Pressure ulcers in patients with COVID-19 acute respiratory distress syndrome undergoing prone positioning in the intensive care unit: A pre- and post-intervention study.

BACKGROUND: Prone positioning has been widely used to improve oxygenation and reduce ventilator-induced lung injury in patients with severe COVID-19 acute respiratory distress syndrome (ARDS). One major complication associated with prone positioning is the development of pressure ulcers (PUs). AIM: This study aimed to determine the impact of a prevention care bundle on the incidence of PUs in patients with COVID-19 ARDS undergoing prone positioning in the intensive care unit. STUDY DESIGN: This was a single-centre pre and post-test intervention study which adheres to the Standards for Reporting Implementation Studies (StaRI) guidelines. The intervention included a care bundle addressing the following: increasing frequency of head turns, use of an open gel head ring, application of prophylactic dressings to bony prominences, use of a pressure redistribution air mattress, education of staff in the early identification of evolving PUs through regular and rigorous skin inspection and engaging in bedside training sessions with nursing and medical staff. The primary outcome of interest was the incidence of PU development. The secondary outcomes of interest were severity of PU development and the anatomical location of the PUs. RESULTS: In the pre-intervention study, 20 patients were included and 80% (n = 16) of these patients developed PUs, comprising 34 ulcers in total. In the post-intervention study, a further 20 patients were included and 60% (n = 12) of these patients developed PUs, comprising 32 ulcers in total. This marks a 25% reduction in the number of patients developing a PU, and a 6% decrease in the total number of PUs observed. Grade II PUs were the most prevalent in both study groups (65%, n = 22; 88%, n = 28, respectively). In the post-intervention study, there was a reduction in the incidence of grade III and deep tissue injuries (pre-intervention 6%, n = 2 grade III, 6% n = 2 deep tissue injuries; post-intervention no grade III ulcers, grade IV ulcers, or deep tissues injuries were recorded). However, there was an increase in the number of unstageable PUs in the post-intervention group with 6% (n = 2) of PUs being classified as unstageable, meanwhile there were no unstageable PUs in the pre-intervention group. This is an important finding to consider as unstageable PUs can indicate deep tissue damage and therefore need to be considered alongside PUs of a more severe grade (grade III, grade IV, and deep tissue injuries). CONCLUSION: The use of a new evidence-based care bundle for the prevention of PUs in the management of patients in the prone position has the potential to reduce the incidence of PU development. Although improvements were observed following alterations to standard practice, further research is needed to validate these findings. RELEVANCE TO CLINICAL PRACTICE: The use of a new, evidence-based care bundle in the management of patients in the prone position has the potential to reduce the incidence of PUs.

Preventing facial pressure injuries among health care staff working in diverse COVID-19 care environments.

The aim of this study was to determine the impact of a specially designed care bundle on the development of facial pressure injuries among frontline health care workers wearing personal protective equipment (PPE) during the COVID-19 pandemic. This was a mixed methods study. First, a pre-posttest observational design was employed to evaluate the impact of the pre-piloted intervention, a care bundle including skin cleansing and hydration, protective material use, facemask selection and skin inspection, developed in line with international best practice guidelines. Data were collected using survey methodology. Frontline COVID-19 staff working in acute, community and ambulance services were invited to participate. Then, judgemental and volunteer sampling was used to select participants to undertake semi-structured interviews to elicit feedback on their perceptions of the care bundle. The sample included 120 acute hospital staff, 60 Ambulance staff, 24 Community Hub staff and 20 COVID-19 testing centre staff. A survey response rate of 61% was realised (n = 135/224). Of the participants, 32% (n = 43) had a facial pressure ulcer (FPI) pre-intervention and 13% (n = 18) developed an FPI while using the care bundle. The odds ratio (OR) was 0.33 (95% CI: 0.18 to 0.61; P = .0004), indicating a 77% reduction in the odds of FPI development with use of the care bundle. Analysis of the qualitative data from 22 interviews identified three key themes, the context for the care bundle, the ease of use of the care bundle and the care bundle as a solution to FPI development. The care bundle reduced the incidence of FPI among the participants and was found to be easy to use. Implementation of skin protection for frontline staff continues to be important given the persistently high incidence of COVID-19 and the ongoing need to wear PPE for protracted durations.

The effect of prone positioning on pressure injury incidence in adult intensive care unit patients: A meta-review of systematic reviews.

