Pressure Injuries Due to Personal Protective Equipment in COVID-19 Critical Care Units

Association between skin injuries and the importance atributed to prevention by health professionals during the pandemic

OBJECTIVE

To verify the association between the occurrence of skin lesions due to the use of products and/or personal protective equipment and the importance attributed to preventive care among health professionals working on the front lines of the struggle against the COVID-19 pandemic.

METHOD

Cross-sectional, analytical study, carried out between May and June 2020, with a convenience sample (n=398) of health workers from 10 professional categories. To verify the existence of an association between the occurrence of skin lesions and exposure variables, a Contingency Table was used to obtain the Prevalence Ratio and respective Confidence Intervals.

RESULTS

260 (65.3%) participants self-declared the development of skin lesions, predominantly nurses (53.8%), women (54.0%), from public institutions (52.8%), characterized by pressure injuries (37.3%), contact/allergic dermatitis (25.8%), or both lesions simultaneously (16.5%). More than half of professionals (53.5%) used preventive products, mainly moisturizers (51.0%).

CONCLUSION

There was probability of an association between professionals who attributed less importance to the predictor "Protocol for proper product PPE and products" and the risk of skin injuries.

Determinants of increased nursing workload in the COVID-era: A retrospective analysis of prospectively collected data

BACKGROUND

COVID-19 is associated with increased nursing workload, therefore a high nurse-to-patient ratio would be required.

AIM

To analyse difference in nursing workload, as expressed with the Nursing Activities Score (NAS), between COVID-19 patients versus control patients without COVID-19 disease (NCOVID-19 group) in an Italian Extracorporeal Membrane Oxygenation (ECMO) centre.

STUDY DESIGN

Retrospective analysis of prospectively collected data, enrolling consecutive patients admitted to a general Intensive Care Unit, between 1st May 2019 and 28th February 2021. A multivariate analysis was then performed to assess if COVID-19 disease was an independent predictor of higher NAS and to assess which other factors and procedures are independently associated with increased workload.

RESULTS

We enrolled 574 patients, of which 135 (24%) were in the COVID-19 group and 439 (76%) in the NCOVID-19 group. The average NAS was higher in the COVID-19 group (79 ± 11 vs. 65 ± 15, T = -10.026; p < 0.001). Prone positioning, continuous renal replacement therapy (CRRT) and ECMO were used more frequently in the COVID-19 group. A higher fraction of patients in the COVID group showed colonization from multidrug resistant bacteria. COVID-19 group had a higher duration of mechanical ventilation and longer ICU stay. The COVID-19 diagnosis was independently associated with a higher NAS. Other independent predictors of higher NAS were the use of prone positioning and continuous renal replacement therapy (CRRT). Colonization from multidrug resistant bacteria and ECMO support were not independently associated with higher NAS.

CONCLUSIONS

The higher nursing workload in COVID-19 patients is mainly due to specific procedures required to treat the most hypoxemic patients, such as prone positioning. Colonization with multidrug resistant bacteria and ECMO support were not independently associated with a higher NAS.

RELEVANCE TO CLINICAL PRACTICE

Higher workload in COVID-19 patients was due to specific interventions, such as prone positioning and CRRT, with the related nursing activities, as continuous presence at patient's bed, mobilization, positioning and complex hygienic procedures.

Skin problems associated with using of personal protective equipment in COVID-19 intensive care units

BACKGROUND

Health care workers, who worked intensively during the COVID-19 pandemic, faced some problems, including skin problems, due to the personal protective equipment (PPE) they used to control the spread of infection.

AIMS

This study aimed to identify the skin problems because of using PPE by nurses during the delivery of health care in three COVID-19 intensive care units (ICUs) within one hospital service.

STUDY DESIGN

The study was designed as a cross-sectional survey. The study was conducted with nurses working in three intensive care units in the metropolitan districts of Ankara, Turkey. The data were collected online with a questionnaire developed by the researchers between December 2021 and June 2022.

