key: cord-0794983-f909i1yf
authors: Pacis, Michelle; Azor-Ocampo, Annielyn; Burnett, Emily; Tanasapphaisal, Chutiwan; Coleman, Bernice
title: Prophylactic Dressings for Maintaining Skin Integrity of Healthcare Workers When Using N95 Respirators While Preventing Contamination Due to the Novel Coronavirus: A Quality Improvement Project
date: 2020-11-19
journal: J Wound Ostomy Continence Nurs
DOI: 10.1097/won.0000000000000713
sha: 0b0150098308961e9a8ee150c27fdfd164eaa376
doc_id: 794983
cord_uid: f909i1yf

PURPOSE: Extended use of N95 respirator masks is far more prevalent during the coronavirus disease 2019 (COVID-19) pandemic. As WOC nurses, we were tasked with formulating procedures for protecting the facial skin integrity of healthcare workers (HCWs) using personal protective devices when caring for patients with suspected or active COVID-19, while avoiding contamination when the masks are donned or doffed. This quality improvement project describes how we approached this project within the limited time frame available as we cared for patients with established and suspected COVID-19. PARTICIPANTS AND SETTING: This project focused on HCW use of N95 respirator masks and dressings currently available in our facility. The 4 WOC nurses acted as quality improvement project directors and as participants. The setting for our project was our facility's simulation laboratory. APPROACH: We evaluated 6 topical products (an alcohol-free liquid acrylate, thin film dressing, thin hydrocolloid dressing, hydrocolloid blister care cushion, thin foam transfer dressing, and thick foam dressing) applied to skin in contact with 3 N95 respirators; all are available on our facility's formulary and all are in widespread clinical use. After the product was applied to the face and nose, the N95 respirator was donned and evaluated for fit. Participants then wore the devices for 10 hours and doffed the mask using established facility procedures. In order to evaluate for potential contamination including possible aerosolization, we applied a commercially available fluorescent lotion to simulate the presence of infectious particles. Contamination was assessed using an ultraviolet light for all dressings except for the alcohol-free liquid acrylate. We also evaluated cutaneous responses (skin integrity, irritation, comfort) during this period. OUTCOMES: We found that contamination of the simulated pathogen did not occur with removal of any of the protective products. No skin irritation was noted with any of the tested products after a 10-hour wear time underneath the N95 respirator masks, but mild discomfort was experienced with 3 of the dressings (thin film dressing and both hydrocolloid dressings). CONCLUSION: Based on these experiences, we recommend application of an alcohol-free liquid acrylate film to prevent facial skin injury associated with friction from the extended use of an N95 respirator mask. We further recommend performing a fit test and user-performed seal check with the use of any topical dressing and especially those that add cushion. For the duration of the COVID-19 pandemic, we recommend use of protective dressings to maintain skin integrity and protection from coronavirus infection as HCWs continue to provide care to all of patients under their care.

