August 2020 Wound and Ostomy Journal Club
Pressure injury prevention for COVID-19 patients in a prone position
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How does this research article compare to our practice, policy and/or procedure?
ReplyDeleteSimilar to those described in the article, PSJMC also uses similar offloading techniques/devices/beds for prone patients in the Covid units. Pressure redistributing surfaces such as our low air pressure mattresses are routinely used in our ICU Covid units for patients that have various wounds and need to be placed in a prone position to optimize gas exchange while intubated. Prone patients' arms and heads are repositioned every 2 hours to provide good skeletal alignment, similarly seen done by ICU nurses in the Covid units at PSJMC. The article discusses many offloading head positioners used for patients to prevent pressure injuries on the forehead, cheek or chin. PSJMC ICU Covid RNs have been using various new offloading donuts, wedges, and headrests to comfortably position their prone intubated patients and prevent pressure injuries. Similar to the article, PSJMC highlights the importance of having staff that is specifically trained to pronate and supinate intubated patients. We usually see at least 4 staff, including RNs and RT, in a Covid ICU room ready to prone a patient.
Discuss the limitations of the article.
There are quite a few limitations to the study noted. The article seemed as if it did a systematic review of various articles related to how to prevent pressure injuries for patients with Covid-19 in the prone position. In a systematic review, various articles related to the topic of choice are collected and critically analyzed, minimizing author bias. A limitation to this article was that the authors did not mention the sample/sample size, design or methods used in many of the articles mentioned. With this, we as the reader do not have a clear understanding of potential flaws or bias throughout the articles chosen. The article also stated that there was a limited amount of research evidence found related to head positioners and dressings for patients in prone position. Given that placing intubated Covid-19 patients in a prone position is a new practice in the healthcare field, it will only be a matter of time the more and more studies come out related to preventing pressure injuries in this position. Although the article talks about various offloading devices used to prevent pressure injuries with prone patients, it does not provide a solution in how to actually turn patients in this position. “Micro shifts” to prevent dislodgement of tubes and devices will ultimately not help prevent pressure injuries of the chest, pelvis, clavicle and shoulders of prone patients.
Megan Kincaid RN 09-19-2020
ReplyDeleteHow does this research article compare to our practice, policy and/or procedure? PSJMC has had great practice with proning covid ICU patients. They use a strong team of Rns, RT's and Doctors to assist in turning, maintaining pressure points are protected and vent tubing is secure. The face/eyes and clavicle/shoulders are well padded with donuts/foam dressings and protective eye wear to prevent skin breakdown of the nose/chin and forhead. Rn's reposition the patients every 2 hours to protect the hips/knees and arms and include lots of pillow support.
What is the sample size of this article? This article doesn't discuss a certain sample size other then just the pros and cons of proning patients with Covid. And it is limited in the discussion of how sick the patients are when they start to prone, what are the outcomes of proning right away vs, how far in the disease process.
ReplyDeleteWhat are the advantages and disadvantages to the proposed recommendations in the article?
There are many advantages to the proposed recommendations in the article that are currently in place to prevent ulcer pressures. The requirement of specialty beds, such as expensive pressure-reducing mattresses, dressings, repositioning the patient when in the chair and altering meals to provide ultimate nutrition would be tailored towards proning covid-19 patients. Every patient must receive a comprehensive skin assessment at the start of the shift, on admission and when transferred. The patient is followed closely for any signs of skin breakdown. The disadvantages to the proposed recommendations in the article, would be that preventing pressure injuries is resource intensive. Assigning a group or team that consisted of nurses, dieticians, and physical therapists to assess, reassess, and follow the patients throughout their hospital stay. This highly elect team would have to be trained and re-trained yearly though classes or HealthStream. Part of the intensified training would be to assign two nurse champions on each unit, who would educate other staff members on pressure ulcer prevention in the prone position.
Discuss the sample size used in the study.
A systematic reviewed on support surfaces has concluded that the choice of mattress used should be based on the patient’s needs and their risk for developing pressure ulcers in the prone position. In Europe, pre covid a multi-centre randomized controlled trail found that patient’s who were in prone position for 16 hours, while being on a ventilator due to ARDS, had a 16% mortality compared to 32.8% mortality from supine. Another systematic literature review was done by Kwee and Rozrn, on the complications of optical injuries, related to proning during surgery. A large critical care study in Australia was conducted utilizing the Z-Flo, reducing occipital pressure injuries by 87.7%. Using prophylactic dressings on patients in prone position, will prevent pressure ulcers based on a recent trail conducted on spinal patients in the operating room. Soft silicone foam multi-layered dressings were found to be effective in pressure ulcer development (p=0.019, OR 0.23, 95% CI 0.05–0.79). A randomized controlled trail study conducted by the Border Trail 1 and Border Trail 11, found that on critically ill patients, a multi-layer soft silicone foam dressing was effective in preventing pressure injuries on the heels and sacrum of those patients.