Hospital-Acquired Pressure Injuries in Adults With Prone Positioning Using Manual Method Versus Specialty Bed: A Retrospective Comparison Cohort Study.

PURPOSE: The purpose of this study was to compare the incidence of hospital-acquired pressure injuries (HAPIs) in patients with acute respiratory distress syndrome (ARDS) and placed in a prone position manually or using a specialty bed designed to facilitate prone positioning. A secondary aim was to compare mortality rates between these groups. DESIGN: Retrospective review of electronic medical records. SUBJECTS AND SETTING: The sample comprised 160 patients with ARDS managed by prone positioning. Their mean age was 61.08 years (SD = 12.73); 58% (n = 96) were male. The study setting was a 355-bed community hospital in the Western United States (Stockton, California). Data were collected from July 2019 to January 2021. METHODS: Data from electronic medical records were retrospectively searched for the development of pressure injuries, mortality, hospital length of stay, oxygenation status when placed in a prone position, and the presence of a COVID-19 infection. RESULTS: A majority of patients with ARDS were manually placed in a prone position (n = 106; 64.2%), and 54 of these patients (50.1%) were placed using a specialty care bed. Slightly more than half (n = 81; 50.1%) developed HAPIs. Chi-square analyses showed no association with the incidence of HAPIs using manual prone positioning versus the specialty bed (P = .9567). Analysis found no difference in HAPI occurrences between those with COVID-19 and patients without a coronavirus infection (P = .8462). Deep-tissue pressure injuries were the most common type of pressure injury. More patients (n = 85; 80.19%) who were manually placed in a prone position died compared to 58.18% of patients (n = 32) positioned using the specialty bed (P = .003). CONCLUSIONS: No differences in HAPI rates were found when placing patients manually in a prone position versus positioning using a specialty bed designed for this purpose.

Incidence of hospital acquired pressure injury in critically ill patients with COVID-19 in prone position admitted to the intensive care unit.

Critical patients have conditions that may favor the occurrence of hospital-acquired pressure injury (HAPI). The objective of this study was to identify the incidence and factors associated with the occurrence of HAPI in patients with coronavirus disease 2019 admitted to the intensive care unit (ICU) who used the prone position. Retrospective cohort study carried out in an ICU of a tertiary university hospital. Two hundred four patients with positive real-time polymerase chain reactions were evaluated, of which 84 were placed in the prone position. All patients were sedated and submitted to invasive mechanical ventilation. Of the prone patients, 52 (62%) developed some type of HAPI during hospitalization. The main place of occurrence of HAPI was the sacral region, followed by the gluteus and thorax. Of the patients who developed HAPI, 26 (50%) had this event in places possibly associated with the prone position. The factors associated with the occurrence of HAPI in patients prone to coronavirus disease 2019 were the Braden Scale and the length of stay in the ICU. The incidence of HAPI in prone patients was extremely high (62%), which denotes the need to implement protocols in order to prevent the occurrence of these events.

Characteristics of COVID-19 patients who developed pressure injuries: a scoping review.

OBJECTIVE: To describe the characteristics of patients with COVID-19 who developed pressure injuries (PIs), the characteristics of PIs experienced, and the incidence and prevalence of PIs among the patients with COVID-19. PIs are associated with increased morbidity, mortality and healthcare expense. PIs have been reported among patients who have contracted COVID-19. Understanding the characteristics of COVID-19 patients, and how PIs are prevented and managed, may inform care and optimise the outcomes for COVID-19-positive patients. METHOD: A scoping review was conducted. All study designs, including grey literature, published in the English language from December 2019 to March 2021, reporting on patients with COVID-19 and PIs, were included. RESULTS: In total, 27 publications (n=4820 patients) were included in the review. The reported incidence rate of PIs was 7.3-77.0%. The causative factors noted were: prone positioning (28.5%); medical devices (21.4%); and medical devices used during prone positioning (14.2%). The most common PI sites were the cheeks (18.7%). PIs occurred on average at 14.7 days post-acute care admission. Of the PIs where staging information was specified (67.7%), the most common was Stage 2/II (45.2%). PI risk may intensify on account of the intrinsic mechanism of COVID-19-associated intensive care treatment. CONCLUSION: PI prevention and management should be prioritised for patients with COVID-19, given the reported high prevalence of PIs and exacerbated risk arising from the use of prone position and medical devices. Further research is required to understand the association between COVID-19 and PIs, and to guide effective prevention and treatment approaches.

