Consensus document on device-related pressure ulcers becomes “more relevant than ever” due to COVID-19 


covid-19 pandemicThe Journal of Wound Care has republished a consensus document to tackle the rising rates of device-related pressure ulcers (DRPUs) among patients and now, due to COVID-19health care professionals. The authors, Amit Gefen (Tel Aviv University, Tel Aviv, Israel) and Karen Ousey (University of Huddersfield, Huddersfield, UK) write that, amid the COVID-19 pandemic, the effects of such pressure ulcers have been brought into sharp focus, given the use of personal protective equipment (PPE) and other devices. 

The document, Device-related pressure ulcers: SECURE prevention, initially published in February 2020, has been republished alongside an article outlining the device-related pressure ulcer risks posed by PPE during the pandemic, which also details how skin damage can be avoided.

The ultimate aim, according to Gefen and Ousey, is to provide frontline staff with a clear and simple strategy on how to prevent the risk of skin damage and/or device-related pressure ulcers during the pandemic, as well as to “point them in the direction of more in-depth guidance on long-term strategies for prevention”, for both themselves and their patients.

“The projected consequences of the COVID-19 pandemic make the consensus document more relevant than ever,” write the authors.

Amit Gefen

Discussing this further, the Gefen and Ousey acknowledge the “steep rise” in the number of intensive care unit (ICU) patients and, subsequently, an associated increase in the number of interactions between healthcare professionals and these patients with risk-causing devices. They speculate that this will lead to a proportional escalation in the absolute numbers of DRPUs among these patients.

“In addition,” they say, “it appears that COVID-19, with its fundamental characteristics of a cytokine storm—endothelial dysfunction, drop in oxygen saturation, hypercoagulability leading to microthromboses and potential effects on cardiac output—interacts with two of the three primary aetiological factors in DRPUs, inflammation and ischaemia.”

According to the authors, these factors can introduce an inherently increased fragility of soft tissues among COVID-19 positive patients, which result from the aforementioned pathophysiological components of the disease. Given this, they argue that the cohort of COVID-19 positive patients who will suffer ICU-acquired DRPUs “is expected to exceed the DRPU rates observed in the same ICUs before the pandemic”.

Karen Ousey

Gefen and Ousey write: “We are seeing a new type of DRPU that has the same known underlying pathophysiology, but which affects a different population: health workers.” While healthcare workers were not previously considered to be at risk of DRPUs, the authors argue that under the current circumstances of the pandemic “the most basic form of PPE”—the face mask—continues to contribute to their incidence.

“Similar to the bioengineering design of numerous types of medical devices for diagnosis and treatment of patients, the designs of PPE, and especially of respirators and goggles, will need to be revisited thoroughly when the first wave of the pandemic ends, to incorporate improvements related to the PPE-skin interactions.”

The consensus document outlines the progress that is required. While optimising PPE for safety and comfort should involve the use of stiffness-matched materials that do not aggressively indent the skin, Gefen and Ousey argue that a low coefficient of friction (COF) at skin-PPE interfaces, and effective release of trapped heat and moisture from these interfaces, is also essential.

However, while work regarding the safety of device designs has already started to appear in the literature, the authors contest that there is no equivalent published bioengineering information related to PPE. They call for “academicians, clinicians, industrialists, and regulatory professionals” to work closely together to bridge this gap “effectively, and promptly”.

Speaking to iWoundsNews, Gefen says that “pioneering” work is already underway in his laboratory. His team are focusing on characterising the mechanical and thermal loading states of tissues at, and near, interfaces with N95 respirators and goggles.


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