This website is intended for healthcare professionals

COVID updateFree Access

Facial pressure injuries and the COVID-19 pandemic: skin protection care to enhance staff safety in an acute hospital setting

    Abstract

    Objectives:

    The aim of this study was to determine the impact of a specially designed care bundle on the development of facial pressure injuries (PI) among frontline healthcare workers wearing personal protective equipment (PPE) during the COVID-19 pandemic. The primary outcome of interest was the incidence of facial PIs. The secondary outcomes of interest were facial pain while wearing PPE and ease of use of the care bundle.

    Methods:

    This study used a voluntary survey by questionnaire, supplemented by a qualitative analysis of interviews from a small purposive sample that took place in one large Irish hospital over a two-month period in 2020. The hospital was a city-based public university teaching hospital with 800 inpatient beds. The intervention was a care bundle consisting of skin protection, face mask selection, material use, skin inspection, cleansing and hydration developed in line with international best practice guidelines. All staff working in COVID-19 wards, intensive care units and the emergency department in the hospital were given a kitbag containing the elements of the care bundle plus an information pamphlet. Data were collected via a survey and interviews.

    Results:

    A total of 114 staff provided feedback on the use of the care bundle. Before using the care bundle 29% (n=33) of the respondents reported developing a facial PI, whereas after using the care bundle only 8% (n=9) of the respondents reported developing a facial PI. The odds ratio (OR) of skin injury development was 4.75 (95% confidence interval (CI): 2.15–10.49; p=0.0001), suggesting that after the care bundle was issued, those who responded to the survey were almost five times less likely to develop a skin injury. Interviews with 14 staff determined that the bundle was easy to use and safe.

    Conclusion:

    Among those who responded to the survey, the use of the bundle was associated with a reduction in the incidence of skin injury from 29% to 8%, and respondents found the bundle easy to use, safe and effective. As with evidence from the international literature, this study has identified that when skincare is prioritised, and a systematic preventative care bundle approach is adopted, there are clear benefits for the individuals involved.

    As of 11 February 2021, there had been more than 200,000 confirmed cases of COVID-19 and over 3800 COVID-19-related deaths in Ireland.1 Over 12,000 people had been hospitalised in Ireland with COVID-19, and over 1200 people had been admitted to intensive care units (ICU).1 While the overall percentage of COVID-19-positive cases requiring ICU care is low (<1%), within older age groups ICU admission rates are as high as 25%.1 This has meant a significant increase in workload for healthcare staff in providing daily frontline care to patients with COVID-19. The care delivery model necessitates the wearing of personal protective equipment (PPE). For COVID-19, recommendations for PPE are gloves, masks, goggles or face shields, and long-sleeved gowns.2,3 Face masks used among healthcare providers depend on the setting, personnel and level of activity.2 Masks include medical masks, respirator N95 or FFP2 standard, or equivalent.2

    Until now, device-related pressure injury (PI) prevention strategies have been directed towards patients.4 However, anecdotal information, nationally and internationally, suggests that facial pressure injuries (FPIs) are a significant problem resulting from wearing protective face masks,4,5 which, without a skin protector, mechanically indent the skin.6 The most common sites where FPIs occur have been reported as the bridge of the nose, cheeks, ears and forehead.5 One study reported the overall prevalence of skin injuries caused by PPE in medical staff as 42.8% (95% confidence interval (CI): 41.30–44.30%).5 This information is consistent with published data subsequent to the SARS epidemic.7 Furthermore, hospital personnel who are not directly involved in patient care must now also wear PPE, meaning that the numbers of professionals and service providers wearing PPE has significantly increased.4 During the current COVID-19 pandemic, evidence through social media channels and anecdotally from those wearing protective masks in healthcare settings has emerged of FPIs caused by the prolonged wearing of face masks.

