Barriers, Facilitators, and Trends in Prone Positioning for ARDS
Bibliographic record
Abstract
Background Prone positioning is a historically underused evidence-based practice for ARDS. Despite increased prone positioning during the COVID-19 pandemic, some patients may remain at risk of nonuse. Research Question What is the current evidence-based gap for prone positioning in ARDS, how is use changing over time, and what are patient-level barriers and facilitators to prone positioning? Study Design and Methods This retrospective cohort included invasively ventilated adults with ARDS and who met prone positioning criteria from six hospitals. The rate of prone positioning among eligible patients was summarized from January 2018 through December 2021. Segmented Poisson regression was used to describe temporal trends. Logistic regression was used to identify patient-level barriers and facilitators to prone positioning. Results Seven hundred ninety-nine patients fulfilled criteria for prone positioning. The mean age was 57 years, 125 patients (15.6%) had COVID-19, mean ICU stay was 19.5 days, and the mortality rate was 50.1%. Prone positioning was used in 297 of 799 patients (37.2%). Prone positioning was increasing before the pandemic with a relative rate (RR) of 1.12 per quarter (95% CI, 1.03-1.22). Prone positioning increased during the pandemic vs before the pandemic (RR, 1.62; 95% CI, 1.02-2.61), but not for patients with nonrespiratory diagnoses causing ARDS (RR, 0.74; 95% CI, 0.22-2.52). Barriers to prone positioning included vasopressor use (OR for withholding prone positioning, 1.15 per 0.1 μm/kg/min norepinephrine equivalent; 95% CI, 1.06-1.26), age (OR, 1.12 per 5 years; 95% CI, 1.03-1.22), and having undergone surgery (OR, 2.41; 95% CI, 1.00-5.81). Facilitators included having COVID-19 (OR for withholding prone positioning, 0.10; 95% CI, 0.04-0.24) or another respiratory illness (OR, 0.42; 95% CI, 0.23-0.79), and receiving neuromuscular blockade (OR, 0.22; 95% CI, 0.13-0.38). Interpretation Despite increased prone positioning during the COVID-19 pandemic, an evidence-based gap persists, especially for patients with nonrespiratory causes of ARDS. Multiple barriers and facilitators must be targeted to increase prone positioning.
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How this classification was reachedexpand
Full frame distilled prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. Learned from the 10,348 direct Codex labels and 10,348 direct Gemma labels. Candidate is the union of thresholded teacher heads; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels or direct frontier model labels.
Codex and Gemma teacher scores by category
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.000 | 0.000 |
| Meta-epidemiology (narrow) | 0.000 | 0.000 |
| Meta-epidemiology (broad) | 0.000 | 0.000 |
| Bibliometrics | 0.000 | 0.000 |
| Science and technology studies | 0.000 | 0.000 |
| Scholarly communication | 0.000 | 0.000 |
| Open science | 0.000 | 0.000 |
| Research integrity | 0.000 | 0.000 |
| Insufficient payload (model declined to judge) | 0.000 | 0.000 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one teacher head, not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".