Assignment 6: Gap Analysis
| Current State | Desired State | Identified Gap-Difference Between Current State and Desired State | Barriers to Best Practice Implementation | Methods used to Identify and Implement Best Practices |
| COVID-19 & Pronation Therapy Evidence-Based Project: Since the emergence of COVID-19, health care providers and researchers have depended on existing knowledge, practices, and interventions to treat the acute respiratory distress and hypoxic respiratory failure that often presents with this novel disease. Recent high level research has validated pronation therapy as a valid intervention for traditional ARDS patients but due to its increase in occurrences with a surge of acutely ill COVID patients there is a need for evidence-based education about the rationale for pronation therapy and standardized guidelines, including a therapy checklist for the critical care team at a 250 bed level 2 trauma center in central Maine. A gap analysis of the literature review will reveal additional information about creation of pronation education and protocols for the nurse educator (Hewner et al., 2021). | All COVID-19 patients, regardless of acuity, are admitted to the medical intensive care unit at a 250 bed, level 2 trauma hospital in central Maine. There has been an increase in the high-risk procedure of proning for COVID-10 patient that exhibit signs of severe hypoxic respiratory failure and acute respiratory distress syndrome according to standardly accepted Berlin Criteria. Current criteria for moderate to severe ARDS is a PaO2:FiO2 ratio < 150 mmHg and FiO2 ≥ 0.6 (The Intensive Care Society, 2019). The desired state would be to have proning guidelines, standardized therapy checklists, and an educational program for the critical care team members. | Pronation therapy prior to COVID-19 was a high-risk, low-volume procedure in the critical care units. There has been considerable turnover in the critical care team and there are currently no standardized guidelines for pronation therapy. There is a verbalized lack of comfort and competency from the critical care team when proning classic ARDS and ARDS with COVID-19 positive patients. | Barriers include the lack of current COVID-19 specific evidence about any interventions, including pronation therapy. There is lack of current education, lack of time for staff training, lack of knowledge about the rationale for pronation therapy for ARDS. | Surveys will be created about pronation therapy and send to key stakeholders on the critical care team about their baseline knowledge of pronation therapy. Education that targets knowledge, skills, and attitudes using the cognitive, psychomotor, and affective learning domains will be created and presented to essential team members. Sustainability of the education will be addressed with the critical care team leadership, and the professional development department to incorporate pronation therapy into initial staff onboarding and annual skill competencies. |
| Current State | Desired State | Identified Gap-Difference Between Current State and Desired State | Barriers to Best Practice Implementation | Methods used to Identify and Implement Best Practices |
| Arias et al., 2017: A systematic literature review by Arias et al. (2017) from 2000 to 2016 of ten peer reviewed articles referencing randomized control trials evaluated proning therapy as a valid treatment for ARDS. This article looked at measurable outcomes that included oxygenation, morbidity and mortality. | 1891 ARDS patients demonstrated that the 90 day survival benefit of the prone position is statistically significant. There were also improvements in oxygenation with the prone position in patients diagnosed with severe ARDS. Prone position is a recommended treatment modality in patients with ARDS. | There were significant differences in the onset and duration of prone positioning in the ten articles reviewed. The PROSEVA trial (Arias et al., 2017) was the largest and had a mean duration of 17 hours, with pronation therapy occurring within 48 hours of tracheal intubation. One RCT limited proning to six hours/day and ranged to a maximum of 20 hours/day in two of the trials reviewed. | Differences in onset and pronation therapy make it difficult for clinicians to adopt formal guidelines. | The PROSEVA trial demonstrated significant short term (28 day) and long term (90 day) survival benefit, was the largest RCT and most statistically significant so Arias et al. (2017) are recommending that it be the basis for pronation therapy adoption. |
| Current State | Desired State | Identified Gap-Difference Between Current State and Desired State | Barriers to Best Practice Implementation | Methods used to Identify and Implement Best Practices |
