patients. Operating department practitioners (ODPs), theatre nurses, and practitioners from relevant surgical specialties (e.g., orthopaedics and neurosurgery) are well-suited for this task.

  3. Team Members for Fine Positioning

    This role involves precise positioning to prevent complications associated with the prone position, such as pressure injuries or mispositioned lines and circuits. Healthcare workers from the aforementioned specialties commonly manage these issues in theatre settings and are well-equipped to fulfil this responsibility.

Strategy

Training and risk mitigation

Based on simulation exercises, a concise training session of approximately 30–45 minutes was proposed, designed in accordance with the Faculty of Intensive Care Medicine (FICM) and Intensive Care Society (ICS) prone positioning guidelines [5]. Given the potential risks associated with prone positioning for both staff and patients, emphasis was placed on training, practice, and repetition. Staff undergoing training were required to demonstrate satisfactory manual handling competencies. The training sessions encompassed theoretical education, practical demonstrations, and hands-on practice using a high-fidelity setup with an intubated mannequin connected to a ventilator and various infusions and catheters as would be encountered in GICU.

Resource dissemination

To facilitate the widespread distribution of information and learning resources across different hospital departments, an online local application was developed (S1 Appendix). This application provided easy access to essential documents such as the FICM and ICS prone position guidelines, training materials (e.g., prone positioning video demonstration), contact information, and a logbook. It was accessible from any browser or mobile device, independent of the staff intranet connection.

Team assembly

Approximately 550 staff members from diverse clinical and non-clinical backgrounds received training over a four-week period. All members were existing UHS staff, and no external hiring was required. Recognising the uncertainties surrounding critical care services during the pandemic, a proactive decision was made to significantly scale up the number of staff trained in prone positioning. As knowledge about the virus and clinical outcomes evolved, more targeted training was provided.

Training delivery and anaesthetic support

Training sessions were conducted by a dedicated nurse-led skills training team over several weeks, with multiple daily drop-in sessions. Separate sessions were held for approximately 60 anaesthetists, accounting for specific airway, ventilation, and cardiovascular considerations during prone positioning episodes. Simulation exercises guided the plans for ensuring 24-hour availability of experienced anaesthetists within the prone team. Additional tiers were added to the on-call anaesthetic rota to maintain safe anaesthetic coverage for other areas, responding to the increasing demand for anaesthetic support services. Recruitment of outpatient nursing staff and theatre teams further bolstered the team.

Staffing structure and roster

Based on training exercises and early experiences with prone positioning in GICU, it was determined that a minimum of five to six members were required in each team. The standard team structure during the peak COVID-19 activity on GICU included one experienced anaesthetist or airway-trained clinician, four team members proficient in manual handling and positioning, and one bedside GICU nurse (typically the nurse assigned to care for that patient). Additional team members were occasionally necessary for repositioning obese or complex patients (such as those with multiple intercostal chest drains etc.).

Initially, prone teams were formed on an ad-hoc basis, utilising available anaesthetists supported by nursing, medical, and support staff. They were deployed throughout the four-week training program. Ensuring comprehensive 24/7 coverage with a fully staffed prone positioning team required meticulous organisation, but increasing patient volume necessitated the development of a structured roster to sustainably perform over 40 prone manoeuvres every 24-hour period.

To evaluate the service, we sought regular feedback from the prone positioning team members. Feedback and learning points were disseminated on a regular basis to promote real-time service improvement.

Results

The prone positioning service at UHS formally commended on March 26, 2020, running continuously for 8 weeks. Utimately, we deployed 78 staff members to full-time prone positioning teams. Minimum staffing for each team was one airway-trained clinician and five other staff members. The same team structure was required for both initial prone positioning, and subsequent re-positions. Throuhgout the first wave of COVID-19, we mechanically ventilated 184 patients, of which 144 received one or more prone positioning cycles. A total of 1208 prone and repositioning manoeuvres were performed, with a higher frequency of manoeuvres occurring outside regular working hours (Fig 2).

Fig 2. Prone position changes during peak COVID-19 activity on GICU.

Fig 2

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Chart A shows the total number of prone position changes which occurred on a given day, during the peak period of activity. Chart B shows the relationship between total prone position changes and the times of day at which they occurred.

Key components of a typical prone positioning shift

Fig 3. Provides an illustration of the essential elements of a typical prone positioning shift.

