Table 4.

Consolidated Framework for Implementation Research outer setting: hospital and societal factors influencing proning use in coronavirus disease acute respiratory distress syndrome

Study Theme (Definition) and Subthemes	(Provider Type and Number) Supporting Quotation
Hospital resources
Hospital dedicated resources to proning	(RN02) There was an educational video created and put on the COVID-19 resource portal, and they knew that there were other institutions using this, so there was a video made here at Hopkins describing it. And I know the prone team—that group, because I became a part of it later on. And I know there was a literature search involved and much thought, and then they got the resources to develop it and put it out there for the entire hospital to use.
Proning EMR order	(APP01) All of a sudden, this magical Epic [EMR] order appeared [and] it wasn’t a nursing communication anymore. So, it became more standardized for supinating and prone . . . over time and with kind of comfort level, that decision [to prone] became more of just as far as we’re going to add a pressor or vasodilator therapy as something that kind of came a little more fluidly.
Dedicated COVID-19 units (hospital created units dedicated wholly to COVID-19 critical care)
Repurposed units presented training challenges	(MD12) And I think there’s excitement, generally, being in the [new COVID-19 ICU]. Those are not all ICU-trained-level nurses, although now they’ve become that. I think, in the beginning, there was certainly a lot of . . . intimidation around, like, “Ugh, how are we going to learn how to do this? How are we going to actually do this?” But now, people have really taken advantage of it and picked it up as time’s gone on.
Developed expertise in proning and ARDS management more broadly	(MD02) The advantage that we had on ICU X [the new COVID-19 ICU] is that these nurses were almost like a blank slate . . . And I would say what’s interesting is these nurses are really good at treating hypoxic respiratory failure. . . . So one, it [proning] was part of the training on how to take care of these COVID ICU patients. And then two, it was just kind of a like—with that was just like full team buy-in.
Implementation of proning may have been better in these units	(RT02) So in the COVID ICUs, we are going to proning immediately. We’re proning patients a lot faster; we’re leaving them prone longer. Whereas in the non-COVID ICUs, we’re kind of waiting a little bit and saying, “Hey we’ve tried APRV for a while; we’ve tried this for a while.” But rather than leaving the patient prone for 24 h or 48 h, they more so are 12 h, 24 h, let’s supinate this patient.
COVID-19 as a novel disease
Lack of other proven therapies refocused care on evidence-based practice	(APP01) I think it came down to that we didn’t really have any targeted treatment for this. And all of the kind of anecdotal data that came out, as far as out of Italy and New York. . . . And fortunately, I think being at Hopkins, the thought was like, “Well, we go evidence-based-wise.” So we’ll continue what we’re doing from the ARDS Network. And it was pretty obvious we were still going to prone. . . . And we have to just go back to our guidelines and our P/Fs of less than 150 and do it early.
Interest in “novel” approaches to new disease process	(MD10) And I think the fact that it was a new disease, not a new syndrome, but a new disease . . . [the] suggestion of “we should prone everyone as soon as they hit those criteria,” I think the ground for that was a lot more fertile than if it had just been, “We’re going to start proning every patient with ARDS.”
Researcher interest in proning	(MD04) And COVID was a new problem, and a lot of people were paying special attention to it, including more than one person in the pulmonary division who was interested in proning, and when somebody is very focused on an aspect of the problem, clinicians understand that this is something worth considering. So, the fact that there’s a researcher prowling around talking about proning raises consciousness.

Definition of abbreviations: APP = advanced practice provider; APRV = airway pressure release ventilation; ARDS=acute respiratory distress syndrome; COVID = coronavirus disease; EMR = electronic medical record; ICU = intensive care unit; MD = medical doctor; P/F = partial pressure of arterial oxygen/fraction of inspired oxygen; RN = registered nurse; RT = respiratory therapist.