| Montanaro, 2021: Based off the Proning Severe Acute Respiratory Distress Syndrome (PROSEVA) randomized control trial (RCT) of 2013, Montenaro (2021) led a proning therapy education initiative in a 24-bed critical care unit. Pre- and post-education surveys demonstrated increased confidence and adherence to evidence-based practice proning guidelines and recommendations. | To create proning checklists, protocols and train staff through didactic education and simulation exercises. | This article referenced high level RCTs that demonstrated reduction in mortality with proning and standardized protocols. Prior to training, surveys revealed that staff lacked confidence and competency in pronation therapy. There is a gap in standardized protocols and education for pronation therapy based on EBP. Montanaro (2021) also described that the protocols were undergoing changes based on the COVID-19 pandemic that started approximately a year and a half after initiation of this education. | Barriers Montanaro (2021) described were limited critical care staffing, frequently changing equipment and medications, and the outbreak of COVID shortly after implementation of the education and protocols. | An interdisciplinary critical care team of physicians, nurses, and respiratory therapists completed a literature review, and used the plan-do-study-act method to test changes in knowledge after proning simulation training. Multiple-choice tests and Likert scale surveys were done at the completion of education and simulation to evaluate outcomes of the sessions. The checklist will serve as a model to base the EBP project on. |
| Current State | Desired State | Identified Gap-Difference Between Current State and Desired State | Barriers to Best Practice Implementation | Methods used to Identify and Implement Best Practices |
| Gallo de Moraes et al., 2020: ARDS remains a source of high morbidity and mortality. In a retrospective and prospective cohort study, Gallo de Moraes et al. (2020) examined identification of patients with refractory hypoxemia and time to pronation therapy after identification 16 months before and 16 months after implementation of a protocolized approach to mechanical ventilation and ARDS. Implementation of the protocol demonstrated that refractory hypoxemia was identified earlier and proning initiated sooner but no statistically significant reduction in mortality. | Gallo de Moraes and team hypothesized that identification of patients in refractory hypoxemia would contribute to earlier proning and improved mortality after protocolization. | Currently the critical care unit was unable to achieve optimal proning times of 16 hours for all patients with many patients only proned three to four hours. There is ongoing variation in the initiation and duration of proning therapy as compared to what the PROSEVA trial recommends. | Barriers included individual provider preferences rather than adherence to the protocol, lack of trained staff, need for supination early due to emergent interventions or cardiac arrest. | The authors identified that lack of mortality benefit could be due to short proning duration and that by addressing those issues, future protocols may improve mortality. Protocolization remains a key strategy to implementation of EBP on a critical care unit. |
| Current State | Desired State | Identified Gap-Difference Between Current State and Desired State | Barriers to Best Practice Implementation | Methods used to Identify and Implement Best Practices |
| The Intensive Care Society, 2019: Guidance from The Intensive Care Society (ICS, 2019) is based on RCTs and a Cochrane systematic review and recommends prone ventilation for 16 plus hours for patients that have moderate to severe ARDS based on the Berlin Criteria. | The desired state is that the ARDS patient with or without COVID-19 will have significant improvement in oxygenation due to pronation therapy without the occurrence of adverse events such as cardiac arrest, line or tube displacement, pressure injury, or staff injury. Creation of proning protocols can decrease adverse events. | According to survey results from the ICS, only 30% of critical care units use a proning checklist and only 58% use proning protocols for the therapy. Lack of standardization may contribute to adverse events and underutilization of proning. | Lack of knowledge of proning EBP and time to create guidelines was identified as barriers to pronation therapy in ICS surveys. | Adoption of available, evidence-based practice proning checklists and guidelines may improve adherence to pronation therapy for critical care units and help decrease adverse events and improve mortality. The ICS Guidance can be used as a baseline tool to create a standardized checklist and protocol for the EBP project. |