Pressure Injury Prevention in Patients in Prone Position With Acute Respiratory Distress Syndrome and COVID-19.

INTRODUCTION: In patients with acute respiratory distress syndrome, prone positioning improves oxygenation and reduces mortality. Pressure injuries occur frequently because of prolonged prone positioning in high-risk patients, and preventive measures are limited. This article describes 2 patients who developed minimal pressure injuries despite several prone positionings. Prevention strategies are also described. CLINICAL FINDINGS: A 64-year-old man and a 76-year-old woman were admitted to the hospital with respiratory insufficiency. Due to acute respiratory distress syndrome, both patients were intubated and received mechanical ventilation and prone positioning. DIAGNOSIS: Both patients had positive test results for SARS-CoV-2 and a diagnosis of acute respiratory distress syndrome. INTERVENTIONS: Patient 1 was in prone position for 137 hours during 9 rounds of prone positioning; patient 2, for 99 hours during 6 rounds of prone positioning. The standardized pressure injury prevention bundle for prone positioning consisted of skin care, nipple protection with a multilayer foam dressing, a 2-part prone positioning set, and micropositioning maneuvers. For both patients, 2-cm-thick mixed-porosity polyurethane foam was added between skin and positioning set in the thoracic and pelvic areas and a polyurethane foam cushion was added under the head. OUTCOMES: Patient 1 developed no pressure injuries. Patient 2 developed category 2 pressure injuries on the chin and above the right eye during deviations from the protocol. CONCLUSION: For both patients, the additional application of polyurethane foam was effective for preventing pressure injuries. These case reports support the addition of polyurethane foam to prevent pressure injuries in patients placed in the prone position.

Incidence of facial pressure injuries in health-care professionals during the COVID-19 pandemic: A systematic review and meta-analysis.

AIM: To evaluate the incidence of facial pressure injuries in health-care professionals during the COVID-19 pandemic in a meta-analysis. METHODS: Related studies were obtained through electronic databases, including PubMed, Embase, Cochrane Library, Web of Science, China National Knowledge Infrastructure (CNKI) Chinese Scientific Journal (VIP) China Biomedical Literature service systems (CBM) and Wanfang Data (from inception to 27 November 2021). The pooled incidence and the 95% confidence interval of facial pressure injuries were calculated with Review Manager v5.4 software. RESULTS: Overall, 16 studies with 14 430 health-care professionals were included. Pooled results showed that the pooled incidence of facial pressure injury in health-care professionals was 58.8% (95% CI: 49.0%-68.7%; p < 0.01). The results of the subgroup analysis showed that the incidence of facial pressure injury in these staff was high, and predominantly stage I pressure injury, in the following cases: in health-care professionals who wore personal protective equipment for longer than 4 h, in those without any training experience, and on the nose. CONCLUSION: Administrators and researchers should pay attention to preventing facial pressure injury related to the wearing of personal protective equipment (PPE) by ensuring all health-care professionals receive training and by limiting prolonged periods of use.

Influencing factors of medical device-related pressure ulcers in medical personnel during the COVID-19 pandemic: A systematic review and meta-analysis.

OBJECTIVE: To determine the influencing factors of medical device related pressure injury (MDRPU) in medical staff by meta-analysis. METHODS: A comprehensive literature search was conducted by PubMed, Embase, Cochrane Library, Web of Science, CNKI, VIP, CBM, and WanFang Data (from inception to July 27, 2022). Two researchers independently performed literature screening, quality evaluation and data extraction, and meta-analysis was conducted with RevMan 5.4 and Stata12.0 software. RESULTS: Total of 11215 medical staff were included in 9 articles. Meta analysis showed that gender, occupation, sweating, wearing time, single working time, department of COVID-19, preventive measures, and level 3 PPE were the risk factors for MDRPU in medical staff (P < 0.05). CONCLUSION: The outbreak of COVID-19 led to the occurrence of MDRPU among medical staff, and the influencing factors should be focused on. The medical administrator can further improve and standardize the preventive measures of MDRPU according to the influencing factors. Medical staff should accurately identify high-risk factors in the clinical work process, implement intervention measures, and reduce the incidence of MDRPU.