Fig 3. The key components of a typical prone positioning team shift.

Fig 3

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Whiteboard refers to a system usually involving a flipchart or wipeable surface used to track patient activity. PPE = Personal Protective Equipment. Donning refers to the process of applying PPE in a structured manner as directed by local guidance. The base layer refers to the primary layer of PPE worn by a clinician. Over-layer refers to a disposable, second layer of PPE worn by a clinician when moving between patients in a cohorted area. Doffing refers to the process of removing PPE in a structured manner to reduce the risk of cross-infection.

Importance of team leadership

Based on our experience, designating a team leader was crucial for effective coordination and communication with the GICU medical team. A simple whiteboard system facilitated patient tracking and safe handover. The team leader role was typically fulfilled by a senior nursing team member or an anaesthetist.

Team brief and introductions

Given the multi-professional nature of the prone positioning teams and the likelihood of staff members not having worked together previously, we conducted a team brief before each shift. This included introductions with first names, roles, and a brief background experience description of each staff member. The team leader provided relevant information about the patients to be repositioned, including any important clinical details.

Utilisation of checklists

ICS and FICM guidelines formed the foundation for the locally adapted prone positioning protocols used at UHS. Checklists, encompassing indications, contraindications, and pre- and post-procedural checks ensured standardised and comprehensive practice. Printed and laminated checklists were readily available at each bed space, and electronic versions were accessible via the MicroGuide™ App and the local intranet (S2 Appendix).

Equipment and drug preparation

To familiarise new prone positioning team members with the critical care environment, a separate equipment and drug trolley was created for easy access to emergency supplies. This approach was derived from simulation-based training sessions and aligned with FICM guidance (4).

Personnel Protective Equipment (PPE)

Following Public Health England (PHE) guidance [6], enhanced PPE was worn by staff to safeguard both themselves and patients. Considering the finite availability of PPE, we practiced the following; ensured comfort and a secure fit before entering clinical areas, cohorting patients to perform sequential prone positioning manoeuvres during a single PPE session, arranged escorts between GICU overflow areas to minimise PPE doffing, and scheduled prone positioning rounds to avoid coinciding with the clinical team’s PPE donning and doffing times.

Documentation of prone positioning episodes

We established a system to log prone positioning and repositioning events, which was essential for workload estimation, safety event reporting, and service improvement. The online logbook system was implemented, with completion responsibility typically assigned to the lead anaesthetist or team leader on each shift. Unfortunately, we did not explicitly record any adverse events in the logbook, as this would typically be recorded in the clinical notes.

The GICU environment can present challenges for staff without prior exposure, leading to feelings of anxiety. Adequate preparation and support during training and deployment are crucial. Here we highlight the importance of familiarising new team members with the GICU environment, and provide recommendations to improve staff experience and wellbeing during mentally and physically demanding prone positioningshifts.

Induction and preparation

To address the potential challenges faced by new or inexperienced team members, it is essential to provide comprehensive training. We recommend that new team members initially join the prone positioning team in a supernumerary role, allowing them to become familiar with the intensive care environment and its unique demands.

Limiting exposure

Working in PPE can be hot and uncomfortable, and prolonged periods in the GICU may increase the risk of cross infection. To improve staff experience and wellbeing, it is advised to limit staff exposure whenever possible. On our unit, in-hour anaesthetic prone positioning shifts were divided between two or three assigned anaesthetists, resulting in positive feedback and improved wellbeing among staff. Additionally, starting staggered prone positioning rounds with sufficient time to complete repositioning manoeuvres, as well as doffing well before handover helps avoid delays and reduces queues at doffing areas.

Continuous auditing and evaluation of service development are essential for improving patient care. While quantifying the impact of individual prone positioning manoeuvres on individual patients is clearly beyond the scope of this report, tracking the overall quantity of manoeuvres performed provides a useful workload metric. We again emphasise the importance of using a logbook here.

In addition to volume metrics, understanding the lived experience of staff members who joined our prone positioning team is crucial. To gather valuable insights on service evaluation, we conducted an internal survey (see supplementary data) targeting 78 full-time team members. The survey comprised 49 questions, and we received 61 responses from a diverse range of healthcare backgrounds.

