New Study Breaks Ground in Preventing Pressure Injuries in COVID-19 Patients

COVID-19 patients' pressure injuries were reduced substantially by adding a wound and skin care nurse to the prone-positioning team, study reveals.

Adding a certified wound and skin care nurse to a multiprofessional prone-positioning team significantly reduced the odds of patients with COVID-19 developing pressure injuries at Penn Medicine Princeton Health, says a study published in American Journal of Critical Care.

Healthcare-associated pressure injuries are a significant complication of placing patients prone, and prolonged prone positioning for patients with acute respiratory distress syndrome (ARDS) is associated with higher rates of new pressure injuries, specifically on the face, cheekbones, and thorax, as well as over bony prominences.

Although many studies have reported the development of pressure injuries in patients with ARDS who are placed prone for prolonged periods, this new study, Pressure Injury Outcomes of a Prone-Positioning Protocol in Patients with COVID and ARDS, is among the first to explore specific strategies for preventing pressure injuries.

The study evaluated the effectiveness of a multiprofessional pronation team that included a certified wound and skin care nurse who had direct supervision and oversight of all skin preparation procedures and trained the team to care for the patients’ skin.

"Throughout the pandemic, we've been honing our efforts to improve outcomes for patients with COVID-19," said senior author and researcher Kari A. Mastro, PhD, RN, NEA-BC, director of practice, innovation and research, Penn Medicine Princeton Health, Plainsboro, New Jersey.

"The results of our study underscore the value of having clinicians with specialized expertise work together to improve patient outcomes and could redefine the strategies used to prevent pressure injuries in this patient population," she said.

During the COVID-19 pandemic, Princeton Health formed a multiprofessional team to ensure the safe transition of critically ill patients from supine to prone and avoid common complications such as pressure injury development, accidental extubations, and loss of intravenous catheters.

The team included a certified wound and skin care nurse specialist, a critical care physician, an anesthesiologist and/or respiratory therapist, a critical care nurse, and persons who move and position patients regularly, such as surgical technicians, according to the article.

"In total," the study authors wrote, "we determined that 10 people with specific and specialized expertise were needed to successfully place a critically ill patient prone and avoid the complications well established in the literature."

Before placing a patient prone, the team worked through different techniques and created a refined, systematic, and smooth process, with step-by-step visual aids.

The intervention group was treated by a team that included a certified wound and skin care nurse, while the comparison group was treated by a prone-positioning team that used the National Pressure Injury Advisory Panel’s prone guidelines but did not include a certified wound and skin care nurse leading the pressure injury prevention strategies.

Significantly fewer patients in the intervention group had pressure injuries develop—8% compared with 60% in the comparison group. Furthermore, patients in the intervention group had a 97% lower adjusted odds ratio of pressure injury developing than those in the comparison group.

Other characteristics analyzed in the study include patient demographics and clinical characteristics, such as length of stay, number of days proned, the patient’s initial and last scores on the Braden Scale, and the use of a specialty surface or bed.

The article details skin care-related prevention, assessment, and intervention strategies, as well as the step-by-step prone-positioning procedure and specific responsibilities of the various team members.