Article originally featured on WoundSource
Calling the COVID-19 pandemic an "unprecedented time" is an understatement. In this time of uncertainty, predicting what to expect can provide some comfort via preparation for the future. We can presume several implications for wound care professionals, based on the clinical course and community response to our evolving situation. Wound care health professionals should be prepared for some unique circumstances on the other side of the curve.
Critical Care Is Risky Business for the Skin
We can anticipate that patients who survive critical care admission will present with a higher incidence of skin integrity concerns. Patients are at higher risk of pressure ulcer development while in the prone position, which is commonly recommended for patients with acute respiratory distress syndrome caused by COVID-19 (infection with the novel coronavirus).1 This position involves the patient lying on their stomach, while arms and legs are supported with pillows or cushions. Tubes, drains, and breathing apparatuses are likely to be touching the face directly, instead of suspended in air.
Furthermore, the highly contagious nature of this disease, combined with shortages of staff and equipment, has led to an approach of limiting time spent in rooms with patients with COVID or PUI (persons under investigation). Less time spent in the rooms leads to less time assessing the skin and repositioning the patient off of bony prominences, which will likely lead to more pressure ulcers.
Intensive care unit (ICU) nurses may be familiar with prone positioning, but nurses who are unfamiliar with placing the patient should have a keen eye when inspecting the skin head to toe for breakdown related to pressure or friction. Pressure ulcers in these patients may not occur in the typical locations (i.e., the sacrum) and may instead occur on the dorsal surfaces of the body, including stomach, genitals, knees, toes, face, and mucous membranes. What would otherwise be discounted as a superficial scab on a knee could actually be an unstageable decubitus ulcer with eschar. Wound professionals must perform thorough assessments on patients and monitor for unusual presentations.
ICU nurses are familiar with the effect that vasopressors have on the skin, especially distal peripheral circulation. By shunting circulation to keep the vital organs operational during a critical condition, skin is more prone to ulcerations from the resulting ischemia. This especially affects the fingers and toes, leading to frequent amputations of the distal extremities caused by gangrenous infections.2 If these patients recover from their acute viral infection, they may be discharged home without adequate vascular follow-up, secondary to the closure of many offices and imaging centers for non-emergency procedures. If a distal extremity manifests with dry, stable eschar, the patient and home care team must remember to withhold sharp or autolytic debridement and keep the ulcer clean and dry until vascular status can be assessed and/or corrected if indicated.3
Put on Your Own Mask Before Helping Others
It's no secret that personal protection equipment (PPE) supply chains have been hit hard by the increased worldwide demand for surgical masks, N95s, and other equipment.4 Photos have emerged of health care workers presenting with dermatitis, pressure ulcers, and skin tears after working long hours in bulky, hot, and tight-fitting protective equipment.5 This risk is exacerbated with the use of makeshift masks, improperly sized masks, or multiple masks at once. Wearing adhesive bandages underneath the masks may damage the integrity of the seal and is not recommended.
I anticipate system-wide approaches to examine and make recommendations on how to prepare and protect the skin of health care workers, especially on the bridge of the nose, sides of the face, and behind the ears. We may also begin to see alternatives offered to help ease direct pressure on the skin, for instance, sewing buttons onto headbands to alleviate pressure from the strap of the mask behind the ears. Treat commercially available solutions with a risk-benefit analysis; integrity of the mask and seal is vital. Creative minds across the world may develop innovative solutions that we can use in the future to reduce device-associated skin injuries for staff and patients.
Stay at Home, Wash Your Hands
Many Americans are heeding the recommendations to shelter in place, stay home, and participate in frequent washing of hands and commonly touched surfaces. Because of shortages, some people are inclined to produce homemade cleaning solutions and hand sanitizers.6 Although preventing viral transmission is of the utmost importance, we realize that frequent use of harsh chemicals, especially homemade ones of unknown potency, is liable to cause dry, cracked skin, which can decrease the barrier function of the skin.
We may also see a rise in allergic reactions due to use of unfamiliar chemicals or brands or even chemical burns caused by concoctions of disinfectants.7 Many people are wearing latex or nitrile gloves to protect themselves while out in public, and this can lead to contact dermatitis or maceration from overhydration caused by sweat.5 Take the time when assessing a patient to check the integrity of their hands and wrists, and inquire as to how often and with what they are cleansing their hands. This is also a great opportunity to educate patients about hygiene practices and skin care basics and to explain the risks of cross contamination when wearing commercial gloves.
Our "New Normal"
The COVID-19 pandemic will certainly shape the future of health care, the economy, and the world at large. Doctors' offices are being closed or transitioned to telehealth visits, research and conferences are being postponed or cancelled, and patients are frightened and isolated. The unemployment rate has skyrocketed, and some patients may have lost their insurance or income. Being aware of the unique challenges that patients, caregivers, and the general public face during their recovery is the first step we can take to get back on track. As we become accustomed to our "new normal," we can still find productive and innovative ways to help our patients. Being flexible and adaptable is nothing "new" and is instead quite "normal" for health care workers.
1. Girard R, Baboi L, Ayzac L, Richard JC, Guérin C; Proseva trial group. The impact of patient positioning on pressure ulcers in patients with severe ARDS: results from a multicentre randomised controlled trial on prone positioning. . Intensive Care Med. 2014;40(3):397-403. https://doi.org/10.1007/s00134-013-3188-1.
2. Newbury A, Harper KD, Trionfo A, Ramsey FV, Thoder JJ. Why not life and limb? Vasopressor use in intensive care unit patients the cause of acute limb ischemia. Hand. 2020;15(2):177-184. https://doi.org/10.1177/1558944718791189
3. Baranoski S, Ayello EA. Wound debridement. In: Wound Care Essentials – Practice Principles. 2nd ed. Ambler, PA: Lippincott Williams & Wilkins; 2008:120.
4. Emanuel EJ, Govind P, Upshur R, et al. Fair allocation of scarce medical resources in the time of COVID-19 [e-pub ahead of print]. N Engl J Med. 2020 March 23. https://doi.org/10.1056/NEJMsb2005114
5. Darlenski R, Tsankov N. COVID-10 pandemic and the skin – what should dermatologists know? Clin Dermatol. 2020. https://doi.org/10.1016.j.clindermatol.2020.03.012
6. Seymour N, Yavelak M, Christian C, Chapman B, Danyluk M. COVID-19 preventative measures: homemade hand sanitizer. EDIS. 2020;2020(2). https://journals.flvc.org/edis/article/view/121171.
7. Zurita A, Katzban A. After spray sanitizer burns at least 4 kids amid coronavirus scare, 7-Eleven owner charged. USA Today. March 11, 2020. https://www.usatoday.com/story/news/nation/2020/03/11/7-eleven-sanitizer.... Accessed April 16, 2020.
About the Author
Lauren graduated with a BSN from the University of Buffalo in Western New York, where she was born and raised. She has held various nursing jobs, but continued to work towards a goal of a career in wound care nursing after she was one of only two students who signed up for a wound care clinical during nursing school. She currently works at the Advanced Wound Healing Center in Orchard Park, NY where she once had her nursing clinicals. She became credentialed in Wound, Ostomy, and Continence Nursing in 2019 and is incorporating her knowledge and skills into her busy clinic practice. When not at work, Lauren enjoys indoor spinning, playing guitar, video games, and rooting for the Buffalo Bills NFL team.