The coronavirus disease 2019 (COVID-19) pandemic has forced health care professionals to take a closer look at the most effective and appropriate measures for pressure injury prevention. In 17% of all COVID-19 cases,¹ pneumonia secondary to acute respiratory distress syndrome is the most common complication; therefore, prone positioning is used as an adjuvant therapy. The prone position allows for dorsal lung region recruitment, end-expiratory lung volume increase, and alveolar shunt decrease.²

To be most effective, this position should be maintained for 10 to 12 hours, thereby increasing prolonged pressure on certain areas of the body.³ However, prone positioning should be supervised and monitored regularly by nursing staff experienced with this positioning technique. Pressure points at highest risk during the prone positioning include forehead, cheeks, nose, chin, clavicle or shoulder, elbow, chest or breasts, genitalia, anterior pelvic bones (iliac crests, ischium, symphysis pubis), knees or patella, dorsal feet, and toes.⁴ Also at high risk are patients with medical devices. These patients should be monitored for medical device–related pressure injury development, and caregivers should check under and around all devices (all tubes, ostomy appliances, electrocardiographic leads, feeding tube, urinary catheter, etc.).^4,5

Positioning Devices for Prone Positioning

Positioning devices are encouraged to help offload one or more pressure points during prone positioning. There are both manual and other proning devices or products that support prone positioning. Specially designed proning devices and products provide an array of materials to assist in redistributing pressure and lowering risk of shear stress. Educating nursing staff on correct use of positioning devices is vital for device effectiveness and prevention of further skin injuries. Encourage teamwork in positioning to avoid friction and shear. Do not “drag” during positioning techniques. Patients in the prone position should be repositioned using small shift changes while lying on any support surface to avoid pressure injuries. Repositioning should be performed while the patient is in the prone position, especially when non-rotating or pulmonary mattresses or beds are used.⁴

Pressure Redistribution Support Surfaces

Whenever possible, patients in the prone position should be placed on specialty beds designed for proning; when this is not an option, redistribution surfaces should be used instead, following manufacturer instructions. Similarly, if prophylactic dressings are used to help pad a bony prominence, manufacturer instructions should be followed.⁴

Prone Positioning Systems

Repositioning patients in the prone position can be challenging. However, specialty beds designed for prone positioning are available, and they include a rotation feature with a 40- to 62-degree rotation. These specialty beds do not replace turning and repositioning, but rather they aid movement of pulmonary secretions and promote ventilation-perfusion matching.⁴

Pressure Injury Prevention Strategies for Prone-Positioned Patients

Prone positioning can be used as a simple intervention in most patients.^4,6 Turning and repositioning frequency in these patients should reflect the patient’s level of activity and tissue tolerance.⁴ Each patient will be able to tolerate prone positioning in different amounts, so make sure you are building your care plan with your individual patient’s needs in mind. Consider using continuous bedside pressure mapping to cue positioning and to aid in developing an individual turning schedule.^4,7

Contraindications to proning in the conscious patient include morbid obesity, facial injury, neurological issues, second and third trimester pregnancy, and the presence of pressure injuries.^4,6 Always use a team of three to six staff members, depending on the patient’s habitus, medical devices, and stability, when turning or repositioning a patient.^4,8 There are various recommendations in prevention of pressure injuries while in the prone position depending on health status, body location, and medical device equipment used.

Proning is typically 16-18 hours in duration but may be greater than 24 hours if tolerated well. Supination periods are typically four hours before the next prone cycle begins.⁸ Prophylactic measures can be used during prone periods to help prevent the development of pressure injuries, such as using liquid skin sealants, hydrocolloids, multilayered foam dressings, and low-profile dressings to protect skin, bony prominences, and high-risk areas of increased pressure such as underneath medical devices.^4,8

Other prevention methods include the use of hydrofiber and/or calcium alginate dressings to wick away and absorb moisture, and making sure medical devices, such as an ostomy appliance or Foley catheter, are checked and emptied regularly. Check and monitor that central lines, arterial lines, and cannulas are secured in a position that won’t result in the development of a medical device–related pressure injury for the patient.⁴ Secure tubes from the patient’s waist to head at the top of the bed, and place lines from waist to feet at the bottom of the bed.⁸ Electrocardiographic leads should be attached to the patient’s back during prone positioning.^4,8

