key: cord-0909988-hgx3g3cq
authors: Padula, William V.; Cuddigan, Janet; Ruotsi, Lee; Black, Joyce M.; Brienza, David; Capasso, Virginia; Cox, Jill; Delmore, Barbara; Holden‐Mount, Sarah; Munoz, Nancy; Nie, Ann Marie; Pittman, Joyce; Sonenblum, Sharon; Tescher, Ann
title: Best‐Practices for Preventing Skin Injury Beneath Personal Protective Equipment During the COVID‐19 Pandemic: A Position Paper from the National Pressure Injury Advisory Panel (NPIAP)
date: 2021-02-03
journal: J Clin Nurs
DOI: 10.1111/jocn.15682
sha: a0fc86710a7260e6ab76be538b6922d9840e2378
doc_id: 909988
cord_uid: hgx3g3cq

COVID‐19 has infected millions of patients and impacted healthcare workers worldwide. Personal Protective Equipment (PPE) is a key component of protecting frontline clinicians against infection. The benefits of PPE far outweigh the risks, nonetheless, many clinicians are exhibiting skin injury caused by PPE worn incorrectly. These skin injuries, ranging from lesions to open wounds are concerning because they increase the susceptibility of viral infection and transmission to other individuals. Early into the COVID‐19 pandemic (April 2020), the U.S. National Pressure Injury Advisory Panel (NPIAP) developed a series of position statements to improve wear‐ability of PPE and protect healthcare professionals and their patients as safe from harm as possible under the circumstances. The NPIAP positions, which were formed by conducting a systematic review of what was known at the time, include: (1) Prepare skin before and after wearing PPE with skin sealants, barrier creams and moisturizers; (2) Frequent PPE offloading to relieve pressure and shear applied to skin; (3) treat visible skin injuries immediately caused by PPE to minimize future infection; (4) non‐porous dressings may provide additional skin protection, but lack evidence; (5) health systems should take care to educate clinicians about placement and personal hygiene related to handling PPE. Throughout all of these practices, handwashing remains a top priority to handle PPE. These NPIAP positions provided early guidance to reduce the risk of skin injury caused by PPE based on available research regarding PPE injuries, a cautious application of evidence‐based recommendations on prevention of device related pressure injuries in patients and the expert opinion of the NPIAP Board of Directors. Clinicians who adhere to these recommendations reduce the prospects of skin damage and long‐term effects (e.g. scarring). These simple steps to minimize the risk of skin injury and reduce the risk of coronavirus infection from PPE can help.

The Coronavirus Disease 2019 (COVID-19) pandemic has infected millions of patients worldwide in nearly every country (World Health Organisation, Geneva, 2020). Healthcare professionals (e.g. nurses, physicians and therapists) are working tirelessly to manage patient needs in all clinical settings while remaining focused on preventing the further spread of Coronavirus Disease 2019 infection. Particularly, in U.S. hospitals, emergency departments and critical care settings, healthcare professionals are contending with prolonged shifts to manage volume surges of COVID-19 positive patients and continuously wearing personal protective equipment (PPE). This has resulted in an alarming increase in skin injury to the faces of staff caused by PPE, particularly from tight masks covering the nose and mouth, and goggles or shields covering the eyes which extend from the face to the ears and back of the head (A. Gefen & Ousey, 2020a) . A survey of 4,306 clinicians across 191 hospitals in China during the month of February 2020, alone, reported that 42.8% of clinicians experienced skin injuries related to PPE use (Jiang et al., 2020) .

Skin injuries to the face, ears and scalp caused are particularly concerning consequences of wearing PPE. These areas of tissue damage, especially around mucous membranes can increase the susceptibility of infection (Li, Lam, Chen, & Ting, 2020) . Once skin tears, it is

This article is protected by copyright. All rights reserved unable to serve as a natural barrier against infection in support of the immune system (A Gefen, 2020; Rundle et al., 2020) . Healthcare professionals with skin tears can become carriers, and therefore present the risk of transmittance of the virus between patients and other healthcare professionals; it is important for healthcare professionals to adhere to self-care of skin tears and open wounds, and good practices to minimize the spread of infection (e.g. handwashing, glove changing) (Rundle et al., 2020) . These skin injuries cause pain and itching, prompting the clinician to touch their face, ears and scalp (A. Gefen & Ousey, 2020a) . These injuries, ranging from small skin lesions (i.e. bruising and superficial wounds) to full-thickness wounds may place healthcare professionals at too great of an exposed risk to continue providing care, potentially limiting the number of available experienced providers thereby further straining the health care system.(A. Gefen & Ousey, 2020b) Healthcare professionals with open facial wounds should be removed from beside clinical duties since there is a risk that the mask could be positioned incorrectly on the face in an attempt to decrease pain over the open wound site, thereby exposing the individual viral susceptibility. Despite good practices such as hand-washing hygiene, changes in practice such as touching the wound or trying to place the mask around the wound could increase exposure to COVID-19. Finally, some of these skin injuries can lead to facial scarring and disfigurement (Hu et al., 2020) .