    FPIs develop when the skin is indented with the continuous use of face masks.8 By definition, PIs are a localised injury to skin or underlying tissue, usually over a bony prominence, because of prolonged pressure or shear.9 FPIs can have a devastating effect on staff who are already overworked and anxious, and place them at an increased risk of developing an infection, including COVID-19 itself.10,11,12 Additionally, single-use face masks were not originally designed to be worn continuously for several hours; therefore, the prolonged use of PPE as seen during the COVID-19 pandemic further contributes to the incidence of FPIs among health professionals.4

    To address this clear and present problem, the research team developed an evidence-based care bundle for use by COVID-19 frontline staff, targeting the prevention of FPIs, with a resultant evaluation of its impact on the acquisition of FPIs, pain and ease of use of the bundle.

    Methods

    Research question

    What is the impact of a care bundle on the development of FPI among frontline healthcare workers?

    Design

    The design used adopted a voluntary survey by questionnaire, supplemented by a qualitative analysis of interviews from a small purposive sample.

    Outcomes

    The primary outcome of interest was the incidence of FPIs. Secondary outcomes of interest were facial pain while wearing PPE and ease of use of the care bundle.

    Site

    This study took place in one large Dublin based, public university teaching hospital, with 800 beds, over the two-month period March–May 2020.

    Access

    Permission to access the staff was provided by the hospital research audit committee (Ref: CA946).

    Population and sample

    All staff (n=300) working in COVID-19 wards, ICU and the emergency department in the hospital were given a kitbag containing the elements of the care bundle plus an information pamphlet. All of these staff were then invited to participate in the study, by voluntarily completing the study questionnaire. Further to the survey, purposive sampling was used to select 14 interview participants who used the bundle. The 14 staff who were selected all had to be working in one of the COVID-19 clinical areas, wearing PPE and using the care bundle. This was essential in order for them to answer the questions asked.

    Intervention

    The care bundle was developed in line with international best practice.6,9,13,14 The bundle consisted of five steps using WaterWipes baby wipes (WaterWipes UC, Drogheda, Ireland), Eucerin Aquaphor Soothing Skin Balm (Beiersdorf, Hamburg, Germany) and Mepitac tape (Mölnlycke Health Care AB, Gothenburg, Sweden).

    All staff were provided with WaterWipes baby wipes to ensure that the facial area was cleansed. The wipes are made with only two ingredients (99.9% water and fruit extract). Research on WaterWipes used with babies has shown that mothers reported a lower incidence of nappy rash.15 It had not been studied in an FPI context before, but was readily available for use during what was a national emergency in Ireland. The manufacturer was also responsive to the research team's call for assistance in developing the care bundle during what was a national emergency at the peak of the first wave of COVID-19.

    Staff then applied Eucerin Aquaphor Soothing Skin Balm once the skin was cleansed and dry. Over-the-counter skin protectants may be an effective, widely available and inexpensive means of reducing the frictional forces applied by PPE on facial skin.4 Given that the balm was a readily available, over-the-counter product, it was chosen for use in the care bundle. Similarly to the wipes, the manufacturer was quickly responsive to helping the research team develop the care bundle.

    Staff then cut Mepitac tape to size and applied it directly to the bridge of the nose and cheekbones. The purpose of the tape was to serve as a barrier against the frictional forces endured by those wearing PPE. The tape is easy to tear, is breathable and can be applied to different areas of the face. Personal experience of using the tape among some members of the research team was the main reason for the selection of this tape. This was a pragmatic choice and the tape was readily available to the research team.

    Thus, the five steps to using the bundle are as follows:

    1. Skin protection, using cleansing and moisturisation

    2. Selection of a face mask appropriate to the level of care to be provided

    3. Material use, application of tape and face mask

    4. Skin and face mask inspection during the clinical shift as appropriate

    5. Skin inspection, cleansing and hydration on removal of the PPE and tape.

    The care bundle was available on a smartphone app which could be downloaded by all participants, and on a poster, many of which were displayed in the PPE donning and doffing area and the staff room within the selected clinical areas. The development of the care bundle and the supply of the kits were made possible through a staff fundraising initiative and support from industry. The fundraising element was coordinated by the Development Office at the Royal College of Surgeons in Ireland (RCSI) University of Medicine and Health Sciences.

