Early in 2020, at the start of the COVID-19 pandemic, nurses at Massachusetts General Hospital noticed a "a stream of safety reports" documenting hospital-acquired pressure injuries among critical care patients placed in the prone position as part of COVID treatment. To explore pressure injuries related to prone positioning, researchers retrospectively reviewed the records of all 147 mechanically ventilated patients admitted to an ICU between April 9, 2020, and June 8, 2020.
The hospital protocol for manual prone positioning of patients was updated in March 2020 and included several pressure injury prevention measures: the use of a commercial endotracheal tube holder secured with adhesive patches, turning the patient's head at least every two hours while in the prone position, microshifting, and the use of a bundle of pressure redistribution products.
During the first 11 days of the prone positioning protocol's use, safety reports indicated a relationship between incident pressure injuries and the use of commercial endotracheal tube holders. As a result, the staff reverted to a previous practice of securing endotracheal tubes with fabric adhesive tape. Early safety reports also revealed that many pressure injuries developed on protruding body surfaces, such as the ears, chin, breasts, penis, and knees, so new pressure redistribution products were added to the protocol.
Patient records and relevant safety reports were reviewed. A total of 91 patients (62%) sustained 128 pressure injuries of stage 2 or greater.
Patient characteristics found to be significant risk factors for pressure injury development in these patients included male sex and a body mass index greater than 40. Other significant risk factors included a duration of prone positioning of more than 32 hours per session and the use of the commercial endotracheal tube holder. A D-dimer laboratory test result greater than 3,200 micrograms per milliliter was significantly associated with the development of sacrococcygeal pressure injuries.
The authors note that theirs was a convenience sample, and that data on some variables were missing as a result of less strict documentation requirements during the COVID-19 surge. They recommend continued research on the effectiveness of various pressure redistribution products and devices.