Limitations
Several limitations in this study may have influenced the outcomes.
Recruitment of qualified patients was minimized due to nursing staff
concerns about increased workload and exposure to COVID-19 and overuse
of personal protective equipment (PPE) to obtain vital signs before and
after position changes. Nurses were thus instructed to gather data on
patient adherence to the protocol once per shift in alignment with
scheduled nursing tasks and to document vital signs from patient
monitors that could be viewed through a glass window on the door of the
room (not all rooms had glass windows, so this alternative was limited).
Not all staff were in-serviced on the protocol, so changing shifts and
turnover in nursing staff also contributed to inconsistencies and
limited potential for recruiting newly admitted qualified patients.
Patient comments regarding proning events were not consistently entered
on the documentation log, so lack of this personal information limited
feedback that may have helped optimize the protocol and increase
compliance. The patients in this study came from a convenience sample
presenting to one inner-city hospital and may not represent other
populations. Their treatment plans and aspects of care were not
controlled, which may have introduced confounding variables that
influenced changes in SpO2 levels (the effects may result from an
unrecognized alternate treatment rather than from proning). The lack of
a control group also increases selection bias, decreases study power,
threatens internal and external validity, and weakens the ability to
draw conclusions about self-proning in these patients. A randomized
prospective study that observes outcomes of proning in the COVID-19
positive patient and other aspects of their care would help determine a
causal relationship between self-proning, improved oxygenation, and
incidence of intubation. It would also be prudent to group patients with
similar case mix index profiles and comorbidities to assess overall
outcomes for those who perform proning.