RESULTS

In this study, 82/120 (68.33%) nurses responded to the questionnaire at least once during the distribution period. The mean of the duration of PPE utilization per each time including goggles, N95 mask, bonnet, face-shield, gloves, boots/shoe covers and coverall was 3.76 ± 1.36 h. The proportion of nurses who experienced any skin problem related to any PPE at least two or more was 74/82 (90.24%). The proportion of pressure sores, acne, skin reaction including allergic dermatitis or contact urticaria, and regional pain varied between 4.9% and 79.3%. The proportion of nurses who applied any protective application to prevent skin problems was 53.66%. Among the protective applications, pressure-reducing surfaces were used the most. The use of protective applications for goggles (p = .010), bonnet (p = .000) and face shield (p = .000) effectively reduced PPE-related skin problems.

CONCLUSION

During the pandemic, nurses faced a wide variety of skin problems because of PPEs. It may be beneficial to design a study programme that reduces the duration of PPEs use in clinics. In addition, there is a need for effective protective applications to prevent skin problems and new development of PPE that do not cause skin problems.

RELEVANCE TO CLINICAL PRACTICE

In the pandemic, skin problems have developed because of the use of PPE in nurses who provide health care, intensively. These problems, which were not seen as a priority in the pandemic, may adversely affect the health of nurses, their performance in the treatment and care process and their work quality.

Physical Burden and Perceived Stress of Personal Protective Equipment During COVID-19 Pandemic: A Retrospective Study in the United Arab Emirates

Introduction

Over the course of the COVID-19 pandemic, personal protective equipment (PPE) has become necessary. According to published research, PPE-related physical impacts were probably underreported during the pandemic.

Objective

To examine the physical burden and perceived stress associated with prolonged PPE wearing among nurses during the COVID-19 pandemic in the United Arab Emirates (UAE).

Methods

This was a cross-sectional retrospective study of 209 nurses working in two hospitals in the UAE. A convenience sampling technique was applied, and the data were collected using an online questionnaire. Data collection was completed within three months (April 2022 to June 2022). The completed questionnaires were analyzed using SPSS version 21. Chi-square statistics was used to test the association of categorical variables at a 5% level of significance.

Results

A total of 209 nurses had a mean age of 38.4 ± 8.7 years. More than 65.1% wore PPE continuously for 4 hrs per day. The most common physical burdens reported were difficulty in breathing (62.2%), excessive thirst (41.6%), and facial itchiness (39.2%). Most participants (95.2%) reported high-stress levels. There was no significant association between the level of stress and the duration of wearing PPE (p = .43 > .05). However, the authors found a statistically significant association between breathing difficulty with face masks and the duration of wearing them (p < .05). In addition, itchiness/rash related to gloves was significantly associated with wearing duration (p < .05).

Conclusion

Findings show that nurses experienced adverse effects from PPE use, which increased with the number of hours of wearing. Further studies with a larger sample size will allow for generalization of the study results.

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.

Skin lesions resulting from use of personal protective equipment in the context of COVID-19: a cross-sectional study

OBJECTIVE

During the SARS-CoV-2 (COVID-19) pandemic, to prevent the transmission of the virus, the use of personal protection products and equipment were recommended by international and national organisations. The need to use it more frequently and for a long time can damage the skin of health professionals. The aim of this study was to estimate the prevalence and factors associated with skin lesions in health professionals resulting from the use of personal protective equipment (PPE).

METHOD

This was a cross-sectional exploratory study through an online questionnaire. The first part of the questionnaire collected socio-labour characterisation data and the second part related to exposure factors. The variables were analysed according to the prevalence and the odds ratio (OR), within a 95% confidence interval (CI).

RESULTS

Of the 398 participants who met the inclusion criteria, 65.3% were self-diagnosed with skin lesions: 37.3% with pressure injury, 25.8% with contact/allergic dermatitis and 2.7% with acne. Regarding the use of PPE, of the 240 professionals who reported using an N95 mask, 80.4% developed injuries, 70.4% of which related to a work regime of >6 hours per day (OR: 2.08, 95% CI: 1.79-2.42).

CONCLUSION

The results of this study showed a significant prevalence of skin lesions in health professionals. Among exposure factors, the N95 mask and goggles stand out. Longer or more frequent exposure time to personal protective products and equipment proved to be important factors to be considered.

