Table 3.

Consolidated Framework for Implementation Research inner setting: intensive care unit factors influencing proning use in coronavirus disease acute respiratory distress syndrome

Study Theme (Definition) and Subthemes	(Provider Type and Number) Supporting Quotation
Staffing (staffing requirements for safe proning and challenges in staffing)	(RN09): You need the physical people to flip people. . . . I [also] need somebody who’s going to know you can’t yank a central line this way. . . . It’s not just [the] physical people, but people who [have] probably done it before, like who can kind of do it safely.
Adequate staff with training needed	(RN10) I mean, I think if we could really figure out about the whole making them a one-to-one versus if it was okay to have them paired with another patient . . . I think if there is a way that they can maintain safety and that we can also have it paired with another patient, I think that’s the best because I don’t think that really staffing is ever going to get better.
Optimal nurse-to-patient ratio unknown	(APP04) I think we also had this real stigma [that] with staffing, that if a patient was proned, at least from a nursing perspective, that it needed to be a one-on-one nurse to patient ratio. . . . Once COVID hit, you would have two proned patients that you were paired together with. . . . I think it made us realize that the act of proning takes a little bit of work to get them flipped, but once they are proned, you aren’t really doing anything with them.
Travel nurses brought different degrees of experience	(RN11) Then the other issue is the number of travelers. . . . We don’t know which ones of them are comfortable with proning, have done it a lot, what their process was, and they’re not that good about knowing our policies.
Frequent attending MD/fellow turnover led to variability in practice	(RN08) What became challenging was . . . when a provider would want them supinated like on a Tuesday, and then we would allow that to happen, and then on Wednesday, a new attending would come in and it would be, “Oh, let’s prone them,” and we were like, “Wait a minute. We just did that, they’re doing okay.”
Team experience with proning
Team agreement	(MD10) Probably the single biggest change was just the rapidity in which people got proned and, I think, the acceptance of the team that we were doing this. I mean, it just happened and there is no whingeing* about it. (RN09) What has changed from our end is every time we see a patient start to not do well or have increase in oxygen or PEEP requirements, we almost automatically know that we are going to end up proning them. But I feel like, in that way, everybody ends up being on the same page almost.
Repeated proning improved comfort	(APP02) I think it’s a lot more comfort with us doing it too. I don’t really sense near as much anxiety about turning a patient, or they may not be stable enough to turn, which was a comment we would hear frequently [before COVID-19]. I mean, you still hear that, certainly, if a patient is unstable, but nearly everybody was felt to be too unstable to prone previously, and now it’s a rare circumstance that you get that feedback.
Decision to prone made by staff members with less training	(MD04) I think proning, especially if you do it with any frequency as we have been doing, it’s a pretty safe thing to do, and therefore the benefit to risk ratio is favorable, and I think interns and residents should have the privilege to [decide to] prone.
Preparation for proning became standard	(MD11) Making sure they have the lines in place, and stuff ahead of the fact probably is an intentional process now, whereas I don’t think we always sort of thought ahead for that.
ICU equipment and layout
ICUs stocked with basic but important equipment	(PT01) I think using the simple equipment worked. Of course, things like using Mepilex bandages to protect bony prominences, and the Z-Flo pillow to prevent kind of pressure ulcers on the face. Those are important.
Wider beds and specialty beds became standard in some units	(RN03) So with these new beds, they’re wider than our regular beds which is helpful. With this supination and proning, we need a little bit more space. They’re also air [mattresses], so they’re better for their pressure injury prevention, and then also the way that the bed tilts in a way that we can still feed the patients because it’s important to feed them.
Room size and patient visibility	(RN04) It was definitely more difficult in [repurposed COVID-19 ICU] . . . because [the rooms] are not ICU rooms, so they’re a lot smaller. . . . A majority of their doors are just wooden regular doors and didn’t even have windows on them. To have a patient that sick that you’re proning and not being able to see them was a big challenge. . . . They replaced the doors to have windows, which is better, but still, it’s definitely much easier with the ICU style, having the glass door window.

Definition of abbreviations: APP = advanced practice provider; COVID = coronavirus disease; ICU = intensive care unit; MD = medical doctor; PEEP = positive end-expiratory pressure; PT = physical therapist; RN = registered nurse.

^*Colloquial for “whining.”