EffEctiveness of Prophylactic fOam dressings in the prevention of saCral pressure injuries in at-risk hospitalised patients: the EEPOC trial.

BACKGROUND: Prophylactic dressings are increasingly used to prevent pressure injuries in hospitalised patients. However, evidence regarding the effectiveness of these dressings is still emerging. This trial aims to determine the clinical and cost-effectiveness of a prophylactic silicone foam border dressing in preventing sacral pressure injuries in medical-surgical patients. METHODS: This is a multicentre, pragmatic, parallel group, randomised controlled trial. A sample size of 1320 was calculated to have >90% power to detect a 5% difference in the primary outcome at an alpha of 0.05. Adult patients admitted to participating medical-surgical wards are screened for eligibility: ≥18 years, admitted to hospital within the previous 36 h, expected length of stay of ≥24 h, and assessed high risk for hospital-acquired pressure injury. Consenting participants are randomly allocated to either prophylactic silicone foam dressing intervention or usual care without any dressing as the control group via a web-based randomisation service independent of the trial. Patients are enrolled across three Australian hospitals. The primary outcome is the cumulative incidence of patients who develop a sacral pressure injury. Secondary outcomes include the time to sacral pressure injury, incidence of severity (stage) of sacral pressure injury, cost-effectiveness of dressings, and process evaluation. Participant outcomes are assessed daily for up to 14 days by blinded independent outcome assessors using de-identified, digitally modified sacral photographs. Those who develop a sacral pressure injury are followed for an additional 14 days to estimate costs of pressure injury treatment. Analysis of clinical outcomes will be based on intention-to-treat, per-protocol, and sensitivity analyses. DISCUSSION: This trial aims to provide definitive evidence on the effect prophylactic dressings have on the development of hospital-acquired sacral pressure injuries in medical-surgical patients. A parallel economic evaluation of pressure injury prevention and treatment will enable evidence-informed decisions and policy. The inclusion of a process evaluation will help to explain the contextual factors that may have a bearing on trial results including the acceptability of the dressings to patients and staff. The trial commenced 5 March 2020 and has been significantly delayed due to COVID-19. TRIAL REGISTRATION: ANZCTR ACTRN12619000763145. Prospectively registered on 22 May 2019.

Pressure Injury Management in Critically Ill Patients with COVID-19 in a Makeshift Hospital in Indonesia: A Report of Two Cases.

ABSTRACT: Patients who are critically ill with COVID-19 need ventilation support in the ICU. However, ICU patients are at higher risk of developing a pressure injury (PI). Unfortunately, PI prevention is not optimally implemented in Indonesia, especially in the makeshift hospitals created during the COVID-19 pandemic. Here, the authors report two cases of critically ill patients with COVID-19 who developed large sacral PIs during hospitalization in a makeshift hospital in Indonesia. The first patient developed a stage 3, 7 × 7-cm sacral PI on the 14th day of hospitalization. The second patient developed a stage 4, 12 × 8-cm sacral PI on the 16th day of hospitalization. Both patients had elevated d-dimer levels and used a noninvasive ventilator for 1 week. The wounds were treated with surgical debridement, silver hydrogel dressing, and hydrocolloid dressing and complemented with static air mattress overlay. The authors recommend that in situations where there is a shortage of healthcare workers, the government should provide pressure-redistribution devices and silicone foam dressings for all critically ill patients to prevent PI development and lighten the workload of healthcare workers.

Pressure Injury Risk Assessment and Prevention in Patients With COVID-19 in the Intensive Care Unit.

