“I was honored to be a member of Urban Augmentation Medical Task Force 804-1. We provided a vital service to the people of Queens in general, and more specifically to the patients and staff of Queens Hospital Center. To have been a part of this mission to combat the novel coronavirus pandemic is something I will never forget. Our sense of accomplishment at Queens Hospital Center was bolstered by the quality improvements we helped bring about that will hopefully endure long after we’ve gone home,” said Lt. Col. Robert Steckler, a 60K, Urologist with UAMTF 804-1.

One of the quality improvements implemented by UAMTF 804-1 was the medical procedure known as prone positioning. Proning is a critical treatment option for COVID-19 patients who have insufficient oxygen within their blood and require mechanical ventilation.

Proning, or lying a patient face down on one’s chest and abdomen (prone) as compared with lying on one’s back (supine), improves the transfer of oxygen from the lungs into the bloodstream and eventually throughout the body’s organs.

Alveoli are the tiny air sacs within the lungs that permit the exchange of oxygen, carbon dioxide and other gases. Prone positioning helps keep more alveoli open and more evenly distributed at the end of expiration, thus improving gas exchange and minimizing ventilator induced damage to the lungs.

Prone positioning is believed to improve survival for some patients with Acute Respiratory Distress Syndrome (ARDS). ARDS is a condition in which fluid collects within the alveoli, thereby depriving oxygen to the organs throughout the body. Oxygenation is significantly better when patients are in the prone position compared to when they are in the supine position. In patients with moderate to severe ARDS, early application of prolonged prone positioning sessions significantly improves oxygenation and reduces mortality.

The technical aspects of prone positioning are not simple, and a coordinated five to seven-person team is required to do it properly. A dedicated team that trains together and refines the procedure through practice and experience is imperative to prone safely, efficiently and with minimal adverse events.

Embedding a Quality Improvement Officer within the Task Force’s Command and Clinical Operations structure helped strengthen the integration of the UAMTF 804-1 soldiers into Queens Hospital Center (QHC) and its staff. This model facilitated close collaboration with the QHC leadership and proved indispensable to formulate, obtain buy-in, coordinate and enact quality of care measures to the benefit of the hospital’s patients and Force Health Protection. Prone positioning was just one of several quality improvement projects that the Task Force promoted and helped put into action.

“We had the opportunity to work with an amazing group of doctors, nurses, assorted hospital support staff and hospital administrators who were generous with their kindness, support, patience and friendship. Without their open arms and enthusiastic acceptance of our ideas and method of operations, we could not have fulfilled our mission at such a high level,” said Steckler.

The success achieved by the UAMTF 804-1 quality improvement proning initiative, combined with the excitement and enthusiasm exhibited by the nurses and doctors of QHC and the Task Force itself, inspired its proning team to implement formal training and more extensive support for the QHC staff so the hospital could carry on confidently long after the UAMTF 804-1 left for home. Explicit procedural steps, a pre-proning safety checklist and post-proning nursing guidelines based on the most current medical literature were written up and were incorporated into the QHC protocols and electronic medical record for documentation purposes. These protocols were subsequently shared with, and are planned to be adopted by, the whole 11 hospital New York City Heath + Hospital Corporation system.

Through coordination with the QHC leadership and nursing staff, a simulation laboratory was set up for training, with an intubated mannequin on a mock ventilator, with multiple tubes and lines including EKG leads, a central venous line, peripheral intravenous line, arterial line and a foley catheter. The mannequin and ventilator were generously provided by FEMA. The simulation laboratory greatly accelerated the training and learning curve of the UAMTF 804-1 proning team and the subsequent training of the QHC staff.

Additional guidelines for patient proning were developed and advocated approximately 16 hours of proning along with scheduled times for patient change of position. The recommendation was to schedule and perform prone positioning in the afternoon, and to return the patient to the supine position after the morning change of shift. This schedule provided ample time for patient hygiene, wound care and any other nursing care during the daytime peak staff hours.

The prone positioning project, in addition to elevating the care of ventilated patients with severe ARDS, also improved hospital wide patient care by enhancing hospital morale and job satisfaction, as the nursing and physician staffs incorporated new sustainable techniques to benefit their sickest patients.

Looking back, Steckler remains honored of his team’s actions, saying, “I could not be prouder of each team member’s attitude and enthusiasm, the quickness with which they mastered proning, and the leadership they demonstrated as teachers of a complex procedure. They epitomized the ‘Be Know Do’ leadership model that we strive for.”