• 1 respiratory therapist (responsible for airway) 
• 2 RNs (on either side of bed)
• 1 physician (unless the patient is very stable)

• Prior to starting, administer sedation and/or analgesia.

Most patients being turned prone are critically ill; unless the patient is very stable, a physician should be in attendance.

At least 2 RNs (one on either side of the bed are needed).
 

2.Perform hand hygiene and don non-sterile gloves, assess need for gown, facemask and shield.

Position all lines and IV tubings that are inserted above the patient's waist towards the head of the bed (e.g. subclavian or upper extremity IVs, radial arterial lines, NG or feeding tubes).

In accordance with the MoHLTC 4 moments of hand hygiene and LHSC infection control policies in an effort to reduce risk of transmission of microorganisms and secretions.

LHSC Hand Hygiene Policy

LHSC Routine Practices Policy

LHSC Donning and Doffing Policy

This will minimize tangling during the turning procedure.

• Place straps on the Vollman Prone Positioner under patient's head, chest and pelvic region. 
• Lay the frame over the patient's torso as follows:
• Place the top edge of the chest piece one inch below the clavicle. 
• Adjust the top edge of the pelvic piece until it rests 1/2 inch above the iliac crest. 
• Adjust the forehead and chin pieces to provide full facial support without interfering with the ETT . 
• Fasten the positioner to the patient using the adjustable straps. 
• Tighten straps.  Attempt to lift the frame to ensure the device is tight.

The chest and pelvic pads keep the abdomen raised off the bed to allow the diaphragm to drop freely and facilitate unrestricted breathing. 

If a patients is positioned prone, without the use of the Vollman frame, the chest and pelvis should be elevated on pillows.  The abdomen should NOT rest directly on the bed.

• Using a draw sheet, move the patient to the side of the bed furthest away from the ventilator. 
• Tuck the straps underneath the patient, pulling through to the opposite side. 
• Carefully tuck the patient's arm that is closest to the centre of the bed under the buttocks.
• Place the leg that is closest to the edge of the bed on top of the other leg, crossing at the ankle. 
• Cross the legs at the ankle, placing the leg that is closest to the edge of the bed on top of the other.
• The individual closest to the patient should maintain close contact with the bed to maintain patient safety and to prevent care giver back strain.

Placing the arm under the body and crossing the ankles protects the patient against limb injury during the turn.

• First, carefully tilt the patient to a 45 degree lateral turn.
• The strap that has been passed under the patient to the side of the bed opposite the ventilator acts as the turning strap. 
• The nurse closest to the ventilator turns the patient by grasping the metal frame and pulling the turning strap towards him/her.
• Turn on the count of the person responsible for the airway.
• Turn to complete pronation.

The initial rotation tests that the frame is positioned successfully.  The second turn to the prone position is smoother from a 45 degree pause, allowing the turning nurse grasp the strap and frame firmly.

Apply nerve protector pads under the ulnar nerve ("funny bone"). Change head position to side lying.

The ulnar nerve is and "exposed" nerve that is susceptible to pressure injuries.  Ulnar nerve palsies can lead to a "claw hand" deformity.

11. Monitor oxygen saturation, respiratory rate, respiratory pressures, minute volume, heart rate, and BP.  Auscultate chest to ensure ETT has not been dislodged.  If available, monitor end-tidal carbon dioxide.

An end-tidal carbon dioxide of "0" indicates extubation (carbon dioxide is always present if the tube is in the airway).  If the end-tidal carbon dioxide suddenly drops, the tube may be partially dislodged.

13. Obtain arterial and mixed venous blood gases and cardiac output measurements 30 minutes after completion of turn.

Many people find prone an uncomfortable position.

15. Remove PPE and perform hand hygiene.

Document procedure and patient response.  Note the time interval between turning and oxygen improvement.

Loosen straps.

The head should be turned  comfortably towards the ventilator.  Lift and gently reposition every hour, monitoring for pressure points (such as the ear).  Inspect  mouth frequently for pressure sores from ETT.

Monitor invasive line sites frequently for pressure or bleeding.
 

Ensure that all ECG leads and cables are clear of the bed surface.  If necessary, ECG leads can be placed over the back while prone

Invasive lines can be hidden under a prone body, making it hard to see if the line has disconnected or is being exposed to pressure.