    Data collection

    Data were collected between March and May 2020. After three consecutive shifts using the care bundle, each participant was invited to voluntarily complete the cross-sectional survey, anonymously on their smartphone. The survey questions elicited information pertaining to the individuals' discipline, the incidence of skin injury before and during the use of the bundle, the nature of the skin injury, pain, comfort and ease of use of the care bundle. The online survey was hosted on a WordPress website and was built by an educational technologist using the Smart forms plugin. Survey data were collected in real time on an Excel spreadsheet (Microsoft Corp., US). To assist with the ease of data analysis, the spreadsheet used a basic tabulation framework to make sense of data. This helped to tabulate data into easily understandable rows and columns, and this assisted in drawing parallels between different research parameters.

    Qualitative data were also collected via a small number of one-to-one semi-structured interviews from selected staff. These participants were asked to elaborate further on safety and their overall perceptions of the care bundle. Set interview questions were as follows, and interspersed within these were further probing questions that arose from interview to interview:

    1. Staff satisfaction: Can you talk to me about your experience of the care bundle?

    2. Can you talk to me about anything else that would have benefitted you in terms of the care bundle?

    3. Protection: Can you talk to me about your experience of how the protective tape interacted with the functioning of the mask?

    4. Recommendations for practice: Would you recommend this care bundle to a colleague?

    5. Is there anything else you would like to discuss around the care bundle and your experiences?

    Each interview was completed by the same person. Interviews were written from speech to text once someone completed their third consecutive shift in their particular clinical setting. Participants signed that the written record was an accurate reflection of what they said. A further member of the team performed the thematic analysis and no disagreements occurred.

    Data analysis

    Survey data were entered onto SPSS version 25 (IBM Corp., US), and analysed using descriptive statistics. Inferential statistical analysis was undertaken using RevMan Version 5.3. (Cochrane Training), with a forest plot generated displaying the odds ratio (OR) and 95% CI. Thematic analysis16 was used to reduce and categorise qualitative data gathered during the semi-structured interviews.

    Results

    Survey

    Demographics

    A total of 114 staff provided feedback on the use of the care bundle. As would be expected, nursing staff accounted for the largest group (68%; n=78). However, a range of staff used the care bundle, as shown in Table 1.

    Table 1. The professional discipline of the staff using the care bundle

    DisciplineFrequencyPercent
    Nurse7868
    Doctor65
    Physiotherapist109
    Healthcare assistant98
    Other1110
    Total114100

    Skin injury before use of the care bundle

    In total, 29% (n=33) of the respondents reported that they had a skin injury before using the care bundle. Table 2 outlines the type of skin injury experienced, and as can be seen, an abrasion was the most common (16%; n=18), followed by a skin tear (9%; n=10).

    Table 2. Type of skin injury, pre-use of the care bundle

    Type of skin injuryFrequencyPercent
    Abrasion1816
    Blister11
    Deep sore44
    Skin tear109
    None8170
    Total114100

    Skin injury during use of the care bundle

    In total, 8% (n=9) of the respondents reported that they had a skin injury while using the care bundle. Table 3 outlines the type of skin injury experienced, and as can be seen, a skin tear (3.5%; n=4) was the most common. The mean number of days to skin injury development was 2.33 (SD: 0.71; median: 2; range: 1–3).

    Table 3. Type of skin injury while using the care bundle

    Type of skin injuryFrequencyPercent
    Abrasion22
    Blister22
    Deep sore11
    Skin tear43
    None10592
    Total114100

    Odds ratio of skin injury development, care bundle versus usual care

    Fig 1 outlines the forest plot of the odds ratio of skin injury development. In the pre-care bundle group 29% (n=33) of the respondents reported that they developed a skin injury, whereas in the post-care bundle group 8% (n=9) of the respondents reported that they developed a skin injury. The OR of skin injury development is 4.75 (95% CI: 2.15–10.49; p=0.0001), meaning that after the care bundle was issued, respondents were almost five times less likely to develop a skin injury.

    Fig 1.