Always hold enteral feeding for 45 minutes to one hour prior to proning.⁸ The swimming or freestyle position should be used to alternate arms and direction of head in reducing risk of pressure injury as indicated. The patient’s head should be shifted or moved every two hours and repositioned every four hours as the patient tolerates.⁴ Turning the head reduces the risks for pressure injury and eye compression.^6,8 Using an offloading head support device or operating room head pillow with the middle cut out can be helpful.⁸ Utilizing a bite block can help prevent injury to the tongue.4 Use an ophthalmic lubricant for the eyes;^4,8 if eyes remain, open gently tape them closed.⁶

COVID-19 Skin Injuries and COVID Toes Versus Deep Tissue Pressure Injury

COVID-19 skin injuries, COVID toes, and deep tissue pressure injury may be misdiagnosed because of the clinical presentation of purple skin discoloration. With so many variations in COVID-19 manifestations, clinicians have sought guidance from the National Pressure Injury Advisory Panel since the start of the pandemic. The origin of COVID-19 skin injury or COVID toes is unknown. COVID-19 skin injuries occur in soft tissue that is not exposed to pressure, and they probably represent tissue ischemia resulting from clotting.⁹

COVID toes may manifest as deep red discoloration, indicating possible vascular inflammation. Treatments have not yet been investigated. Research is ongoing and continues to evolve.¹⁰ Clinicians are encouraged to submit cases to the American Academy of Dermatology COVID-19 registry (https://www.aad.org/member/practice/coronavirus/registry).⁹ This phenomenon has been a new challenge for clinicians, who have a vital need for knowledge to enable them to identify clinical the features and presentation of COVID-19 skin involvement correctly and to manage this condition optimally.¹¹

Conclusion

The prone positioning technique may improve oxygenation and survival, but it can put patients at a higher risk of pressure injuries. Prevention planning and education are key to continuity of care with these complex patients. Practical knowledge of vigilant head-to-toe skin assessments, regular monitoring, documentation, and various preventive strategies is essential in optimizing care and best outcomes.

References

1. Ghelichkhani P, Esmaeili M. Prone position in management of COVID-19 patients; a commentary. Arch Acad Emerg Med. 2020;8:e48.

2. Richter T, Bellani G, Scott Harris R, et al. Effect of prone position on regional shunt, aeration, and perfusion in experimental acute lung injury. Am J Respir Crit Care Med. 2005;172(4):480-487. doi:10.1164/rccm.200501-004OC

3. Kallet RH. A comprehensive review of prone position in ARDS. Respir Care. 2015;60:1660-1687. doi: 10.4187/respcare.04271

4. National Pressure Injury Advisory Panel. Pressure Injury Prevention PIP Tips for Prone Positioning. https://cdn.ymaws.com/npiap.com/resource/resmgr/online_store/posters/np…. Accessed November 11, 2020.

5. European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel, and Pan Pacific Pressure Injury Advisory Panel (EPUAP-NPIAP-PPPIA). Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline. 3rd ed. EPUAP-NPIAP-PPPIA; 2019. https://guidelinesales.com/. Accessed October 22, 2020.

6. Bamford P, Bentley A, Dean J, Whitmore D, Wilson-Baig N. ICS Guidance for Prone Positioning for the Conscious COVID Patient. https://emcrit.org/wp-content/uploads/2020/04/2020-04-12-Guidance-for-c…. Accessed November 11, 2020.

7. Why prone? Why now? Improving outcomes for ARDS patients. Crit Care Nurse. 2019;39(5):84.

8. Penn Medicine. Proning During COVID-19. https://www.pennmedicine.org/updates/blogs/penn-physician-blog/2020/may…. Accessed November 11, 2020.

9. National Pressure Injury Advisory Panel. Skin Manifestations with COVID-19: The Purple Skin and Toes that you are seeing may not be Deep Tissue Pressure Injury. An NPIAP White Paper https://cdn.ymaws.com/npiap.com/resource/resmgr/white_papers/COVID_Skin…. Accessed November 11, 2020.

10. National Pressure Injury Advisory Panel. COVID Skin Manifestations. https://cdn.ymaws.com/npiap.com/resource/resmgr/white_papers/COVID_Skin…. Accessed October 22, 2020.

11. Bristow IR, Borthwick AM. The mystery of the COVID toes - turning evidence-based medicine on its head. J Foot Ankle Res. 2020;13(1):38. doi:10.1186/s13047-020-00408-w