key: cord-0885777-si5hi4a8 authors: Worsley, Peter R.; Spratt, Fran; Bader, Dan L. title: COVID19: Challenging tissue viability in both patients and clinicians date: 2020-06-23 journal: J Tissue Viability DOI: 10.1016/j.jtv.2020.06.003 sha: ab125990c1978411877c8a968292883da5f1cb34 doc_id: 885777 cord_uid: si5hi4a8 nan The recent coronavirus pandemic has exposed healthcare systems worldwide to elevated pressures in every sense of the word. Since the start of the year there has been a sharp increase in critically ill individuals requiring prolonged periods in intensive care units (ICUs). Historically, ICUs has reported a high incidence of pressure ulcers (PUs), with those requiring mechanical ventilation at a particularly high risk [1] . This has been exacerbated for COVID19 patients, who often present with acute respiratory distress syndrome (ARDS), requiring management in the prone position to optimise respiratory function and oxygenation [2] , creating a challenge for clinicians to maintain skin integrity [3] . To date, patient requiring prolonged prone positioning has been limited to a few cases associated with other respiratory disorders. However, during this pandemic the numbers of patients who would benefit from treatment in the prone position escalated rapidly, with prolonged use of proning for days and weeks overwhelming critical care staff. Although there is limited available data, case studies have revealed severe pressure ulcers in areas of the face following extended prone management for coronavirus [4] . In addition, patients will are exposed to medical devices attached to the skin for therapeutic and monitoring purposes, creating points of stress on vulnerable skin sites. The international tissue viability community have answered the call to provide better guidance to maintain skin integrity in these highly vulnerable individuals, with recent publications including national and international guidelines. These guidelines follow similar principles including, although not limited to: 1. Regular repositioning with respect, where possible, to legs, arms, head and the torso. 2. Regular skin checks, with sites on a prone patient including; the face, neck, arms, chest/breasts, iliac crests, genitals, legs, knees and feet. 3 . Medical Device management, checking skin under devices, use of prophylactic dressings, avoiding excessive strap tensions. 4 . Use of high specification support surfaces and positioning devices. As an exemplar of implementing the above guidelines, the University Hospital Southampton Foundation Trust (UHS) has established a team of at least 5 members from across the Trust to specifically prone patients, providing the most medical benefit whilst maintaining patient safety and skin integrity. This included members from both the anaesthetic department to ensure safety of the airways and the Tissue Viability team demonstrating their integral role in addressing the concerns over skin integrity. As a result, patients adopted the prone position generally for 16 hours followed by a change to supine posture for 6 hours. Skin monitoring and positional changes (legs, arms and head) occurred at least every four hours, but preferably every three hours to prevent pressure ulcers. The team members learnt very quickly, adapting to a new role within an unfamiliar environment and becoming a vital part of the critical care journey for these COVID19 patients. As a result of this initiative, only three documented pressure ulcers have been observed over a 3 month period, each associated with device-related skin damage involving, for example, endotracheal tube-related damage on the corner of the mouth. It became evident that integration of the Tissue Viability team ensured that skin was checked thoroughly, and when the first signs of damage were detected appropriate interventions were implemented. A further perhaps unpredicted complication affecting tissue viability arose from the prolonged use of Personal Protective Equipment (PPE), required for all healthcare workers managing COVID19 patients. Wearing of PPE, typically the FFP3 masks, can cause anxiety and often can be uncomfortable for healthcare workers. PPE-related skin injuries, initially highlighted through case reports [5] , have now been established as a serious consequence of managing this pandemic. Indeed, a recent large multi-centre, cross-sectional survey in China revealed an overall prevalence of skin injuries estimated at 42.8%. This included medical device-related pressure ulcers, representing the most common form of damage, moisture associated skin dermatitis and skin tears. Survey data from our host institution (UHS) revealed that over 80% of healthcare workers found the PPE to be uncomfortable and 60% reported skin changes following use, in the form of redness, indentation, rash and acne. It is interesting to note that skin tears only represented a small fraction of the total, despite several reports citing them as a key issue [6] . The most common areas of skin damage include the nasal bridge, cheeks and forehead, which are associated with the use of respiratory protective equipment (RPE). These tightfitting masks form a protective barrier between the wearer's respiratory tract and the ambient atmosphere, sealed against the skin. As with many other medical devices, these incorporate generic designs and relatively stiff materials [7] , typically using a one-size fits all principle. Accordingly, they are often over-tensioned to achieve an appropriate seal and, as such, result in elevated interface pressures, temperatures and humidity. This is particularly challenging as staff have to wear RPE devices for prolonged periods, to accommodate clinical demands. This has resulted in repetitive prolonged loading over already compromised skin sites, which could lead to damage. Sadly, this appears to be entirely preventable with improved device designs and evidence-based fitting of protective equipment. Indeed, many clinicians have actively prevented skin damaged through the use of prophylactic dressings, although no commercial dressing has been specifically designed for this purpose. What is certain is that products used under a mask would change the shape and conformity of the face which may potentially enhance the risk to individuals, although this could be mitigated with appropriate fit testing. It is also of note that many healthcare institutions have had to change PPE equipment due to resourcing issues. As an example, in UHS a staff nurse working on an ICU, had no issues with skin integrity whilst wearing the FFP3 mask for which he was originally tested. Unfortunately, the mask stopped being available and he had to undertake fitting for a different make of mask. He later reported the new mask even felt uncomfortable during the testing process and within a few days he had skin damage caused by both pressure and friction to the bridge of the nose. The damage was both distressing and stressful for this nurse as it caused a lot of pain and prevented him from working effectively. It is interesting to note that these events do not represent a new occurrence. Indeed, there have been reports of ill-fitting PPE devices for female workers and those of black and Asian ethnicity several years prior to COVID19 [8] . The implications are that skin irritation may increase the risk of COVID19 infection, predisposing individuals to inadvertently touch their face and break PPE protocol. Clearly, those working on the frontline of health and social care deserve better standard of equipment. Although guidelines have been issued for preventing PPE-related skin damage, the root cause of ill-fitting devices must be addressed. This is the least we can do for healthcare workers around the world, who are giving so much in this time of need. COVID19 has focused attention on a number of issues associated with tissue viability, including the challenges of managing a prone patient and preventing medical device related pressure ulcers. It has also highlighted that no one is immune from the risk of skin damage, particularly in the case where equipment that interfaces with the skin has not been designed appropriately with due consideration to tissue viability. Incidence and risk factors for pressure ulcers in the intensive care unit Società Italiana di Anestesia Analgesia Rianimazione e Terapia Intensiva (SIAARTI) Airway Research Group, and The European Airway Management Society. The Italian coronavirus disease 2019 outbreak: recommendations from clinical practice Prone position for acute respiratory distress syndrome: A systematic review and meta-analysis Facial Pressure Ulcers in a COVID-19 50-year-old Female Intubated Patient Skin damage among health care workers managing coronavirus disease-2019 Update to device-related pressure ulcers: SECURE prevention. 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