    Fig 1. Forest plot: odds ratio of skin injury development, care bundle versus usual care

    Pain while wearing PPE with the care bundle

    Staff rated their pain on a scale of 0–10 while using PPE with the care bundle. As can be seen in Table 4, the mean pain score was 3.18 (SD: 2.44; median: 3; range: 0–10).

    Table 4. Pain while wearing personal protective equipment (PPE) with the care bundle

    Scale: 0=no pain, 10=worst pain imaginable
    Mean3.18
    Median3
    Standard deviation2.44
    Minimum0
    Maximum10

    Pain once the PPE was removed

    Staff also rated their pain, on a scale of 0–10, once the PPE was removed. As can be seen in Table 5, the mean pain score was 1.73 (SD: 2.11; median: 1; range: 0–9).

    Table 5. Pain once the PPE was removed

    Scale: 0=no pain, 10=worst pain imaginable
    Mean1.73
    Median1.00
    Standard deviation2.11
    Minimum0
    Maximum9

    How easy was the care bundle to use?

    Staff rated, on a scale of 0–10, how easy they found the care bundle to use. As can be seen in Table 6, the mean score was 7.76 (SD: 3.06; median: 9; range: 0–9).

    Table 6. Ease of use of the care bundle

    Scale: 0=difficult, 10=easy
    Mean7.76
    Median9
    Standard deviation3.06
    Minimum0
    Maximum10

    Would you recommend this care bundle to a colleague?

    Staff rated, on a scale of 0–10, how likely they would be to recommend the care bundle to a colleague. As can be seen in Table 7, the mean score was 8.25 (SD: 2.61; median: 10; range: 0–10).

    Table 7. Recommendations for using the care bundle

    Would you recommend this care bundle to a colleague? (0=least likely, 10=very likely)
    Mean8.25
    Median10
    Standard deviation2.61
    Minimum0
    Maximum10

    Interviews

    One-to-one semi-structured interviews (n=14) were completed, where participants were asked to elaborate further on safety and their overall perceptions of the care bundle. The majority of respondents were nurses (64.2%; n=9) (Table 8).

    Table 8. The professional discipline of interview respondents

    Interview participants
    Doctor2
    Healthcare assistant2
    Nurse9
    Physiotherapist1
    Total14

    Following thematic analysis using the approach designed by Attride-Sterling,16 three themes emerged from the data:

    1. The care bundle maintained my safety

    2. The care bundle and its effect on my mask

    3. Ease of use of the care bundle.

    Theme 1: The care bundle maintained my safety

    Each of the 14 respondents (N1 to N14) commented on how the care bundle prevented further FPIs. The particular FPIs mentioned were pressure sores, blisters and redness. The following participants summed up the sentiments expressed by all interview participants.

    It was so good I didn't have any marks coming out but I usually mark so easily. I felt like it really helped alleviate the pressure as well.

    (N2)

    It definitely prevented a pressure sore on my nose. I had what looked like an abrasion when this all started (Covid). Now I don't even get redness.

    (N6)

    It is clear from the quotes that participants felt that using the care bundle in its entirety helped prevent a new FPI.

    Theme 2: The care bundle and its effect on my mask

    One of the issues that the research team was wary of prior to the use of the care bundle was that it may affect the efficacy of the face mask seal. Each participant expressed that the elements of the care bundle did not compromise the protective nature of the face mask. The quotes from the following participants represent those of the whole group.

    No not at all, the dressings we were using before the bundle affected the seal but the tape as part of the bundle didn't. It definitely helped a lot.

    (N2)

    No it didn't interfere with the seal on my mask like some other dressings did.

    (N5)

    Mask functioned well. I didn't notice a difference in the seal.

    (N9)

    Initial concerns held by the research team were not realised because the care bundle elements did not reduce or interfere with the efficacy of the face mask as an item of PPE. The education contained in the smartphone touch-app given to every participant assisted in this.

    Theme 3: Ease of use of the care bundle

    The research team deemed it important to ascertain if the care bundle was easy to use. This was important considering the intense nature of providing COVID-19 care and treatment. Participants talked about the ease with which they used the care bundle, forming the view that it was not a chore to use it. The comments made by these two participants were a representation of what every participant expressed.