BACKGROUND: Patients critically ill with COVID-19 are at risk for hospital-acquired pressure injury, including device-related pressure injury. METHODS: Braden Scale predictive validity was compared between patients with and without COVID-19, and a logistic regression model was developed to identify risk factors for device-related pressure injury. RESULTS: A total of 1920 patients were included in the study sample, including 407 with COVID-19. Among the latter group, at least 1 hospital-acquired pressure injury developed in each of 120 patients (29%); of those, device-related pressure injury developed in 55 patients (46%). The Braden Scale score area under the receiver operating characteristic curve was 0.72 in patients without COVID-19 and 0.71 in patients with COVID-19, indicating fair to poor discrimination. CONCLUSIONS: Fragile skin and prone positioning during mechanical ventilatory support were risk factors for device-related pressure injury. Clinicians may consider incorporating factors not included in the Braden Scale (eg, oxygenation and perfusion) in routine risk assessment and should maintain vigilance in their efforts to protect patients with COVID-19 from device-related pressure injury.

Protective equipment-related pressure ulcers in healthcare workers during COVID-19 pandemic: A systematic review.

AIM: This systematic review was carried out to examine pressure ulcers in healthcare staff due to the use of protective equipment during COVID-19 pandemic and the precautions taken to prevent these injuries. METHOD: Relevant studies were retrospectively searched. Seven English keywords identified from MESH were used while searching. The search was carried out in five international databases by trying various combinations of these words during February 15-25, 2021. This systematic review was updated by rescanning databases on December 20, 2021 and a total of 611 studies were attained. RESULTS: 17 studies which met the study inclusion criteria, which were conducted mostly through online survey method in different study designs and which included a total of 24,889 healthcare professionals were examined. The incidence of PPE-related pressure ulcers was found to be between 30% and 92.8%. Grade I pressure ulcers were the most common (44.1%-82%). The incidence of skin problems except PPE-related pressure ulcers such as itching, redness and dry skin was found to be between 42.8-88.1%. Risk factors that frequently played a role in the development of PPE-related pressure ulcers and other skin problems were longer use of PPE and sweating. PPE-related pressure ulcers and other skin problems were more frequent over the nose (nasal bone/nasal bridge), ears, forehead and cheeks. PPE-related itching, redness and dry skin mostly occurred. Several dressing applications were found to be effective in the prevention of PPE-related pressure ulcers and other skin problems that might develop especially on the facial region. CONCLUSION: PPE-related pressure ulcers and other skin problems were found to be higher among healthcare professionals. Data regarding the sealing of dressing applications against viral transmission in the prevention of PPE-related pressure ulcers and other skin problems are limited. It is estimated that future studies will be performed to prevent device-related pressure ulcers in healthcare workers. It is suggested that there is a need to conduct studies with larger samples where expert researchers make observations for pressure ulcers in order to determine the prevalence and incidence of PPE-related pressure ulcers.

Skin injuries due to Personal Protective Equipment and preventive measures in the COVID-19 context: an integrative review. / Lesões de pele por Equipamentos de Proteção Individual e medidas preventivas no contexto da COVID-19: revisão integrativa.

OBJECTIVE: to identify the diverse scientific evidence on the types of skin lesions caused due to the use of Personal Protective Equipment in health professionals during the COVID-19 pandemic and to verify the recommended prevention measures. METHOD: this is an integrative review carried out in the MEDLINE, CINAHL, LILACS, SCOPUS, Science Direct, Web of Science and SciELO databases. The search was conducted in a paired manner, constituting a sample of 17 studies categorized according to the types of skin lesions and preventive measures. RESULTS: the main types of skin lesions related to mask use were stage 1 pressure ulcers, acne and cutaneous depression. Regarding the use of glasses and face shields, the most frequent were stage 1 and 2 pressure ulcers. Xerosis and irritant contact dermatitis occurred due to using gloves and protective clothing, respectively. The main preventive measures recommended were using hydrocolloid or foam dressing in the pressure regions, moisturizers and emollients. CONCLUSION: a considerable number of skin lesions associated with using the equipment were noticed, and the data obtained can guide the professionals in identifying risks and promoting preventive measures to avoid their occurrence.