Demographic profile

The majority of respondents were female (80%) and aged 25–54 years old (87%). Participants joined the team from various healthcare backgrounds, including medical, nursing, operating theatres, and research teams. 62% had not specifically volunteered for a role.

Anxiety

Most respondents reported feeling anxious, primarily related to infection risk and concern for spreading the infection to their families. There was also concern about returning to out-of-hours working patterns after working routine hours for some time.

Training

Formal training on prone positioning was provided to 92% of respondents, with 100% feeling adequately prepared to some extent. 84% had physically practiced on a person or mannequin, and 82% were shown and encouraged how to use our checklist. However, only 78% felt they received sufficient training, and they reported certain resources, such as using the prone positioning team web application, were less clearly emphasised with only 27% reporting they were shown how to use it. Potentially then, the quantity of prone positioning manoeuvres performed was an underestimate.

Of the respondents that had used the web application, 94% found it useful. 39% were aware of our prone positioning team training video, and all found it useful. Free text comments for training reported that some staff were not formally told of training sessions, and happened to find out from colleagues. Some thought that the mannequin size was not reflective of the real patients, and that the available checklists and videos were not highlighted during the face-to-face training sessions. Of the respondents that underwent training, 57% went on the join the prone positioning team, but mentored or supernumerary shifts were available to only 17% of team members. Of those who did not have this opportunity, 70% reported that they would not have found it helpful anyway.

Team dynamics and roles

Assigned roles varied, with 42% of respondents reporting they had undertaken the role of team leader during a shift. Teamwork within the prone positioning team was highly valued, with 93% reporting good teamwork. When asked specifically if there was good teamwork between the prone positioning team and the resident GICU team the majority (71%) agreed. Some reported mixed messages (%) from GICU teams about which patients required prone positioning, and some raised concerns (%) about perceived tension amongst teams and some obstructive comments about the use of muscle relaxants. There was a particularly strong feeling of teamwork between respondents and anaesthetists, with 98% reporting good teamwork. 95% reported always knowing who the team leader was and 70% reported they would know how to escalate any concern and importantly, felt their concerns would be taken seriously. 34% reported witnessing a clinical problem or emergency during a prone positioning procedure, with the majority (66%) of issues surrounding the ventilator or breathing circuit.

Checklist utilisation

The majority (93%) reported usually or always using the prone positioning checklist, with 91% finding it useful in preventing patient safety incidents. However, availability of the checklist was a concern, with only 65% reporting it was usually or always physically accessible. 9% reported that they witnessed incidents that they believed would have been prevented by the use of the checklist.

PPE and safety

80% reported they had access to appropriate PPE for every shift, but concerningly 62% reported they had spent longer than four hours in PPE at any one time. A small percentage (7%) tested positive for COVID-19, and 7% reported physical injuries. Comments included exacerbation of existing musculoskeletal symptoms, and sore skin from wearing PPE.

Wellbeing

The reported number of prone positioning shifts undertaken varied, with 19% reporting they completed no shifts, and 2% reporting more than 40. The majority of people (65%) completed between one and 20 shifts. When asked about work intensity, the vast majority reported heavy (65%) or very heavy (7%). Breaks were usually or always sufficient for 84% of respondents, but sadly 11% reported negative psychological health effects, necessitating time off work for recovery.

Overall satisfaction

Despite the challenges faced, the majority (88%) felt proud to work on the prone positioning team, 82% felt valued, and 90% expressed willingness to join the team again.

Discussion

Here we present the establishment of a dedicated prone positioning service in response to overwhelming demand during the COVID-19 pandemic. Our aim was to alleviate the workload and pressure on critical care clinical teams by rapidly training a large number of staff. We discuss the positive impact of safe and timely prone manoeuvres on benchmarked outcomes and staff well-being.

One notable aspect of our approach was the training of a significantly larger number of staff than those who ultimately joined the prone positioning team. This strategy aimed to create a larger pool of trained individuals, which could be considered beneficial. However, it also strained resources. Focusing teaching efforts on the smaller number of staff who joined the team could have further improved their confidence. While the methods we describe are generally transferable, it is important to note that our large, university teaching hospital may have greater access to resources than smaller centres. To gain insight into the lived human experience, we conducted a survey that received a high response rate. Although open surveys are susceptible to bias, the strong participation mitigates some of this risk. Nevertheless, it is worth acknowledging that the survey did not include responses from members of the clinical teams, which may limit our understanding of their perceptions. In addition, we did not record adverse events in our logbook which were typically written in the clinical notes. We would add a reporting feature for any future work.