| Current State | Desired State | Identified Gap-Difference Between Current State and Desired State | Barriers to Best Practice Implementation | Methods used to Identify and Implement Best Practices |
| Clarke et al., 2021: There is not enough current research on pronation therapy and SARS-CoV-2 (COVID-19) ARDS patients who require prone positioning. Clarke et al. (2021) examined 20 mechanically ventilated patients in a prospective cohort study and found that prone positioning improved oxygenation. | Prone positioning has been demonstrated in RCTs to improve oxygenation and mortality and morbidity for non-COVID ARDS patients, and researchers hypothesize that the same interventions will have positive outcomes for ARDS patients that are COVID positive. | Early data on lung compliance for COVID patients was inconsistent and current data is indicating that lung compliance for ARDS with COVID is similar to ARDS without COVID. This is reinforcing pronation therapy as a valid strategy. | This was a prospective study with a small convenience sample size of only 20 patients that may limit generalizations about study findings. | Given the new nature of COVID, large, high level evidence that is specific to proning and the COVID population is limited. This is a study that is consistent with previous EBP about ARDS and COVID and reinforces the ongoing education project implementation. |
| Current State | Desired State | Identified Gap-Difference Between Current State and Desired State | Barriers to Best Practice Implementation | Methods used to Identify and Implement Best Practices |
| Venus et al., 2020: Venus et al. (2020) performed a retrospective literature review of prone positioning and COVID-19 patients diagnosed with hypoxic respiratory failure with or without mechanical ventilation. Prone positioning is standard practice for severe ARDS with or without COVID. Seven studies of 385 patients, all proned, all COVID positive, were found to demonstrate improved oxygenation and decreased dyspnea. | Pronation therapy will be recognized as having a clinical benefit for COVID-19 patients with hypoxic respiratory failure and ARDS per Berlin criteria. | None of the studies reviewed were RCTs, only observational or single center studies. Clinicians continue to report lack of standardization with proning timing for initiation and duration of therapy. | Lack of randomized controlled trials to understand benefits and adverse effects of prone positioning in COVID patients with ARDS who are spontaneously breathing and mechanically ventilated. | Seven observational studies demonstrated clinical benefit with prone positioning for COVID-19 ARDs patients, continuing to support this intervention and the need for guidelines, education, and checklists in the critical care units at the central Maine hospital. |
References
Arias, C. D., Pokharel, B., Papathanassoglou, E., & Norris, C. M. (2017). Prone positioning for the treatment of adult respiratory distress syndrome. CONNECT: The World of Critical Care Nursing, 11(3), 49–54. https://doi.org/10.1891/1748-6254.11.3.49
Clarke, J., Geoghegan, P., McEvoy, N., Boylan, M., Ní Choileáin, O., Mulligan, M., Hogan, G., Keogh, A., McElvaney, O. J., McElvaney, O. F., Bourke, J., McNicholas, B., Laffey, J. G., McElvaney, N. G., & Curley, G. F. (2021). Prone positioning improves oxygenation and lung recruitment in patients with SARS-CoV-2 acute respiratory distress syndrome; a single centre cohort study of 20 consecutive patients. BMC Research Notes, 14(1), 20. https://doi.org/10.1186/s13104-020-05426-2
Gallo de Moraes, A., Holets, S. R., Tescher, A. N., Elmer, J., Arteaga, G. M., Schears, G., Patch, R. K., Bohman, J. K., & Oeckler, R. A. (2020). The clinical effect of an early, protocolized approach to mechanical ventilation for severe and refractory hypoxemia. Respiratory Care, 65(4), 413–419. https://doi.org/10.4187/respcare.07243
Hewner, S., Chen, C., Anderson, L., Pasek, L., Anderson, A., & Popejoy, L. (2021). Transitional care models for high-need, high-cost adults in the United States: A scoping review and gap analysis. Professional Case Management, 26(2), 82–98. https://doi.org/10.1097/NCM.0000000000000442
Montanaro, J. (2021). Using in situ simulation to develop a prone positioning protocol for patients with ARDS. Critical Care Nurse, 41(1), 12–24. https://doi.org/10.4037/ccn2020830
The Intensive Care Society. (2019). Prone position guidance in adult critical care 2019. https://www.ics.ac.uk/ICS/News_Statements/Prone_Positioning_in_Adult_Critical_Care_.aspx
Venus, K., Munshi, L., & Fralick, M. (2020). Prone positioning for patients with hypoxic respiratory failure related to COVID-19. CMAJ : Canadian Medical Association Journal = Journal de l’Association Medicale Canadienne, 192(47), E1532–E1537. https://doi.org/10.1503/cmaj.201201
