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.