Our findings align with previous work that emphasises the benefits of a multidisciplinary approach to prone positioning, which reduces complications in critically ill COVID-19 patients [7]. We also address barriers identified in another study, specifically focussing on knowledge and team culture [8]. While other centres have established prone positioning teams, they have not provided detail on training methods or explored the human impact through surveys [9,10]. Some centres with smaller teams limited their service to daytime hours [11,12], though interestingly their survey results echoed our findings, highlighting general satisfaction but with occasional power struggles.

To ensure the successful implementation or re-initiation of a prone positioning service, several factors should be considered. These include workload projections, the impact on other hospital areas, and collaboration among multiple teams and stakeholders. We recommend the formation of a dedicated "setup" team comprising senior personnel from relevant departments to provide effective leadership. Adequate training, including in-situ, high-fidelity simulation, is crucial, and maintaining a logbook for prone manoeuvres and complications facilitates risk identification, ongoing education, and team development. Prioritising rest and support for team members are essential for maintaining their well-being and performance. Regular feedback from the team members also provides valuable insights for improvement.

Although our work provides valuable insights, some questions remain unanswered. Future work could explore the direct impact of dedicated prone positioning teams on clinical outcomes. Additionally, incorporating the perspectives of clinical team members who were not surveyed would provide a more comprehensive understanding of the service’s effectiveness. Evaluating the long-term sustainability and cost-effectiveness of prone positioning services across different healthcare settings is also necessary. Finally, exploring the potential benefits of advanced technologies, such as robotics or artificial intelligence, in prone positioning could open new avenues for future investigation.

Conclusion

The COVID-19 pandemic was devastating and exhaustive to NHS staff, but has prompted innovative and collaborative approaches to healthcare delivery, yielding substantial improvements in patient outcomes. Here, we share our local experiences of initiating, organising, and implementing a dedicated prone ventilation service. Amid the peak COVID-19 activity in our GICU, we successfully conducted over 1200 individual prone positioning episodes, alleviated the burden on critical care staff and ensured the safe and timely provision of prone ventilation in our patients, contributing to excellent benchmarked outcomes. By sharing our experiences, we hope to inspire and encourage similar initiatives that enhance healthcare delivery and alleviate some of the challenges faced by critical care teams.

Supporting information

S1 Appendix. Prone positioning app and logbook.

(TIFF)

Click here for additional data file. (6MB, tiff)
S2 Appendix. The general intensive care unit prone ventilation checklist.

(TIFF)

Click here for additional data file. (5.2MB, tiff)
S1 File

(DOCX)

Click here for additional data file. (217KB, docx)

Abbreviations

AHRF

Acute hypoxic respiratory failure

ARDS

Acute respiratory distress syndrome

ACCP

Advanced Critical Care Practitioner

COVID-19

Coronavirus Disease 2019

FICM

Faculty of Intensive Care Medicine

GICU

General Intensive Care Unit

ICNARC

Intensive Care National Audit and Research Centre

ICS

Intensive Care Society

ODPs

Operating department practitioners

PPE

Personnel protective equipment

PHE

Public Health England

SARS-CoV-2

Severe acute respiratory syndrome Coronavirus 2

UK

United Kingdom

UHS

University Hospital Southampton

Data Availability

All relevant data are within the paper and supporting files.

Funding Statement

The authors received no specific funding for this work.

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Decision Letter 0

Tommaso Tonetti

10 Oct 2023

PONE-D-23-22349Organisation and delivery of a dedicated multidisciplinary prone ventilation team in the intensive care unit: strategies and lessons from COVID-19PLOS ONE

Dear Dr. Bracegirdle,

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Reviewer #1: The authors of this manuscript aimed to highlight the role of a prone positioning team to alleviate the workload and pressure on critical care clinical teams. They discussed the positive impact of safe and timely prone maneuvers on outcomes. They also pointed out the benefits of a multidisciplinary approach to prone positioning, which reduces complications in critically ill COVID-19 patients.

The manuscript sheds light on an interesting topic, is based on impressive empirical evidence, and makes an original contribution. I only have some minor comments for final improvements:

1- I would recommend adding an abstract that provides a comprehensive synopsis of the contents of the prospective manuscript that consists of 4 paragraphs: Background, Methods, Results, and Conclusions.