During the early phases of the COVID-19 pandemic, the U.S. National Pressure Injury Advisory Panel (NPIAP) reviewed available evidence on how to safely use the N95 respirator masks to prevent infection transmission while protecting the skin, releasing a position paper in April 2020 (Cuddigan, et al, 2020) which has been used to guide subsequent work addressing this concern (Desai, et al., 2020; Smart, et al., 2020) . The NPIAP also evaluated impact of surgical masks since the U.S. Centers for Disease Control and Prevention (CDC) has identified them as an acceptable alternative PPE to N95 masks during surgical procedures, or whenever healthcare professionals anticipate need for protection against splashes and sprays (U.S. Centers for Disease Control and Prevention, 2020). These NPIAP positions are available online (https://npiap.com/page/COVID-19Resources, National Pressure Injury Advisory Panel, Boston, MA; 2020). The same mechanical forces (i.e. pressure and shear) combined with the tolerance of skin and soft tissue for pressure, shear and friction that cause device-related pressure injuries in our patients are now causing pressure injuries in fellow healthcare providers wearing PPE including masks, face shields and goggles for long periods of time. N95 respirator masks have a

This article is protected by copyright. All rights reserved particularly high risk for injury due to infection control requirements for a tight fit, especially if the mask is not properly fitted to an individual's face; skin injury can also occur as a result of moisture accumulation under the mask (Bischoff et al., 2018) .

According to Darlenski and Tsankov, facial skin injury can make individuals more susceptible to spread of COVID-18 infection (Darlenski & Tsankov, 2020) . Fortunately, these injuries to the face, ears and scalp that healthcare professionals are most susceptible to are also preventable if proper steps are taken. This NPIAP position paper reaffirms several important best-practices to improve the safety of healthcare professionals in hospitals and other healthcare facilities. These positions are comprehensive in terms of their science, practicality to be carried out in an efficient cost-effective manner, and with resources available for healthcare facilities in In the context of this report, evidence was extracted from the systematic review conducted by the GGG regarding the etiology of pressure injuries and prevention of device related pressure injuries in patients and translated specifically for an understanding of skin injury to the face, ears and scalp caused by PPE in all healthcare personnel. Pressure injuries result in

This article is protected by copyright. All rights reserved skin and underlying soft tissue damage caused by pressure and shear, usually over a bony prominence but may also be related to a medical device or other object ( 

Before and after PPE wear, cleanse the face with a pH balanced cleanser to reduce bacterial/viral surface contamination. Skin moisturizers can be applied but must be allowed to dry before the mask is reapplied. 

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Cyanoacrylates can also be used as skin prepthese skin protectants are used as a "glue" to protect skin from tears or lacerations (Eaglstein & Sullivan, 2005) . However, cyanoacrylates must be applied cautiously to avoid getting them into the eyes and mucous membranes (Yin et al., 2019) . Skin protectants can also prevent overhydration and maceration of skin from moisture accumulation in the mask (Parnham, Copson, & Loban, 2020) . Skin protectants should be dry before applying the mask.

The use of petrolatum or mineral oil is not advised as a skin prep; these products can cause the mask to slip out of place and require frequent reapplication that involves touching the 

PPE should be frequently offloaded to allow skin and soft tissue across the face, behind the ears, and pressure points on the scalp to recover and reperfuse (A. Gefen & Ousey, 2020c) .

Remove the mask from your face for 15 minutes every 2 hours outside of areas of patient contact. If this time frame is not practical, attempt to lift the mask by the sides for 5 minutes every 2 hours with clean hands. Any pressure relief will be provided to the skin and soft tissue will be beneficial (Visscher et al., 2015) . However, we want to emphasize that offloading should be done with clean hands, and outside of areas of patient contact (Tomas et al., 2015) . The seal between PPE and the staff member's skin should not be broken in an area present with infected patients (Gurses et al., 2019) . If possible, switching to PPE with fewer direct contact points, such as face masks that can remain on place using a head band rather than ear loop, would be worthwhile.

