Infection Prevention: Prevent Pressure Injuries Caused by PPE

At the onset of the pandemic, William Padula, PhD, MS, MSc, saw something distressing among the frontline doctors and nurses speaking on TV. "They had deep dark cuts and bruises all along their forehead, underneath their eyes and on the bridges of their nose," says Dr. Padula, an assistant professor of pharmaceutical and health economics at the University of Southern California and president of the National Pressure Injury Advisory Panel (NPIAP). "It was right there in plain sight that pressure injuries were highly prevalent in medical workers donning PPE for 12- to 18-hour shifts."

The phenomenon is a danger not just in terms of pressure injury development, but also infection control and personal safety. "In addition to potential for scarring, open cuts and wounds caused by PPE make providers more susceptible to infections," says Dr. Padula.

Some providers might think this is old news with the pandemic hopefully nearly over and all-day mask-wearing requirements coming to an end. However, the Association for Professionals in Infection Control and Epidemiology (APIC) says the CDC's updated Interim Public Health Recommendations for Fully Vaccinated People, which says they no longer have to wear masks, do not apply to healthcare settings.

"Healthcare facilities should continue to follow all current COVID-19 infection prevention and control recommendations, including those addressing the use of PPE to protect themselves and others from COVID-19," states APIC.

Given that the end to maximum PPE usage still isn't in sight for healthcare facilities, how can you protect against possible pressure injuries to yourself and your staff?

Dr. Padula says the pandemic led NPIAP to renew the industry's focus on its guidelines for pressure injury prevention, and how they overlap with PPE donnage. That led to a peer-reviewed position paper in the Journal of Clinical Nursing with recommendations based only on strong, clear evidence. NPIAP offers a downloadable poster of the guidelines.

NPIAP recommends that providers offload pressure and protect skin by using films, moisturizers and other technology before donning PPE. The five to 10 minutes needed to do this obviously is a rate-limiting step, says Dr. Padula, so have necessary products on hand and easily available. NPIAP also recommends providers remove their masks or eye protection every couple hours for five to 15 minutes to alleviate pressure.

There are different pressure points produced by surgical masks versus N95 masks. "On a surgical mask, it's on the back of your ears," says Dr. Padula. "On an N95 mask, it's heavy pressure on the bridge of your nose."

He has personally purchased gadgets on Amazon that tie surgical mask ear straps together to alleviate pressure. "It's a simple solution," he says, adding, "If you're stuck wearing a mask with ear loops, you need to take it off and massage the back of your ears every hour or so to let blood flow back into that space, because there's not even a layer of fat. It's just skin on cartilage."

Michelle Pacis, BSN, RN, CWOCN, a nurse in the department of wound, ostomy and continence at Cedars-Sinai Medical Center in Los Angeles, was also jarred by TV reports featuring injured providers at the onset of the pandemic. With LA still months away from the nightmares New York City and Italy were experiencing, she and her colleagues decided to be proactive about the negative impact masks have on skin integrity after hours of wear.

Our skin is our first line of defense against any kind of infection.
— Michelle Pacis, BSN, RN, CWOCN

"Within our scope of practice as wound care nurses, we're concerned with skincare," she says. "We wanted to see what we could do to help our fellow colleagues whenever we would be that hard-hit, which we eventually were."

The nurses embarked on a quality improvement project, published late last year in the Journal of Wound, Ostomy, and Continence Nursing. The goal was to identify a prophylactic dressing that would maintain providers' skin integrity while preventing contamination due to COVID-19. They evaluated six topical skincare products — alcohol-free liquid acrylate, thin film dressing, thin hydrocolloid dressing, hydrocolloid blister care cushion, thin foam transfer dressing and thick foam dressing — all applied to skin in contact with N95 respirators.

After each product was applied, an N95 was donned and evaluated for fit. The nurses wore the devices for 10 hours, then doffed the mask using established facility procedures. They evaluated their faces for potential contamination, including possible aerosolization, by applying a commercially available fluorescent lotion to simulate the presence of infectious particles, and using an ultraviolet light for all dressings except for the alcohol-free liquid acrylate.

They found no skin irritation and no contamination of the simulated pathogen when removing any of the skin products, but mild discomfort was experienced with the thin film dressing and both hydrocolloid dressings. "In terms of comfort level, the thicker the product was, the more comfortable it was," says Ms. Pacis.

Ultimately, the nurses recommend application of an alcohol-free liquid acrylate film in conjunction with a mask fit test and a user-performed seal check. Make sure you have a proper fit, because safety trumps comfort, points out Ms. Pacis.

"Our skin is our first line of defense against any kind of infection," says Ms. Pacis. "Aside from the precautions we suggested, try to get a good night's rest, hydrate and continue your routine skincare. All of that can help keep your skin as healthy as it can be so it can help protect you." OSM