    The poster was easy to follow.

    (N7)

    The poster was easy to follow and I found the bundle easy to use.

    (N1)

    An easy-to-use care bundle ensured that participants used the bundle every day before fitting their face mask and at the end of the shift.

    Discussion

    The COVID-19 outbreak is challenging for all healthcare professionals on a collective and individual level.17 The need for this study was borne out of the fact that the safety of frontline staff was of paramount importance during the COVID-19 emergency. A clear and present threat to staff safety was the emergence of FPIs because of the prolonged wearing of protective face masks and goggles. Skin tears or friction lesions as a result of intensive and prolonged use of PPE have been reported and photographed extensively in the general media worldwide since the COVID-19 outbreak began. FPIs have also been recently reported in dermatology literature.18,19,20 The importance of training and providing safe PPE for frontline staff is vital in order to ensure the health and wellbeing of staff and to ensure safe staffing of COVID-19 care areas.21

    This study involved the development of an easy-to-use, evidence-based, five-step care bundle for use by COVID-19 staff. The key elements of the bundle included face wipes, moisturiser and protective tape, with each element acting in synergy. Thus, the bundle emerged as an all-in-one protector for staff against FPIs. This is of particular importance, given the negative impact that FPIs have in terms of the risk of pain, discomfort and infection, including that of COVID-19 itself.10,11,12 The systematic education touch-app available on the smartphones of participants ensured ready access and ease of use. Nonetheless, only 38% of those who received the care bundle responded to the survey. It was presumed that everyone installed the touch-app, but this may not have been the case. Indeed, some participants may have used the bundle but not installed the app. Another possible reason for the response rate was that all staff were working in COVID-19 facing areas during the worst of the pandemic and may simply not have had the time, energy or inclination to respond to the survey.

    In this study, the research team determined the incidence of FPIs among staff who responded to the survey, working in COVID-19 clinical areas within an 800-bed, public university teaching hospital in Dublin, Ireland. The use of the bundle was associated with a reduction in the incidence of skin injury from 29% to 8% among those who responded. It is important to highlight the incidence of this problem among staff as the growing use of FPIs in COVID-19 care areas has been extensively reported across social media platforms. However, this incidence figure is below the 42% reported by Jiang et al.5 The reason for this difference may be that the study by Jiang et al.5 was reported as the first cross-sectional survey completed by COVID-19-facing medical staff early in the pandemic. By the time the current study took place, the application and wearability of PPE may have been better. Furthermore, the study by Jiang et al.5 took place across 161 hospitals in China, whereas the present study took place in one Irish hospital, and as such may reflect a different context to data collection. Additionally, in a recently published practical tip sheet on maintaining skin health and integrity for staff wearing PPE for prolonged periods of time, a recommendation for future research in this area was to determine the incidence of FPIs among healthcare workers wearing PPE in order to evaluate the maintenance of integrity of mask function when a prophylactic dressing is applied.22 In the present study, the impact of a specially designed care bundle on the development of FPIs among frontline healthcare workers wearing PPE has been examined, partially addressing this gap in the literature. However, previously employed skin protection methods used by participants and how this may have affected the outcomes was not addressed.

    Crucially, this study sought to ascertain if the care bundle reduced the chances of staff acquiring an FPI and if the care bundle enhanced comfort. It is important to emphasise the association between pain and discomfort with infection control measures. A study carried out in Italy reported that even mild facial skin abrasions, itching or burning sensation, instinctively resulted in users touching masks, respirators or goggles in order to adjust their position to reduce the level of discomfort or pain.20 In the current study, survey data demonstrate that using the care bundle made it less likely that staff would develop an FPI, while survey data also showed that the bundle reduced pain. Interview data augmented this with participants paying particular attention to the ease of use of the bundle, specifically how it did not interfere with the protective mask, and how it was not a burden for them to use. The interaction between the chosen protective tape and mask functioning was of importance in the present study. Whether applying prophylactic dressings onto sensitive facial sites may compromise the seal of a medical face mask is an ongoing debate among clinicians and researchers alike. In the present study, interview data clearly demonstrated that the protective tape did not affect the seal or functioning of face masks as reported by healthcare providers.