The prevalence of facial pressure injuries among nurses during COVID-19 pandemic and its relationship to COVID-19 infection

AIM

The aim of this study was to investigate the prevalence of facial pressure injuries related to personal protective equipment use in nurses and the relationship with getting COVID-19 infection.

DESIGN

The study used descriptive and correlational online survey design.

METHODS

Nurses in Turkey were recruited via an electronic link sent to their social media platforms (e.g., Facebook, Instagram, Twitter), WhatsApp, and e-mail during the study: March-April 2021. Of them, 603 participants completed the survey form from all over Turkey.

RESULTS/FINDINGS

Facial pressure injuries develop in nurses due to use of personal protective equipment. The rates of facial pressure injuries were higher in the nurses who were younger (p=0.002) and those who had less experience years (p=0.005) than the other nurses. The statistically significant variables were determined as age, status of using face shield, status of wearing overalls and status of wearing shoe covers (p<0.05). We determined that facial pressure injuries were not significantly associated with getting COVID-19 infection (p>0,05).

CONCLUSIONS

This study showed that facial pressure injuries associated with personal protective equipment use among nurses, who work on the frontlines in the COVID-19 pandemic period, is highly prevalent. Experiencing facial pressure injuries did not have a significant effect on the participants' statuses of getting infected with COVID-19. Providing training in health institutions may present an effective strategy in lowering problems.

Covid-19 and personal protective equipment: The experience of nurses engaged in care of Sars-Cov-2 patients: A phenomenological study

AIM

The study aims to explore the experiences of nurses who have worked in Covid-19 wards providing care for Covid-19 patients.

BACKGROUND

During the Covid-19 pandemic, personal protective equipment (PPE) was considered an effective and guaranteed protective measure.

METHODS

This is a descriptive qualitative study with thematically analysed interviews. Twelve nurses working (specify context) were interviewed.

RESULT

Three themes emerged from interviews: (1) confidence with PPE used during the Covid-19 crisis, (2) training in the use of PPE and (3) technical requirements for PPE.

CONCLUSIONS

This study clarified the importance of PPE quality and choice in establishing comfort for nurses and providing better patient care. These results could suggest useful elements to improve the PPE products by making them more comfortable for health care workers.

IMPLICATIONS FOR NURSING MANAGEMENT

Our results are important to promote and suggest prevention measures that are as comfortable and suitable as possible for health workers involved in the Covid-19 emergency, and also for potential future similar crises.

Prevention of Endotracheal Tube-Related Pressure Injury: A Systematic Review and Meta-analysis

BACKGROUND

Hospital-acquired pressure injuries, including those related to airway devices, are a significant source of morbidity in critically ill patients.

OBJECTIVE

To determine the incidence of endotracheal tube-related pressure injuries in critically ill patients and to evaluate the effectiveness of interventions designed to prevent injury.

METHODS

MEDLINE, Embase, CINAHL, and the Cochrane Library were searched for studies of pediatric or adult patients in intensive care units that evaluated interventions to reduce endotracheal tube-related pressure injury. Reviewers extracted data on study and patient characteristics, incidence of pressure injury, type and duration of intervention, and outcomes. Risk of bias assessment followed the Cochrane Collaboration's criteria.

RESULTS

Twelve studies (5 randomized clinical trials, 3 quasi-experimental, 4 observational) representing 9611 adult and 152 pediatric patients met eligibility criteria. The incidence of pressure injury was 4.2% for orotracheal tubes and 21.1% for nasotracheal tubes. Interventions included anchor devices, serial endotracheal tube assessment or repositioning, and barrier dressings for nasotracheal tubes. Meta-analysis revealed that endotracheal tube stabilization was the most effective individual intervention for preventing pressure injury. Nasal alar barrier dressings decreased the incidence of skin or mucosal injury in patients undergoing nasotracheal intubation, and data on effectiveness of serial assessment and repositioning were inconclusive.

CONCLUSIONS

Airway device-related pressure injuries are common in critically ill patients, and patients with nasotracheal tubes are particularly susceptible to iatrogenic harm. Fastening devices and barrier dressings decrease the incidence of injury. Evidence regarding interventions is limited by lack of standardized assessments.