If abrasions or pressure injury develops on the face, behind the ears or over the scalp from the mask, treat the visible injury or open wound with topical moisturizers, liquid skin sealants/protectants, cyanoacrylate or a protective non-porous dressing (Visscher et al., 2015) .

Areas that are hard to view (e.g. behind ears, areas of scalp covered by hair) will likely require extra attention. Advice of an occupational health practitioner should be sought with regard to the safety of returning to work with an open facial wound, as well as the availability of an alternative

This article is protected by copyright. All rights reserved mask that may relieve pressure on the site of the open wound (Patel et al., 2017) . Powered and supplied air respiratory protection (PAPR) masks may offer an alternative to N95 or surgical masks to relieve areas of injured skin while providing a substantial barrier of protection, although these devices are expensive and in short supply globally (Roberts, 2014) . Persons with deep tissue injury or full thickness pressure injury occurring on the face should be referred for professional wound care to minimize scarring or future exposure (Vincent et al., 2019) . These wounds should be considered serious due to the risk of infection and scarring as they heal.

Note that nonvisible tissue damage under the skin, such as deep tissue pressure injury, is always a point of concern and should be monitored (Edsberg et al., 2016) . Also, bruising and erythema on the surface of skin for individuals with darker skin tones is more difficult to detect (Lyder, 1998 Mar) . As a result, individuals doing self-assessment should closely monitor all signs or symptoms of pressure injury, including pain (A. Gefen & Ousey, 2020a).

After reviewing the evidence on both pressure injury prevention and effective use of PPE, the NPIAP believes that there are critical uncertainties regarding the safe use of thin prophylactic dressings under N95 masks (A. Gefen & Ousey, 2020c) . NPIAP cannot make a recommendation regarding this proposed strategy (pro or con) at this time.

provides important evidence-based recommendations for prevention of pressure injuries from oxygen delivery masks in patients, any application of those recommendations to providers during the current COVID-19 pandemic comes with an important caveat (Kottner et al., 2019) .

That is, the essential function of a PPE mask (i.e. to prevent COVID-19 transmission from patient to provider) cannot be compromised. (Ippolito et al., 2020) There is evidence to show that thin prophylactic dressings placed under medical devices (e.g. facial oxygen masks) in patient populations reduces the risk of pressure injuries (Kottner et al., 2019) . This provides indirect evidence for implementing this practice in clinicians wearing N95 respirator masks. However, there are no comparable studies in clinicians wearing N95 respirator masks that can ensure the wearer's safety from viral penetration when a dressing is placed under a respirator type mask, possibly altering the fit of the mask on the face. Dressings with a porous outer surface are particularly problematic; the dressing may allow the transfer of fluids or microorganisms onto

This article is protected by copyright. All rights reserved the skin. NPIAP is aware of some preliminary clinical reports of confirmation of the proper fit of an N95 mask to occupational health and safety specifications after the application of thin prophylactic foam dressings (Jones, Stoler, & Suyama, 2013) . There is also a report that there is less aerosolization of microorganisms upon dressing removal when thin hydrocolloid dressings are used. These preliminary reports are not sufficient evidence to recommend routine use of thin prophylactic dressings at this time due to critical uncertainties regarding whether this practice will increase the risk of COVID-19 infection. NPIAP recognizes that pressure from surgical masks, PAPRs and face shields can also lead to facial skin injury. These PPE items are not designed to fit as tightly and therefore pressure can be redistributed by applying thin foam or hydrocolloid dressings under these devices. Attention should be given to the forehead, nose, cheeks and backs of the ears where PPE comes into the most direct contact (Desai, 2020).

For hospitals and clinicians who do wear prophylactic dressings under the N95 respirator mask, strips of non-porous dressings such as thin hydrocolloid should be applied to areas of pressure from the mask, which is usually the nasal bridge and cheek bones (Cai, Zha, & Chen, 2019). Dressings should not be stacked one atop the other, as multiple dressings will increase the pressure applied to the skin. After applying dressings, confirm the fit of the N95 mask should always be confirmed with a seal check by blowing out and checking for leaks before patient contact.

To reduce the risk of transmission, follow infection control practices at the healthcare facility. When it is time to remove the dressings, assume dressings are contaminated and exercise caution with removal (Lenski & Scherer, 2016) . NPIAP recommends that you close your eyes and hold your breath in exhalation during dressing removal to avoid potential transmission of aerosolized COVID-19.

