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Preventing pressure injuries in proned patients

Specialized nursing vastly improves skin protection

March 2022

HOSPITALS DEVOTE a lot of energy and resources to preventing pressure injuries, one of eight conditions originally flagged in the CMS’ 2008 hospital-acquired conditions initiative. A potentially life-threatening complication, pressure injuries—even without Medicare penalties—can also be very expensive.

Covid took that risk and multiplied it, given how many ICU patients since the beginning of the pandemic have needed to be proned while ventilated to improve both their oxygenation and mortality. While the literature is clear on the risk that proning poses for pressure injuries, particularly on patients’ face, cheeks, thorax and bony prominences, a study in the January 2022 issue of the American Journal of Critical Care is one of the first to look at a specific strategy for preventing pressure ulcers among critically ill proned patients.

The research reported on outcomes achieved by multidisciplinary prone-positioning teams across Philadelphia’s Penn Medicine Health System. (All the hospitals have closed ICUs.) The difference between the two teams: One, called the intervention group in the study, included a certified wound and skin care nurse at the bedside while patients were proned, heading up efforts during pronation to protect patients’ skin. The comparison team provided standard care, which did not include the certified wound and skin care nurse being at the bedside.

“The value of specially trained nurses as care partners is an important message. Teams make a big difference in patient outcomes.”


~ Kari Mastro, PhD, RN
Penn Medicine Princeton Health

The results: Among patients in the intervention group, 8% developed pressure ulcers vs. 60% in the comparison group. Patients who had a wound and skin care nurse heading up skin-protection efforts during pronation had a 97% lower adjusted odds ratio of developing a pressure ulcer than people in the other group.

“Having a certified wound and skin care nurse at the bedside providing direct supervision while patients are proned made the significant difference,” says lead author Kari Mastro, PhD, RN. Dr. Mastro is director of practice, innovation and research at Penn Medicine Princeton Health in Plainsboro, N.J.

Specialized expertise
Data were collected relatively early in the pandemic: Feb. 1 through Aug. 30, 2020. During at least a few of those months, OR techs—who are highly skilled at pronation—were available to work in the ICUs while operating rooms were shut down.

Those OR techs were available to both the intervention and comparison teams. Furthermore, both the comparison and the intervention groups used the prone guidelines for preventing pressure ulcers from the National Pressure Injury Advisory Panel, as well as Penn Medicine’s own proning protocol. That protocol was developed by wound care nurse and study coauthor Connie Johnson, MSN, RN, WCC, during the early months of the pandemic. Ms. Johnson and her team tried out different prone-positioning techniques on volunteer staff members.

The wound and skin care nurse was available to the team members proning patients in the comparison group, Dr. Mastro explains, stopping in to check their work and to give advice. “The difference is that, in the intervention group, the certified wound and skin care nurse took an active role while the patient was actually being moved,” she says.

According to the study, it took a team of 10 people, each with specialized expertise, to successfully prone critically ill covid patients and avoid pressure ulcers: the wound and skin care nurse as well as an intensivist, an anesthesiologist (or respiratory tech), a critical care nurse, and several staff members to actually move and position patients.

During pronation, the wound and skin care nurse supervises all skin protection, including the placement and use of lubricants, flexible silicone dressings, cushions and fluidized pillows, and positioning; specialized training allows the nurse to tailor prevention interventions to a patient’s particular build. Because turning patients is so complicated and labor-intensive, it is done only at scheduled times in the morning and evening. In addition, respiratory therapists and critical care nurses work together to reposition patients’ faces and bodies every four hours to reduce pressure-ulcer risk.

Nurse training
Using a nurse trained in wound and skin care during pronation has become standard practice across Penn Medicine. Given how many covid patients have needed to be proned over the past two years, two other nurses at Penn Medicine Princeton Medical Center now work closely with the wound and skin care nurse there.

“We’ve also been very specific about training our ICU nurses further in skin protection,” Dr. Mastro says. “That helps with prevention.”

The proning protocol has remained the same, although the proning team has become smaller now that the protocol “is so ingrained,” she points out. The ICU physician may no longer be in the room while patients are being turned if an anesthesiologist is present. Or a respiratory therapist may be there instead of an anesthesiologist to ensure the airway remains intact.

But the certified wound or skin care nurse is present, or one of the nurses who’ve been specially trained to fill that role. Dr. Mastro points out that training for nurses in wound and skin care is available through the National Pressure Injury Advisory Panel. While certification in wound and skin care is valuable, training clinical nurses in wound and skin preservation makes a big difference in reducing pressure injuries.

“The value of specially trained nurses as care partners is an important message,” Dr. Mastro says. “Teams make a big difference in patient outcomes.”

Phyllis Maguire is Executive Editor of Today’s Hospitalist.

Published in the March/April 2022 issue of Today’s Hospitalist


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