To determine the prevalence of complications in patients with COVID-19 undergone prone positioning, focusing on the development of prone-related pressure ulcers. Cross-sectional study conducted in the hub COVID-19 centre in Milan (Italy), between March and June 2020. All patients with COVID-19 admitted to intensive care unit on invasive mechanical ventilation and treated with prone positioning were included. Association between prone-related pressure ulcers and selected variables was explored by the means of logistic regression. A total of 219 proning cycles were performed on 63 patients, aged 57.6 (10.8) and predominantly obese males (66.7%). The main complications recorded were: prone-related pressure ulcers (30.2%), bleeding (25.4%) and medical device displacement (12.7%), even if no unplanned extubation was recorded. The majority of patients (17.5%) experienced bleeding of upper airways. Only 15 prone positioning cycles (6.8%) were interrupted, requiring staff to roll the patient back in the supine position. The likelihood of pressure ulcers development was independently associated with the duration of prone positioning, once adjusting for age, hypoxemic level, and nutritional status (OR 1.9, 95%CI 1.04–3.6). The use of prone positioning in patients with COVID-19 was a safe and feasible treatment, also in obese patients, who might deserve more surveillance and active prevention by intensive care unit staff.

Background/Objectives: Hospital bed shortage is a widespread issue affecting healthcare systems globally, often exacerbated by bed-blocking, a phenomenon where patients remain hospitalized longer than medically necessary due to discharge delays. The aim of this study was to evaluate the prevalence of patients with bed-blocker status admitted to the internal medicine wards. Methods: This cross-sectional study was conducted at an academic tertiary-level hospital in Milan (Italy) from 1 January to 31 December 2023. All adult patients identified as ready for discharge by the bed management service, but whose actual discharge was delayed by more than 24 h, were included. Clinical data were retrieved from electronic medical and nursing records. This study adhered to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. Results: Out of 2480 admissions to the internal medicine wards, 147 patients (5.9%) experienced delayed discharge. The median hospital length of stay was 22 days (IQR: 15.0–33.0); the median duration of appropriate stay was 6 days (IQR: 2.0–13.0), and the median length of delayed stay was 14 days (IQR: 7.0–21.0). Waiting for transfer to lower-intensity care facilities was the primary cause of delayed discharge. Complications during delayed stays included delirium (31.3%) and hospital-acquired infections (35.4%), particularly urinary tract infections (17.7%). Logistic regression identified older age (≥75 years), extended hospital length of stay, emergency admissions, and discharge to long-term care as independent predictors of bed-blocker status. Conclusions: This study highlights delayed discharges as a significant issue in internal medicine wards, driven by advanced age, caregiver absence, and high dependency in activities of daily living.

To evaluate the muscle strength and functional level of patients discharged from intensive care unit (ICU) in relation to the swimmer position as a nurse intervention during pronation. Prospective study conducted in the hub COVID-19 center in Milan (Italy), between March and June 2020. All patients with COVID-19 discharged alive from ICU who received invasive mechanical ventilation were included. Forward continuation ratio model was fitted to explore the statistical association between muscle strength grades and body positioning during ICU stay. Over the 128 patients admitted to ICU, 87 patients were discharged alive from ICU, with available follow-up measures at hospital discharge. Thirty-four patients (39.1%) were treated with prone positioning as rescue therapy, for a total of 106 pronation cycles with a median duration of 72 (IQR 60–83) hours. Prone positioning did not influence the odds of showing particular level of muscle strength, in any of the evaluated districts, namely shoulder (OR 1.34, 95%CI:0.61–2.97), elbow (OR 1.10, 95%CI:0.45–2.68) and wrist (OR 0.97, 95%CI:0.58–1.63). Only in the shoulder district, age showed evidence of association with strength (OR 1.06, 95%CI:1.02–1.10), affecting people as they get older. No significant sequalae related to swimmer position were reported by physiotherapists or nurses. Swimmer position adopted during prone ventilation is not associated with worse upper limb strength or poor mobility level in COVID-19 survivors after hospital discharge.