Feasibility of nasal bridge pressure injury prevention using a protective dressing and the Halyard Fluidshield® N95 mask in a COVID-positive environment

The purpose of this study was to prevent nasal bridge pressure injury among fit-tested employees, secondary to long-term wear of the N95 mask during working hours. A prospective, single-blinded, experimental cohort design. Participants were enrolled using the convenience sampling methods and randomisation was utilised for group assignment. Eligibility was determined by a COVID Anxiety Scale score and non-COVID clinical assignment. Participants with a history of previous skin injury or related condition were excluded. The experimental group was assigned Mepilex Lite® and the control group used Band- Aid®. Formal skin evaluations were done by Nurse Specialists who are certified in wound and ostomy care by the Wound, Ostomy, Continence, Nursing Certification Board (WOCNCB®). Fit test logs were provided to participants to measure subjective user feedback regarding mask fit and level of comfort. The results of this feasibility trial are promising in supporting the use of a thin polyurethane foam dressing as a safe and effective dressing to apply beneath the N95 mask. Additional research is needed to validate results due to limited data on efficacy and safety of the various barrier dressings as a potential intervention to prevent skin breakdown to the nasal bridge.

Health care workers' experience of personal protective equipment use and associated adverse effects during the COVID-19 pandemic response in Singapore

Aim

One of the greatest challenges in responding to the COVID‐19 pandemic is preventing staff exposure and infection by ensuring consistent and effective use of personal protective equipment (PPE). This study explored health care workers' experience of prolonged PPE use in clinical practice settings and their concerns regarding PPE supply, effectiveness and training needs.

Design

A descriptive cross‐sectional design was adopted in this study.

Methods

Health care workers (N = 592) from an acute care hospital completed an online survey from July to September 2020 assessing: (i) usage frequencies, side effects and interference with patient care; and (ii) perceptions of access to PPE, likelihood of exposure to infection and adequacy of PPE training.

Results

PPE‐related side effects were reported by 319 (53.8%) participants, the majority being nurses (88.4%) and those working in high‐risk areas such as the emergency department (39.5%), respiratory wards (acute 22.3% and non‐acute 23.8%) and COVID‐19 isolation ward (13.8%). The average time wearing PPE per shift was 6.8 h (SD 0.39). The most commonly reported symptoms were from donning N95 masks and included: pressure injuries (45.5%), mask‐induced acne (40.4%) and burning/pain (24.5%). Some 31.3% expressed that PPE‐related side effects had negatively affected their work. The odds of having PPE‐associated side effects was higher in women (OR 2.10, 95% CI [1.29–03.42], p = .003) and those working in high‐risk wards (OR 3.12, 95% CI [2.17–4.60], p < .001]. Most (90.1%) agreed that PPE supplies were readily available, sufficient for all (86.1%) and there was sufficient training in correct PPE use (93.6%). Only 13.7% of participants reported being ‘highly confident’ of overall PPE protection.

Conclusions

Prevention and management of PPE‐related adverse effects is vital to: preserve the integrity of PPE, improve adherence and minimize viral transmission.

Impact

The high incidence of PPE‐associated pressure injuries and perception that PPE use can interfere with clinical care should inform future development of PPE products, and strategies to better equip health care workers to prevent and manage PPE‐related side effects.

Design of a wearable device for physiological parameter monitoring in a COVID setting

The study focuses on the realization of an accurate device for the detection of different physiological parameters. It has been realized a simple portable system containing the necessary electronics and ensuring the monitoring of the blood oxygenation, the body temperature, the air quality, the respiratory rate and the ECG. The main processing unit consists in a Raspberry Pi Zero W connected to the Healthy Pi4. The latter provides the interface for the clinical pulse-oxymeter while the measures of temperature and quality air are provided using the I2C protocol. The Bluetooth module is finally used to provide the ECG and blood rate data. The collected data are elaborated using Matlab and Python. To evaluate the accuracy of the realized device some experimental tests have been conducted on different subjects, comparing subjects working in Covid area with others resting at home. In both cases the monitoring time was 4 hours. Results have shown good performances of the system, detecting accurately the differences of the parameters values between the two situations. The usability of the device was assessed by administering a questionnaire to the healthcare personnel involved in the experimentation. The outcome shows a good usability of the system as well as an acceptable dressing time.