Healthcare facilities should establish clear policies for educating healthcare professionals on these steps to maintain personal hygiene in order to protect themselves from COVID-19 as well as the health of vulnerable, non-infected patients in addition to those presenting with COVID-19. PPE items, including masks, goggles and shields should be fitted to the shape and size of the individual user's features; in fact, N95 masks come in multiple sizes (Desai, 2020).

This article is protected by copyright. All rights reserved should be directed to follow manufacturer specifications since items such as N95 mask usage can vary between manufacturers. Incorrect fit of PPE on an individual can increase the risk of skin injury to the face, ears and scalp and exposure to COVID-19 (A. Gefen & Ousey, 2020c) .

Facilities should invest in training healthcare professionals on proper practices for donning and offing procedures related to PPE.

Handwashing or hand-sanitizing before and after handling PPE remains an important step in these recommendations as well; however, this task should be done in tandem with needs to wash hands for other purposes to avoid over-washing (Beiu, Mihai, Popa, Cima, & Popescu, 2020) .

National shortages of PPE have led to facilities reusing certain products after sterilizing them, such as N95 masks (Dai, Zaman, Padula, & Davidson, 2020; Rowan & Laffey, 2020) . This sterilization process can impact the integrity and fit of the product (Jinadatha et al., 2015) . When items such as N95 masks are reapplied, the clinician should also check the fit and seal of the mask.

As the field of PPE development and manufacturing advances in parallel with the ongoing effort to manage and prevent the spread of COVID-19, we have several recommendations for future research to improve our understanding of safe PPE wearing as well as PPE enhancements. First, the use of dressings under masks is not recommended by the NPIAP, although Gefen and Ousey have indicated that research on the biomechanical features of some dressings support this use (A. Gefen & Ousey, 2020b) . More real-world evidence about dressings in combination with PPE would be helpful to create barriers between the PPE and the skin. Second, more research into enhancements in PPE designs, such as alternatives to ear-loops on surgical masks, or foam resurfacing over sharp edges of goggles and shields could provide us with knowledge to better guide clinicians towards proper use (Parush, Wacht, Gomes, & Frenkel, 2020) . Third, customizable PPE, with the use of 3D-printing or other rapid prototyping mechanisms to fit individuals' faces more appropriately offers a promising area of development (Manero et al., 2020) . Fourth, the field would benefit from additional research to collect data data on the incidence, prevalence, and permanence of skin injury caused by PPE across the many countries dealing with COVID-19 surges (Jiang et al., 2020) . Fifth, the field would also benefit

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Healthcare facilities need to be prepared for volume surges due to COVID-19 in many ways, as well as caring for non-COVID-19 patients who may become cross-exposed to infection as a result of multiple patient-clinician interactions. Facilities are being tested in terms of bed capacity, clinician preparedness, and the availability of masks, gloves and other PPE measures to establish barriers between patients and healthcare professionals. As facilities place orders and stockpile these essential products, they also need to consider stocking up on some of the products that reduce the risk of skin injury, such as skin protectants and prophylactic dressings.

This NPIAP position paper reaffirms these important best-practices to improve the safety These NPIAP positions, developed early in the COVID-19 pandemic, represent a combination of tactics and products that can prove resourceful to reduce the risk of facial skin injury caused by PPE. These positions are not sanctioned as medical advice for healthcare professionals to abide by, but should be weighed with the tasks at hand to serve each patient at present, as well as continue to confidently serve the next patient while minimizing risk of spreading infection. Healthcare professionals who adhere to these recommendations improve the

This article is protected by copyright. All rights reserved prospects of less skin damage and long-term effects such as scarring. These recommendations also promote good hygiene and best practice to protect healthcare professionals from exposure to infection from COVID-19 or transmittance between multiple patients. These simple steps to minimize the risk of facial skin injury from PPE can help. The NPIAP encourages further research on the prevention of PPE related injuries without increasing the risk of infection for health care providers.

Finally, clinicians in hospitals, outpatient facilities and nursing homes will continue to cope with unexpected emerging challenges related to COVID-19 that are difficult to control for with respect to PPE wear. These recommendations represent best-practices, but we also advise that clinicians use their best judgement to achieve safe PPE wear without compromising care to the COVID-19 patient or other patients in a facility. With time, additional variables that impact the threshold between COVID-19 and PPE will will hopefully be quantified to better inform practical implementation of these recommendations. 

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