OBJECTIVE: Numerous systematic reviews have examined the impact of prone positioning on outcomes, including pressure injury (PI). The objective of this meta-review was to synthesise the evidence on the effect of prone positioning on the incidence and location of PIs in adult intensive care unit patients. REVIEW METHOD: This is a meta-review of published systematic reviews. Five databases were searched; data were extracted by three authors and adjudicated by a fourth. The AMSTAR-2 tool was used to quality appraise the selected articles, which was completed by three authors with a fourth adjudicating. RESULTS: Ten systematic reviews were synthesised. The cumulative incidence of PI in 15,979 adult patients ranged from 25.7% to 48.5%. One study did not report adult numbers. Only one review reported the secondary outcome of PI location. PIs were identified in 13 locations such as the face, chest, iliac crest, and knees. Using the AMSTAR-2, three reviews were assessed as high quality, six as moderate quality, and one as low quality. CONCLUSION: The high incidence of PI in the prone position highlights the need for targeted preventative strategies. Care bundles may be one approach, given their beneficial effects for the prevention of PI in other populations. This review highlights the need for proactive approaches to limit unintended consequences of the use of the prone position, especially notable in the current COVID-19 pandemic.

Facial pressure injuries and the COVID-19 pandemic: skin protection care to enhance staff safety in an acute hospital setting.

OBJECTIVES: The aim of this study was to determine the impact of a specially designed care bundle on the development of facial pressure injuries (PI) among frontline healthcare workers wearing personal protective equipment (PPE) during the COVID-19 pandemic. The primary outcome of interest was the incidence of facial PIs. The secondary outcomes of interest were facial pain while wearing PPE and ease of use of the care bundle. METHODS: This study used a voluntary survey by questionnaire, supplemented by a qualitative analysis of interviews from a small purposive sample that took place in one large Irish hospital over a two-month period in 2020. The hospital was a city-based public university teaching hospital with 800 inpatient beds. The intervention was a care bundle consisting of skin protection, face mask selection, material use, skin inspection, cleansing and hydration developed in line with international best practice guidelines. All staff working in COVID-19 wards, intensive care units and the emergency department in the hospital were given a kitbag containing the elements of the care bundle plus an information pamphlet. Data were collected via a survey and interviews. RESULTS: A total of 114 staff provided feedback on the use of the care bundle. Before using the care bundle 29% (n=33) of the respondents reported developing a facial PI, whereas after using the care bundle only 8% (n=9) of the respondents reported developing a facial PI. The odds ratio (OR) of skin injury development was 4.75 (95% confidence interval (CI): 2.15-10.49; p=0.0001), suggesting that after the care bundle was issued, those who responded to the survey were almost five times less likely to develop a skin injury. Interviews with 14 staff determined that the bundle was easy to use and safe. CONCLUSION: Among those who responded to the survey, the use of the bundle was associated with a reduction in the incidence of skin injury from 29% to 8%, and respondents found the bundle easy to use, safe and effective. As with evidence from the international literature, this study has identified that when skincare is prioritised, and a systematic preventative care bundle approach is adopted, there are clear benefits for the individuals involved.

Prevention of pressure ulcers among individuals cared for in the prone position: lessons for the COVID-19 emergency.

OBJECTIVE: Pressure ulcers (PUs) involve the destruction of skin and underlying tissue due to prolonged pressure and shear forces. These ulcers are painful and significantly reduce a person's quality of life. PUs are also expensive to manage and impact negatively on the achievement of cost-effective, efficient care delivery. METHOD: Prone positioning is a postural therapy that aims to enhance respiratory function through increasing oxygenation levels. In contemporary clinical practice, ventilation in the prone position is indicated for patients with severe acute respiratory distress syndrome. However, despite its advantages in terms of respiratory function, several studies have examined complications of prone position ventilation and have identified PUs (facial PUs as well as PUs on other weight-bearing areas of the body) as a frequent complication in patients who are already in a precarious medical situation. International data suggest that up to 57% of patients nursed in the prone position develop a PU. The aim of this clinical review is to identify and review evidence-based recommendations developed to facilitate the selection and application of preventive interventions aimed at reducing PU development in patients ventilated in the prone position. Given the current COVID-19 crisis, this review is timely as intensive care unit (ICU) patients with COVID-19 require ventilation in the prone position at a level that is disproportionate to the general intensive care population. Up to 28% of patients admitted to the ICU with confirmed infection due to severe COVID-19 are cared for in the prone position. The scope of this review is limited to adult individuals only. RESULTS: The skin assessment should be undertaken before proning and following positioning the patient back into the supine position. Although it is essential to keep the skin clean and moisturised, using pH-balanced cleansers, there is inconsistency in terms of the evidence to support the type of moisturiser. Use of positioning devices in addition to repositioning is recommended to offload pressure points on the face and body. Further, using dressings such as hydrocolloids, transparent film and silicone may be of benefit in decreasing facial skin breakdown. CONCLUSION: Given the importance of PU prevention in this cohort of patients, adopting a focused prevention strategy, including skin assessment and care, offloading and pressure redistribution, and dressings for prevention may contribute to a reduction in the incidence and prevalence of these largely preventable wounds.