Th e novel coronavirus, which causes the disease COVID-19, is a new strain that has a high rate of transmission, morbidity, and mortality, resulting in a global pandemic. 1 Healthcare work-ers (HCWs) must use personal protective equipment (PPE), including an N95 respirator mask, to prevent transmission of the virus. However, prolonged use of PPE has led to nationwide shortages, resulting in optimization of supply usage. One of these strategies is to extend the use of disposable N95 respirator masks. 1 The Centers for Disease Control and Prevention (CDC) defines extended use as wearing the same N95 respirator mask between COVID-19 patient encounters without removal. This method is recommended because it carries the least risk for contamination associated with frequent donning, doffing, and manipulation of the PPE. 2 However, prolonged use has also resulted in skin damage among HCWs, especially on the nasal bridge and cheeks. 3 Thus, an immediate need for safe and effective guidelines for the healthcare community pertaining to facial skin breakdown from PPE has occurred. 3 Adequate skin protection not only provides overall comfort for the frontline HCW but also prevents pathogen entry via any break in the skin, the body's first line of defense. [4] [5] [6] According to the National Pressure Injury Advisory Panel (NPIAP), medical device-related pressure injury has been extensively discussed with numerous evidence-based practice guidelines on how to mitigate its occurrence in patients but not in HCWs. 5, 7 Protection of the skin is a core objective and value of WOC nursing; this mission extends to protecting colleagues' skin during prolonged wear time. We were also challenged to formulate a procedure that prevents contamination when donning and doffing of N95 respirator masks along with any protective topical dressing. Information regarding this topic is limited but rapidly evolving. 1, 5, 7, 8 Early recommendations included application of protective ointments or thin film dressings to areas subject to adhesion, pressure, and friction, along with adequate hydration and maintenance of a daily skin care routine. [9] [10] [11] [12] Evidence on whether the use of these products compromises the efficacy of the PPE and the safety of the HCW is sparse. In addition, no known skin protection product has been specifically tested for permeability to the novel coronavirus. 5, 10 To address this unique situation, our WOC nurse team compared 4 different categories of prophylactic dressings under N95 respirator masks. Our aims were to guide our facility's procedures in the areas of (1) prevention of facial skin breakdown of HCWs while maintaining the appropriate fit of N95 respiratory masks and (2) prevention of self-contamination via aerosolization while doffing these topical devices. We used the outcomes of this quality improvement project to assist the WOC team in formulating a guideline for HCWs in our facility.

We evaluated 3 N95 respirator masks already in widespread use in our facility; 2 are masks that have no added features for comfort (Figures 1 and 2) , and 1 mask has built-in padding for the nose (Figure 3 ). The N95 respirator masks we used were the N95 Moldex 1500 Series (Moldex, Culver City, California), N95 Healthcare and Surgical Mask, Halyard FLUIDSHIELD* N95 Particulate Filter Respirator and Surgical Mask (Halyard, Alpharetta, Georgia), and 3M Disposable Respirator 1870+ (3M, Minneapolis, Minnesota). All of these personal protective devices were applied using current facility procedures.

In order to protect skin in contact with these devices, we selected 6 products (5 dressings and a liquid polymer acrylate). Five were already on our facility's formulary, and one was bought at a local drugstore, with the intention of adding it to the formulary pending the results of this study. The products we evaluated were an alcohol-free liquid acrylate dressing (Adapt No Sting Skin Protective Wipe; Hollister, Libertyville, Illinois), a thin film dressing (3M, Saint Paul, Minnesota), a thin hydrocolloid dressing (Convatec, Bridgewater, New Jersey), a hydrocolloid blister care cushion (Band-Aid; Johnson & Johnson Consumer Health, Skillman, New Jersey), a silicone-based thin foam transfer dressing (Mölnlycke, Peach Tree Corner, Georgia), and a hydrophilic polyurethane membrane matrix with a semipermeable polyurethane dressing as a thicker foam element (Ferris Mfg Corp, Fort Worth, Texas). Dressings were selected that met the following characteristics: (1) designed to protect the skin from friction, pressure, or moisture; (2) comfortable to wear on the face; and (3) easy to don and doff (ie, easy to apply and remove). Since our target audience was HCWs practicing in our facility, 4 WOC nurses in our department applied masks and dressings to themselves. Thus, they acted both as project administrators and participants in this quality improvement project.

Each WOC nurse applied each of the 5 dressings on the bridge of the nose and the cheekbones, performed a seal check using procedures described elsewhere, [13] [14] [15] wore the mask and dressing for 3 to 10 hours underneath the 2 N95 respirator masks that covered the nose and mouth, and made note of any skin irritation or discomfort associated with wearing the mask. Because the third N95 respirator included a nose cushion, we limited our evaluation of this device to the alcohol-free liquid acrylate dressing. We made this decision because the additional padding provided by the foam and thin hydrocolloid dressings was deemed duplicative and might adversely affect device fit (Figures 1-3) . The thin hydrocolloid dressing was cut into strips and applied to the bridge of the nose and cheekbones. This process was repeated for all dressings that we have tested under the N95 respirator masks ( Figures 4A, 4B , 5A, and 5B).