Auditing completion of nursing records as an outcome indicator for identifying patients at risk of developing pressure ulcers, falling, and social vulnerability: An observational study.

AIM: To evaluate the completion of nursing records through scheduled audits to analyse risk outcome indicators. BACKGROUND: Nursing records support clinical decision-making and encourage continuity of care, hence the importance of auditing their completion in order to take corrective action where necessary. METHOD: This was an observational descriptive study carried out from February to November 2020 with a sample of 1131 electronic health records belonging to patients admitted to COVID-19 hospital units during three observation periods: pre-pandemic, first wave, and second wave. RESULTS: A significant reduction in nursing record completion rates was observed between pre-pandemic period and first and second waves: Braden scale 40.97%, 28.02%, and 30.99%; Downton scale: 43.74%, 22.34%, and 33.91%; Gijón scale: 40.12%, 26.23%, and 33.64% (p < 0.001). There was an increase in the number of records completed between the first and second waves following the measures adopted after the quality audit. CONCLUSIONS: The use of scheduled audits of nursing records as quality indicators facilitated the detection of areas for improvement, allowing timely corrective actions. IMPLICATIONS FOR NURSING MANAGEMENT: Support from nursing managers at health care facilities to implement quality assessment programmes encompassing audits of clinical record completion will encourage the adoption of measures for corrective action.

Facial ulcers in patients with COVID-19 admitted to ICU: review of the evidence.

OBJECTIVE: Many patients with COVID-19 admitted to intensive care undergo prone positioning. These patients are at risk of developing facial pressure ulcers (PUs). This study aimed to identify evidence-based recommendations to prevent or reduce their incidence. METHOD: A multi-case study was undertaken using secondary data published between November 2020 and April 2021 discussing facial PUs in patients with COVID-19. CINAHL and MEDLINE electronic databases were analysed. Sixteen publications met the inclusion criteria. The overall quality of evidence was low. RESULT: Studies reported a high incidence of facial PUs. The evidence suggests key preventive areas are skin assessment, pressure-redistribution surfaces, eye coverings, education, medical devices and prophylactic dressings. Recommendations included skin cleaning and moisturising, eye coverings, replacing endotracheal tube holders and using hydrocolloid or film dressings. CONCLUSION: Considering the severe implications for patients and healthcare systems caused by facial PUs, ICUs should develop strategies to prevent and minimise them.

Pressure injuries during the SARS-CoV-2 pandemic: A retrospective, case-control study.

AIM OF STUDY: The main objective of this study was to ascertain whether severe alterations in hypoxemic, inflammatory, and nutritional parameters in patients diagnosed with SARS-CoV-2 infection were associated with the occurrence and severity of developed dependency-related injuries. The secondary objective was to determine whether there were prognostic factors associated with the occurrence and severity of developed dependency-related injuries during the SARS-CoV-2 pandemic. MATERIAL AND METHODS: A retrospective, single-centre, case-control study was conducted to compare SARS-CoV-2 patients who developed dependency-related injuries after the first 48 h after admission with a control group made up of SARS-CoV-2 patients without dependency-related injuries. The cases of the 1987 patients diagnosed with SARS-CoV-2 infection during the study period were reviewed. Data from 94 patients who developed dependency-related injuries and from 190 patients who did not develop them during hospital admission were analysed. RESULTS: High baseline dependency levels, prolonged hospital stays, and low oxygen saturation levels on arrival in emergency department triage were associated with the occurrence of dependency-related injuries among patients diagnosed with SARS-CoV-2 infection. CONCLUSIONS: SARS-CoV-2 infection can lead to complications such as dependency-related injuries. Although there are several non-modifiable variables associated with the occurrence of dependency-related injuries in these patients, it is essential to conduct further research and introduce consensus guidelines to reduce their incidence and prevalence.

Medical Device-Related Pressure Injuries in Infants and Children.

