Sustainable Implementation of Prone Positioning for the Acute Respiratory Distress Syndrome

PROJECT SUMMARY/ABSTRACT This career development award will support Chad Hochberg, MD MHS, to become an independent investigator in critical care implementation science. In this award, Dr. Hochberg will build on his prior NHBLI-funded F32 studies investigating the changes in critical care practice that occurred early in the coronavirus disease 19 (COVID-19) pandemic. With this award, he seeks further training in 1) Informatics to monitor and support implementation, 2) Survey methodology, and 3) Developing, adapting, and evaluating implementation strategies for intensive care unit (ICU) implementation trials. To achieve these goals, he has outlined a 5-year career development plan that involves targeted didactics, hands-on research experience, and intensive mentoring. This research and training will be facilitated by the highly supportive training environment at the Johns Hopkins University, and guided by an experienced mentorship team with relevant expertise. Acute respiratory distress syndrome (ARDS) is a common and deadly form of respiratory failure in patients receiving mechanical ventilation. Prone positioning, a key evidence-based practice (EBP) for ARDS, involves positioning patients to lie on their stomachs, facilitating less injurious mechanical ventilation. Despite strong evidence that prone positioning reduces risk of death, it was historically underused. However, during the early COVID-19 pandemic, the use of prone positioning in patients with COVID-19 ARDS drastically increased compared to historic practice. Yet, preliminary data show falling proning rates, and other implementation experience suggests that without active intervention, appropriate use of this life-saving measure will decline. The strategies needed to support the sustainability of prone positioning in ICU practice are unknown. In this K23, Dr. Hochberg will use an established implementation framework, the dynamic sustainability framework, to structure an investigation into the strategies needed to support sustainability of prone positioning in ICU practice. In Aim 1, he will use granular patient-level data combined with staff surveys of ICU implementation climate from the five-hospital Johns Hopkins Health System, and evaluate the associations between the continued use of proning over time with specific patient characteristics and ICU implementation climate domains. In Aim 2, he will further explore the influence of ICU climate and culture on proning processes using a sequential explanatory mixed methods design. Finally, in Aim 3, he will conduct a pilot implementation trial to support further penetration and sustainability of prone positioning in routine ICU practice, and will assess the feasibility, acceptability, and appropriateness of this intervention using validated implementation surveys of ICU staff. This research and training will establish a strong foundation for a career focused on implementation science in critical care, and provide the preliminary data and experience for Dr. Hochberg to conduct a future R01-level multisite intervention to improve the implementation of prone positioning and other EBPs for ARDS.