We applied the alcohol-free liquid acrylate to the bridge of the nose, cheekbones, chin, and areas behind the ears to match the contours of the N95 respirator it was tested with, as well as the forehead for protection from goggles if worn by staff ( Figures 6A-6D ). At the time of this study, our facility was not yet providing eye protection to all staff members. We observed some staff members using store-bought goggles; therefore, we took its use into consideration.

Using the simulation laboratory at our facility, we observed for self-contamination while doffing PPE and removal of the protective dressing under ultraviolet (UV) light. A commercially available fluorescent lotion (Glo Germ lotion; Glo Germ Co, Moab, Utah) was used to simulate the presence of infectious particles. This lotion has been repeatedly used at our hospital to train staff in the proper technique for handwashing and donning and doffing of PPE by observing users' hands under UV light to see if the simulated germs were effectively washed away or if the user was self-contaminated in the doffing process. Previous studies have used a similar germ-simulating product to visualize cross contamination in the food industry and the healthcare setting. [16] [17] [18] [19] The germ-simulating lotion was liberally applied to each dressing on the participant's face to represent respiratory droplets. The mask was applied using CDC-recommended guidelines for donning and doffing. 20 Dressings were also applied and removed using manufacturer instructions and facility policies. After wearing, the participant then removed each dressing as quickly and comfortably as possible in an attempt to simulate aerosolization or other contamination of infectious particles. While under a UV light, 3 members of the WOC nurse team (who had worn the mask and dressing) observed for evidence of aerosolization or other contamination upon doffing, and we carefully inspected the WOC nurse's face who had worn the mask and dressing for any other areas of contamination. We documented contamination using photography and videos taken using a mobile camera (iPhone; Apple, Cupertino, California). Photographs and videos were carefully scrutinized at the end of the simulation for additional evidence of aerosolized droplets in the air or on the subject's clothing, hands, face, neck, and hair and for other evidence of contamination.

The alcohol-free liquid acrylate was excluded from UV testing. Removal of this product involves use of an adhesive remover wipe and washing with soap and water. In theory, the vigorous scrubbing needed to remove all residues should also remove potential infectious particles, as with handwashing. In our experience, the fluorescent lotion is difficult to completely wash away. Therefore, observation of removal under UV light may have been misleading. Since the liquid acrylate wears like a "second skin," we hypothesize it does not prompt possible self-contamination via readjustment of the mask or dressing as much as the other products tested.

We found no evidence of contamination of the germ-simulating lotion with removal of any of the 5 dressings we evaluated (Table) . In addition, we did not experience skin irritation or loss of skin integrity with any of the tested products after a 10-hour wear time underneath the N95 respirator masks (Table) . We found that all dressings provided protection from friction. Thicker dressings provided more padding for pressure relief. Indentations from the mask were still noted on the wearer's face with all dressings except the hydrophilic polyurethane membrane matrix (thick foam) dressing. However, the added bulk of this dressing made it difficult to achieve an occlusive seal and caused the N95 respirator to slip from the bridge of the wearer's nose, creating a possibility of contamination. Otherwise, all other dressings passed the user-performed seal check.

Due to the urgency of the need that drove our quality improvement project, we acknowledge limitations to findings. All dressings were tested and evaluated exclusively by 4 WOC nurses, resulting in a small test population. All findings in this study are observational and influenced by our experience as clinicians, by individualized pain tolerance, and by individualized characteristics of our skin. At the time of the study, our hospital was limiting the use of Qualitative Fit Test Kits and N95 respirator masks for direct patient care needs alone. Therefore, we were not able to fit test our N95 respirator masks after the application of these products, so a user-performed seal check was done instead. This test alone is not typically used to determine proper fit. [13] [14] [15] In the simulation laboratory, we had limited ability to simulate aerosolization of germ-simulating lotion. In order to address this limitation, we liberally applied the product and purposely simulated rough handling of the dressings. We have previously observed this phenomenon in germ-simulating powder from a previous training setting, but this formulation was not available for use at the time of this study.