Background: The combination of prone positioning and extracorporeal membrane oxygenation (ECMO) in patients with acute respiratory distress syndrome (ARDS) is recognized as safe but its use has been limited due to potential complications.Aim: To report the prevalence of pressure ulcers and other complications due to prone positioning in adult patients receiving veno–venous ECMO.Study Design: This cross‐sectional study was conducted in a tertiary level intensive care unit (ICU) in Milan (Italy), between January 2015 and December 2019. The study population was critically ill adult patients undergoing veno–venous ECMO. Statistical association between pressure ulcers and the type of body positioning (prone versus supine) was explored fitting a logistic model.Results: In the study period, 114 patients were treated with veno–venous ECMO and 62 (54.4%) patients were placed prone for a total of 130 prone position cycles. ECMO cannulation was performed via femoro–femoral configuration in the majority of patients (82.4%, 94/114). Pressure ulcers developed in 57.0% of patients (95%CI: 44.0%–72.6%), most often arising on the face and the chin (37.1%, 23/62), particularly in those placed prone. The main reason of prone positioning interruption was the decrease of ECMO blood flow (8.1%, 5/62). The fitted model showed no association between body position during ECMO and occurrence of pressure ulcers (OR 1.3, 95%CI: 0.5–3.6, p = .532).Conclusions: Facial pressure ulcers were the most frequent complications of prone positioning. Nurses should plan and implement evidence‐based care to prevent such pressure injuries in patients undergoing ECMO.Relevance to Clinical Practice: The combination of prone positioning and ECMO shows few life‐threating complications. This manoeuvre during ECMO is feasible and safe when performed by experienced ICU staff.

To investigate the impact of tracheostomy on clinical outcomes in adults with acute respiratory distress syndrome (ARDS) who require mechanical ventilation (MV). This systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Three electronic databases including PubMed, The Cochrane Library, and EMBASE to identify relevant studies on ARDS patients receiving MV were searched from inception to July 31, 2024. The reviewers assessed the risk of bias of included studies according to the Cochrane Risk of Bias 1 tool or JBI checklists, as appropriate. Two reviewers independently screened the literature and extracted the data. Outcomes among patients who underwent tracheostomy were compared and analyzed. Twenty studies involving 4,022 patients with ARDS who required tracheostomy were included, comprising 2 randomized controlled trials, 5 prospective studies, 12 retrospective studies, and 1 case series. On average, tracheostomized patients spent 30.2 days in the ICU and 44.8 days in the hospital, with an overall mean duration of MV of 27 days. Tracheostomy-related adverse events were reported in 15 studies and local bleeding was the most common complication. Of the 1,074 patients with tracheostomy, 626 (58.3%) were successfully weaned from the ventilator. Mortality outcomes were documented in 18 studies, indicating that 883 out of 2,302 (38.4%) of these patients died during hospitalization. Tracheostomy in MV patients with ARDS does not have a clearly defined impact on ICU length of stay due to variability in study findings. However, it remains a safe intervention with generally minor complications. Future research should focus on standardized weaning protocols and multidisciplinary rehabilitation strategies to potentially improve patient outcomes. Tracheostomy allows for a more controlled and gradual weaning process in patients with ARDS requiring prolonged MV. Moreover, although current evidence does not indicate a significant reduction in ICU length of stay, tracheostomy contributes to more effective patient management during the weaning by facilitating oral hygiene, improving mobility, and enabling both verbal communication and oral feeding.

To investigate the prevalence of upper limb peripheral nerve injuries (PNI) in adult patients admitted to the intensive care unit (ICU) with acute respiratory distress syndrome (ARDS) undergoing prone positioning. This systematic review with meta-analysis was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Meta-analysis of Observational Studies in Epidemiology (MOOSE) reporting guidelines. Four electronic databases including PubMed, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), The Cochrane Library, and EMBASE were searched from inception to January 2024. The quality of the included studies was evaluated according to the Joanna Briggs Institute Critical Appraisal Tools. A proportion meta-analysis was conducted to examine the combined prevalence of upper limb PNI among patients requiring prone positioning. A total of 8 studies (511 patients) were pooled in the quantitative analysis. All studies had a low or moderate risk of bias in methodological quality. The overall proportion of patients with upper limb PNI was 13% (95%CI: 5% to 29%), with large between-study heterogeneity (I² = 84.6%, P<0.001). Both ulnar neuropathy and brachial plexopathy were described in 4 studies. During the COVID-19 pandemic, prone positioning has been used extensively. Different approaches among ICU teams and selective reporting by untrained staff may be a factor in interpreting the large variability between studies and the 13% proportion of patients with upper limb PNI found in the present meta-analysis. Therefore, it is paramount to stress the importance of patient assessment both after discharge from the ICU and during subsequent follow-up evaluations. Specialized training is essential to ensure safe prone positioning, with careful consideration given to arms and head placement to mitigate potential nerve injuries. Therefore, healthcare protocols should incorporate preventive strategies, with patient assessments conducted by expert multidisciplinary teams.