2- I have marked a few typos and grammar mistakes which need to be corrected. ( file attached )

3- What was the time elapsed from the conception of the Prone Team initiative to training and first intervention? It would be better to add this information to “figure one” to illustrate the time frame for this stage.

4- What was the final number of the prone team? How many were in each category according to your staffing requirements classification?

5- It would be better to add a table demonstrating the results of the internal survey for the prone team members. And what is the significance of these results?

6- How much was the capacity of the ICUs where the prone team worked at?

7- Can you elaborate on the indications and contraindications of the prone positioning?

8- What were the recorded adverse events that occurred during the prone positioning?

9- A list of all abbreviations used in this manuscript should be added.

Reviewer #2: I read with great interest the study of Bracegirdle and colleagues in which the authors described in details the Organisation and delivery of a dedicated multidisciplinary prone ventilation team in the intensive care unit to face the COVID-19 pandemic. First of all I would like to congratulate everyone on the research team and on the prone ventilation team for working so hard with the aim of improving patient's care. I have few major and minor comments:

Major comments:

At the end of the "Background session" the authors report the UHS GICU as a positive (low mortality) outlier for risk-adjusted 28-day mortality from COVID-19 until August 31st, 2020. The authors state that they attributed these positive outcomes, at least in part, to the swift implementation of the dedicated prone service. Reference 3 is no more available online and should be changed. While it is not my intention to question the beneficial survival effects following team implementation, the statement is not supported by any clinical data and therefore should be removed by the authors. Data regarding mortality would be very interesting but, since the team was established very early in during the first stages of the pandemic, I doubt that comparisons before and after team implementation can be made.

The timeline for a full team rollout is unclear. How many weeks were necessary before the team was fully implemented in the clinical practice?

The authors state that quantifying the impact of individual prone positioning manoeuvres on individual patients would be beyond the scope of the report. I disagree with the authors. Clinical outcomes would be extremely important to fully understand whether such a massive use of resources translates to clear clinical benefits. At least, I would report the incidence of adverse events during manoeuvres before and after the implementation of the dedicated team (incidence of unplanned extubations etc…)

Minor comments:

It is not clear whether manoeuvres of supination following a pronation cycle require there same number of trained personnel. The authors should clarify this aspect.

Figure 1 is not really informative.

It is not clear whether the extra personnel came from other departments or specifically hired to work in the pronation team.

Reviewer #3: In this paper the authors proposed a document that investigate the approach used for prone positioning and described the results obtained in terms of workload and pressure on critical care clinical teams. Furthermore, the evaluate the the positive impact of safe and timely prone manoeuvres on benchmarked outcomes and staff well-being.This paper should be considered as a procedure useful in one dedicated center but I am not sure the results produced could be generalizable in other center. Overall is not clear what is the aim of the paper and how the limited analysis proposed could be useful for other center. The analysis of the results are scanty and in my opinion is limited interest. The use of checklist is interesting but should be verify the internal and external consistency and ithe ncidence of latent error that can impact in terms of the outcome and in terms of the safe of the procedure. Furthermore, should be clarify the impact of the simulation in this specific context.

Reviewer #4: Dear Authors,

Thank you for the work you have done.

The degree of organization certainly influenced the outcome of the patients (as for any catastrophic event).

However I think the work is a little bit prolix and not well organized.

The reader risks getting lost while reading. I tried to suggest some changes (marry some paragraphs, synthesize others).

I believe it could also be useful to build a table to summarize the major outcomes (reduction of adverse events, type of staff trained, staff satisfaction).

**********

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Reviewer #1: No

Reviewer #2: No

Reviewer #3: No

Reviewer #4: No

**********

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PLoS One. 2023 Dec 28;18(12):e0296379. doi: 10.1371/journal.pone.0296379.r002

Author response to Decision Letter 0

14 Nov 2023

Reviewer 1

“I would recommend adding an abstract that provides a comprehensive synopsis of the contents of the prospective manuscript that consists of 4 paragraphs: Background, Methods, Results, and Conclusions”

We agree. We have added a structured abstract into the manuscript.

“I have marked a few typos and grammar mistakes which need to be corrected”

We agree with all corrections offered and have kept them all.