Contamination was not observed with removal of any of dressings we evaluated. While we found that 3 of the dressings created discomfort with removal of topical adhesives, we ultimately concluded that this outcome may have paradoxically limited aerosolization or other contamination since it required the wearer to handle the dressing more carefully. The alcohol-free liquid acrylate film dressing was removed with an adhesive remover and washing with soap and water. Because there was no adhesive appliance to remove, we hypothesize there was nothing to aerosolize. We found the dressings evaluated were comfortable to wear, easy to apply, and easy to remove. The foam dressings and the thin hydrocolloid dressing were easily customized in a cut-tofit fashion to the wearer's preference. We hypothesize that a cut-to-fit approach of the thin hydrocolloid dressing may be a cost-effective solution since 1 unit of product may be cut into multiple pieces ( Figures 7A-7D ). However, this may be more time-consuming in preparation and application. The hydrocolloid blister care cushion was commercially readymade and potentially more user-friendly (Figures 8 A-8D) . The thick foam dressing (hydrophilic polyurethane membrane matrix with a semipermeable polyurethane) was nonadherent and required the use of an additional adhesive product, as well as more surface area for dressing application. In this case, the dressing's border was extended near the subject's eyes. The thin foam dressing was minimally adherent. The use of a secondary adhesive product would help with securement, but similar issues with the need for additional surface area would then arise. We experienced mild pain upon removal of the thin film dressing, and both hydrocolloid dressings. Removal of the customized hydrocolloid strips may have been mildly painful due to the larger application surface. Pain was reduced with the use of a skin adhesive remover wipe.

In addition to aerosolization, our observations led us to conclude that other avenues for self-contamination may occur. The thin film dressing, which has the lowest profile of all the topical adhesive dressings, was difficult to remove with tactile cues alone. We assert this may produce a potential for contamination since it required the most manipulation to remove ( Figures 9A-9D) . The thin foam dressing (silicone-based transfer dressing) allowed the germ-simulating lotion to transfer directly onto the skin underneath. This implies that porous dressings may allow the transfer of fluids or microorganisms to the skin. If using a foam dressing, the outer layer should be nonpermeable (Figures 10A-10D) . The bulky nature of the thick foam dressing (hydrophilic polyurethane membrane www.jwocnonline.com matrix with a semipermeable polyurethane) caused the N95 respirator mask to be easily displaced. This resulted in frequent manipulation and readjustment of the mask by the wearer (Figures 11A-11D ).

Our observations during this procedure also led us to conclude that contamination of surfaces and exposure to airborne particles are possible during dressing changes of colonized wounds. 21 Nevertheless, we searched the literature and found no specific studies demonstrating aerosolization of respiratory droplets while doffing facial PPE.

The results of this initiative guided creation of a resource for our facility's inpatient staff regarding skin protection with extended wear of the N95 respirator mask during this COVID-19 pandemic. The alcohol-free liquid acrylate dressing was the only prophylactic dressing at our facility that met all the criteria established at the beginning of this study. Application of this product before donning of the N95 respirator mask provides comfort and protection from friction, maintains an accurate seal, and offers easy application and removal with nothing to aerosolize for potential of self-contamination. It does not provide pressure relief. Preliminary findings demonstrate the successful use of thin hydrocolloid dressings without contamination and aerosolization upon dressing removal. However, we recommend caution when exploring topical dressing options that offer more padded protection from tight-fitting respirators, since these may affect the appropriate fit and thereby compromise the safety of the HCW. Regulatory entities and all manufacturers' guidelines at the time of this study indicated that the application of any topical dressing between the HCW and the N95 respirator mask is discouraged and would require a fit test with each application. 1, 2, [13] [14] [15] 22 

Based on outcomes of this quality improvement project, we recommend application of an alcohol-free liquid acrylate film dressing to prevent facial skin injury associated with friction from the extended use of an N95 respirator mask. We further recommend performing a fit test and user-performed seal check with the use of any topical dressing and especially those that add cushion. For the duration of the COVID-19 pandemic, HCWs in our facility will continue to use protective dressings to maintain skin integrity and protection from coronavirus infection as HCWs continue to provide care to all of patients under their care. 

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