    Limitations

    More critically, some elements of bias could have affected the study. For example, the staff who took part in the study did so voluntarily by receiving and using the care bundle pack, and thus staff were not randomly selected. However, not everyone responded to the survey. Had the nonresponders completed the survey then findings may have been different. Also, the responses of those who completed the survey were based solely on self-response with no validation of injury, such as photographs of injury or whether those who sustained an FPI were already susceptible to skin injury or used additional skincare strategies. Additionally, the improvement in skin condition attributed by the authors to the care bundle may have been due to other factors, such as differing lengths of time wearing PPE or the particular ward setting in which participants worked, a factor which may have affected the mean length of skin damage of 2.33 days. Wear time is a factor that should be addressed in future studies as it may differ from person to person or ward to ward. Changes in staff wellbeing, or the fact that they were part of the study and received training, is something that could also have been explored in greater detail. These are all important factors that require exploration in future studies on the bundle, in order to enhance the validity of what was found in this study and to reduce possible bias. Allied to this point is that while the care bundle consisted of five steps to be completed sequentially, it is not clear what the critical step, or steps, were; again, this needs to be validated in future studies, perhaps leading to a more refined process of application, wear and removal of the bundle elements. Despite this, it has been highlighted that when using care bundles in clinical practice, it is the consistent application of all the elements of the bundle that yields success.23 Thus, we have followed this guidance, and as such the purpose was not to explore the impact of one element of the bundle over another, rather it was to explore the effect of the bundle as a whole.

    Conclusion

    This study has demonstrated that it is possible to reduce the incidence of FPIs and reduce pain. However, more needs to be done to ensure the prevention of FPIs and associated pain from prolonged wearing of PPE. Clinical colleagues are working in circumstances that are challenging and research suggests that frontline staff are experiencing anxiety, depression and insomnia during the COVID-19 outbreak.24 It is of the utmost importance that researchers stand in solidarity with clinical colleagues on the frontline, providing evidence-based solutions to problems they are encountering during these unprecedented times. This study has provided an intervention that can help prevent the emergence of FPIs that compromise staff safety when they are providing care to COVID-19 patients in acute care settings. However, it does require further investigation to ensure that the products used directly affected the outcomes.

    Protection of frontline healthcare workers is a priority, to ensure that staff may work without harm from the use of equipment that is meant to be, in the first instance, protective in nature. Throughout the COVID-19 pandemic, it has become apparent that staff have experienced FPIs from the prolonged use of PPE. In response to this, the research team quickly developed an easy to use five-step care bundle. In the sample responding to the survey, the use of the care bundle was associated with a reduction in the incidence of facial pressure injury from 29% to 8%, and the bundle was reported as being easy to use, safe and effective. Consistent with evidence from the international literature, when skincare is prioritised, and a systematic preventative care bundle approach is adopted, there are clear benefits for the individuals involved. Furthermore, reaching out to frontline staff to provide support has the added benefit of enhancing wellbeing. This has never been more important than during the current pandemic, where clinical colleagues are facing unprecedented safety challenges in their day-to-day work.

    Reflective questions

    • How can facial pressure injuries be prevented by a skin protection care bundle?

    • How can staff safety be enhanced in COVID-19 wards by using a skin protection care bundle?

    • What are the steps in developing a skin protection care bundle?

    Declaration of interest: Eucerin Aquaphor Soothing Skin Balm (Beiersdorf, Hamburg, Germany) and WaterWipes baby wipes (WaterWipes UC, Drogheda, Ireland) were both donated. Fleming Medical (County Limerick, Ireland) distributed Mepitac tape (Mölnlycke Health Care AB, Gothenburg, Sweden) at a reduced cost. The authors have no conflicts of interest to declare.

    Acknowledgements

    The study was supported by a fundraising campaign led by RCSI, University of Medicine and Health Sciences, Dublin.

    References