“What was the time elapsed from the conception of the Prone Team initiative to training and first intervention? It would be better to add this information to “figure one” to illustrate the time frame for this stage.”

We agree this should be clearer. We have updated both the manuscript and Figure 1 to reflect timelines.

“What was the final number of the prone team? How many were in each category according to your staffing requirements classification?”

We agree this is important information. Total numbers joining the team have been highlighted in the manuscript, and the survey data provides information on demographics including categories.

“It would be better to add a table demonstrating the results of the internal survey for the prone team members. And what is the significance of these results?”

We considered this point carefully. For initial drafts, our survey data was presented in a table. However, it was the consensus of our group that a narrative summary was more appropriate. For completeness we will upload the full survey data as supplementary material for the interested reader. We do try to highlight the significance of the team members lived human experience, and we hope this is clear from our discussion.

“How much was the capacity of the ICUs where the prone team worked at?”

We agree this is important contextual information, and have updated the manuscript to reflect this. UHS is a large tertiary hospital with 1200 inpatient beds. We have multiple critical care environments (general, cardiac, neurological, paediatrics) with a total capacity of 54 level 3 beds plus separate HDU capacity. GICU has 32 beds.

“Can you elaborate on the indications and contraindications of the prone positioning?”

We agree this is important. Indications and contraindications of prone positioning can be found in the section ‘utilisation of checklists’ as well as on the checklist itself (appendix 2).

“What were the recorded adverse events that occurred during the prone positioning?”

Whilst we recorded prone positioning events, we did not explicitly record adverse events in our logbook. Typically, any adverse events would have been documented in the bedside clinical notes. We accept this is a significant limitation of our work and we regret not considering building this in during the planning phase. Any future projects will have adverse event reporting built into our methods. We have updated the ‘documentation of prone positioning episodes’ and discussion sections to reflect this weakness.

“A list of all abbreviations used in this manuscript should be added.”

PLOS ONE does not specify an abbreviation list is necessary. However, we agree that given multiple abbreviations have been used throughout, it seems reasonable to include one. We have added a full list at the beginning of the manuscript.

Reviewer 2

“At the end of the "Background session" the authors report the UHS GICU as a positive (low mortality) outlier for risk-adjusted 28-day mortality from COVID-19 until August 31st, 2020. The authors state that they attributed these positive outcomes, at least in part, to the swift implementation of the dedicated prone service. Reference 3 is no more available online and should be changed. While it is not my intention to question the beneficial survival effects following team implementation, the statement is not supported by any clinical data and therefore should be removed by the authors. Data regarding mortality would be very interesting but, since the team was established very early in during the first stages of the pandemic, I doubt that comparisons before and after team implementation can be made.”

Thank you for highlighting issues with reference 3. It referred to an ICNARC report published in June 2020, highlighting that UHS was a positive outlier in terms of mortality from COVID-19. I have checked and agree with the reviewer that this report seems to be no longer available. I have therefore updated this reference to include a review article published by our department, that quotes and references the original ICNARC report. We do feel it important to maintain the statement as it provides context for why we feel our model of prone ventilation teams worked so well.

In regards to clinical data, we actually do have comparison data, but we maintain it is beyond the scope of this manuscript which is designed to be a report of service development. However, we agree that clinical data is important and interesting, so have added a reference to a cohort study published by our group that examines the clinical outcomes of the cohort of patients who underwent prone positioning at our centre. The study highlights that whilst oxygenation indices were improved, the sample size is too small to draw meaningful evidence survival benefit.

Jackson A, Neyroud F, Barnsley J, Hunter E, Beecham R, Radharetnas M, et al. Prone Positioning in Mechanically Ventilated COVID-19 Patients: Timing of Initiation and Outcomes. J Clin Med. 2023;12: 4226. doi:10.3390/jcm12134226

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10342481/

“The timeline for a full team rollout is unclear. How many weeks were necessary before the team was fully implemented in the clinical practice?”

We agree this was not clear. As per our response to Reviewer 1, we have updated both the manuscript and Figure 1 to reflect this.

“The authors state that quantifying the impact of individual prone positioning manoeuvres on individual patients would be beyond the scope of the report. I disagree with the authors. Clinical outcomes would be extremely important to fully understand whether such a massive use of resources translates to clear clinical benefits. At least, I would report the incidence of adverse events during manoeuvres before and after the implementation of the dedicated team (incidence of unplanned extubations etc…)”

We feel the first point about clinical data has been answered in our response above.