PURPOSE: The purpose of this study was to describe medical device-related pressure injuries (MDRPIs) in hospitalized pediatric patients. DESIGN: A prospective, descriptive study. SAMPLE/SUBJECTS AND SETTING: The sample comprised 625 patients cared for in 8 US pediatric hospitals. Participants were aged preterm to 21 years, on bed rest for at least 24 hours, and had a medical device in place. METHODS: Two nursing teams, blinded to the other's assessments, worked in tandem to assess pressure injury risk, type of medical devices in use, and preventive interventions for each medical device. They also identified the presence, location, and stage of MDRPI. Subjects were observed up to 8 times over 4 weeks, or until discharge, whichever occurred first. RESULTS: Of 625 enrolled patients, 42 (7%) developed 1 or more MDRPIs. Two-thirds of patients with MDRPIs were younger than 8 years. Patients experiencing MDRPIs had higher acuity scores on hospital admission, were more frequently cognitively and/or functionally impaired, or were extreme in body mass index. Respiratory devices caused the most injuries (6.19/1000 device-days), followed by immobilizers (2.40/1000 device-days), gastric tubes (2.24/1000 device-days), and external monitoring devices (1.77/1000 device-days). Of the 6336 devices in place, 36% did not have an MDRPI preventive intervention in place. Clinical variables contributing to MDRPI development included intensive care unit care (odds ratio [OR] 8.9, 95% confidence interval [CI] 1.9-43.6), use of neuromuscular blockade (OR 3.7, 95% CI 1.7-7.8), and inotropic/vasopressor medications (OR 2.7, 95% CI 1.7-4.3). Multivariable analysis indicated that Braden QD scores alone predicted MDRPI development. CONCLUSION: Medical devices are common in hospitalized infants and children and these medical devices place patients at risk for MDRPI.

Prevención de lesiones cutáneas causadas por productos y equipos de protección personal durante COVID-19: revisión de alcance.

OBJECTIVE: Identify, summarise and present key recommendations published in the literature to prevent skin damage in health professionals as a result of personal protective equipment (PPE) during the covid-19 pandemic. METHOD: A scoping review, based on the Joanna Briggs Institute guidelines, was carried out between December 2019 and May 2020. The studies included male and female health professionals, who wore PPE during the global pandemic, in any given scenario. Headings and abstracts were analysed. Two independent investigators reviewed the full text. RESULTS: Eight publications were included. All of them focused on preventing pressure ulcers (PU) caused by PPE. Hygiene, hydration and the use of skin barriers were highlighted as preventive measures. There were different views around the type of humectant/skin barrier recommended to avoid skin damage. CONCLUSION: More studies identifying the most suitable strategies to maintain health professionals' skin integrity during the covid-19 pandemic are needed.

OBJETIVO: Identificar, resumir y presentar las recomendaciones publicadas para prevenir lesiones cutáneas (cualquier alteración de la piel) por el uso de productos y equipos de protección personal (EPP) en profesionales de la salud durante la pandemia del COVID-19. MÉTODO: Se realizó una revisión de alcance, basada en las sugerencias del Instituto Joanna Briggs, entre diciembre de 2019 y mayo de 2020. Se incluyeron estudios realizados con profesionales de la salud de ambos sexos, que utilizaron productos y EPP durante la pandemia, en cualquier escenario de la atención sanitaria. Se examinaron los títulos y resúmenes de los estudios. Dos revisores independientes evaluaron el texto completo, según los criterios de inclusión establecidos. RESULTADOS: Ocho publicaciones fueron seleccionadas. Todas se centraron en los cuidados relacionados con la prevención de lesiones por presión (LPP). Resaltaron la higiene e hidratación, y el uso de protectores cutáneos como medidas preventivas. CONCLUSIÓN: Es necesario llevar a cabo investigaciones en busca de mejores estrategias para mantener la integridad de la piel de los profesionales de la salud en el ejercicio de su profesión durante el COVID-19. CONFLICTO DE INTERÉS: Este artículo es parte de un proyecto apoyado por el Ministerio de Ciencia, Tecnología e Innovaciones (MCTI) y el Consejo Nacional de Desarrollo Científico y Tecnológico (CNPq) de Brasil.