We absolutely agree that the reporting of adverse events is important. As in our response to Reviewer 1, this is a weakness of our work and we regret not recording this.

“It is not clear whether manoeuvres of supination following a pronation cycle require there same number of trained personnel. The authors should clarify this aspect.”

We agree this is not clear and have updated the manuscript to reflect this.

“Figure 1 is not really informative.”

We have updated Figure 1 to include timelines. This addresses concerned from both Reviewer 1 and 2, and therefore we suggest keeping it.

“It is not clear whether the extra personnel came from other departments or specifically hired to work in the pronation team.”

We agree this is not clear and have updated the ‘Team Assembly’ section to reflect this.

Reviewer 3

“This paper should be considered as a procedure useful in one dedicated center but I am not sure the results produced could be generalizable in other center. Overall is not clear what is the aim of the paper and how the limited analysis proposed could be useful for other center.”

We agree that as a service development report, our results cannot be generalised to other centres. We acknowledge we are a large, well-resourced centre and that smaller centres may not have similar levels of staffing and resources to pull from. We have tried to emphasise this in paragraph 2 of our discussion.

“The use of checklist is interesting but should be verify the internal and external consistency and ithe ncidence of latent error that can impact in terms of the outcome and in terms of the safe of the procedure.”

We agree that the use of checklists is not infallible, however, the context here is important. This was an exceptional time, when uncertainty and fear of what would come was on everyone’s minds. Arguably, checklists reduced the cognitive workload of what was a very repetitive task performed in difficult circumstances. Our checklist was written with FICM and ICS standards in-mind and we might argue that adherence would only improve safety rather than increase the incidence of error.

“Furthermore, should be clarify the impact of the simulation in this specific context.”

We agree the impact of training and simulation should be explored. Under “training” in the evaluation section, we highlight that 84% of our team had simulated practice on a person or manikin. In addition, we highlight that 100% felt adequately prepared after our simulation sessions.

Reviewer 4

“However I think the work is a little bit prolix and not well organized.

The reader risks getting lost while reading. I tried to suggest some changes (marry some paragraphs, synthesize others).”

We agree the initial draft required some re-structuring and we hope we have satisfied this. It is now structured as Abstract, Abbreviations, Background, Methods, Results, Discussion and Conclusion.

“I believe it could also be useful to build a table to summarize the major outcomes (reduction of adverse events, type of staff trained, staff satisfaction).”

This article aims to only describe to roll-out of new prone positioning service. We are able to state absolute number team members deployed, and of manoeuvres performed, but exploring outcomes is beyond the scope of this work. As per our response to Reviewer 1 and 2, we have added a reference for a cohort study describing clinical outcomes in our cohort of patients that underwent prone positioning and hope you find it interesting. We have also updated the manuscript to include the significant limitation that our logbook did not record adverse events.

As per our response to Reviewer 1, we did initially present our survey results in a table, but it was the consensus of our group that a narrative summary flowed much better. We have however now updated the supplementary files to include the full survey responses.

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Decision Letter 1

Tommaso Tonetti

11 Dec 2023

Organisation and delivery of a dedicated multidisciplinary prone ventilation team in the intensive care unit: strategies and lessons from COVID-19

PONE-D-23-22349R1

Dear Dr. Bracegirdle,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Tommaso Tonetti

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

**********

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The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: N/A

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: (No Response)

Reviewer #2: Thanks to the authors for addressing my major concerns. I appreciate that the lack of clinical data and adverse events before and after implementation of the pronation team has been added as a main limitation of the study. I have no additional comments.

**********

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Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Ahmed Uosef

Reviewer #2: No

**********

Acceptance letter

Tommaso Tonetti

18 Dec 2023

PONE-D-23-22349R1

PLOS ONE

Dear Dr. Bracegirdle,

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on behalf of

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Associated Data

    This section collects any data citations, data availability statements, or supplementary materials included in this article.

    Supplementary Materials

    S1 Appendix. Prone positioning app and logbook.

    (TIFF)

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    S2 Appendix. The general intensive care unit prone ventilation checklist.

    (TIFF)

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    (DOCX)

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    Attachment

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