COVID update

Facial pressure injuries and the COVID‑19

pandemic: skin protection care to enhance
staff safety in an acute hospital setting

Objectives: The aim of this study was to determine the impact of a
specially designed care bundle on the development of facial pressure
injuries (PI) among frontline healthcare workers wearing personal
protective equipment (PPE) during the COVID-19 pandemic. The
primary outcome of interest was the incidence of facial PIs. The
secondary outcomes of interest were facial pain while wearing PPE
and ease of use of the care bundle.
Methods: This study used a voluntary survey by questionnaire,
supplemented by a qualitative analysis of interviews from a small
purposive sample that took place in one large Irish hospital over a
two-month period in 2020. The hospital was a city-based public
university teaching hospital with 800 inpatient beds. The intervention
was a care bundle consisting of skin protection, face mask selection,
material use, skin inspection, cleansing and hydration developed in
line with international best practice guidelines. All staff working in
COVID-19 wards, intensive care units and the emergency department
in the hospital were given a kitbag containing the elements of the
care bundle plus an information pamphlet. Data were collected via a
survey and interviews.
Results: A total of 114 staff provided feedback on the use of the
care bundle. Before using the care bundle 29% (n=33) of the
respondents reported developing a facial PI, whereas after using the
care bundle only 8% (n=9) of the respondents reported developing a
facial PI. The odds ratio (OR) of skin injury development was 4.75
(95% confidence interval (CI): 2.15–10.49; p=0.0001), suggesting
that after the care bundle was issued, those who responded to the
survey were almost five times less likely to develop a skin injury.
Interviews with 14 staff determined that the bundle was easy to use
and safe.
Conclusion: Among those who responded to the survey, the use of
the bundle was associated with a reduction in the incidence of skin
injury from 29% to 8%, and respondents found the bundle easy to
use, safe and effective. As with evidence from the international
literature, this study has identified that when skincare is prioritised,
and a systematic preventative care bundle approach is adopted,
there are clear benefits for the individuals involved.
Declaration of interest: Eucerin Aquaphor Soothing Skin Balm
(Beiersdorf, Hamburg, Germany) and WaterWipes baby wipes
(WaterWipes UC, Drogheda, Ireland) were both donated. Fleming
Medical (County Limerick, Ireland) distributed Mepitac tape
(Mölnlycke Health Care AB, Gothenburg, Sweden) at a reduced cost.
The authors have no conflicts of interest to declare.

COVID-19  ●  facial pressure injury  ●  personal protective equipment  ● PPE ●  staff safety  ● wound ●  wound healing

A
s of 11 February 2021, there had been
more than 200,000 confirmed cases of
COVID-19 and over 3800 COVID-19-
related deaths in Ireland. 1 Over
12,000  people had been hospitalised in
Zena Moore,1,2,3,4,5 PhD, MSc (Leadership in Health Professionals Education),
MSc (Wound Healing & Tissue Repair), FFNMRCSI, PG Dip, Dip First Line Management,
RGN, Professor, Chair of Nursing, SWaT Director; Natalie L McEvoy,1,6 MSc, PGDip,
BSc, RGN, Research Nurse; Pinar Avsar,1 PhD, MSc, BSc, RGN, Senior Post Doctoral
Researcher*; Linda McEvoy,6 MSc, BSc, HDip (Neurosciences), RCPI Dip, RGN, Clinical
Audit and Governance Manager; Gerard Curley,6,7 Professor of Anaesthesia and Critical
Care, and Consultant in Anaesthesia and Intensive Care; Tom O’Connor,1,2,5 EdD, MSc
Ad Nursing, PG Dip Ed, BSc, Dip Nur, RNT, RGN, Professor; Aglecia Budri,1 PhD, BSc,
RGN, Lecturer; Linda Nugent,1,2 PhD, MSc Advancing Nursing Practice, FFNMRCSI,
PG Dip Ed, BSc, RGN, Lecturer; Simone Walsh,1 PMP, MSc Public Health, BSc Nursing
Management, PG Cert Medical Toxicology, RGN, Senior Research Projects Manager;
Frank Bourke,1 Learning Technologist; Declan Patton,1,2,8 PhD, MSc, PGDipEd,
PGCRM, BNS(Hons), RNT, RPN, Professor
*Corresponding author email: pinaravsar@rcsi.ie
1  School of Nursing and Midwifery and Skin Wounds and Trauma Research Centre, RCSI
Ireland with COVID-19, and over 1200 people had
been admitted to intensive care units (ICU).1 While
the overall percentage of COVID-19-positive cases
requiring ICU care is low (<1%), within older age
groups ICU admission rates are as high as 25%.1 This
has meant a significant increase in workload for
healthcare staff in providing daily frontline care to
patients with COVID‑19. The care delivery model
necessitates the wearing of personal protective
equipment (PPE). For COVID‐19, recommendations
for PPE are gloves, masks, goggles or face shields, and
long‐sleeved gowns. 2,3 Face masks used among
healthcare providers depend on the setting, personnel
and level of activity.2 Masks include medical masks,
respirator N95 or FFP2 standard, or equivalent.2
Until now, device-related pressure injury (PI)
prevention strategies have been directed towards
patients.4 However, anecdotal information, nationally
and internationally, suggests that facial pressure injuries
© 2021 MA Healthcare ltd

University of Medicine and Health Sciences, Dublin. 2  Fakeeh College of Health Sciences,
Jeddah, Saudi Arabia. 3  Faculty of Medicine, Nursing and Health Sciences, Monash
University, Australia. 4  Department of Public Health, Faculty of Medicine and Health
Sciences, Ghent University, Belgium. 5  Lida Institute, Shanghai, China. 6  Beaumont
Hospital, Dublin. 7  School of Medicine, RCSI University of Medicine and Health Sciences,
Dublin. 8  Faculty of Science, Medicine and Health, University of Wollongong, Australia.
(FPIs) are a significant problem resulting from wearing
protective face masks,4,5 which, without a skin protector,
mechanically indent the skin.6 The most common sites
where FPIs occur have been reported as the bridge of the
nose, cheeks, ears and forehead.5 One study reported

162 JOURNAL OF WOUND CARE  VOL 30, NO 3, MARCH 2021

Downloaded from magonlinelibrary.com by 157.051.109.245 on June 3, 2021.


the overall prevalence of skin injuries caused by PPE in
medical staff as 42.8% (95% confidence interval (CI):
41.30–44.30%).5 This information is consistent with
published data subsequent to the SARS epidemic.7
Furthermore, hospital personnel who are not directly
involved in patient care must now also wear PPE,
meaning that the numbers of professionals and service
providers wearing PPE has significantly increased.4
During the current COVID-19 pandemic, evidence
through social media channels and anecdotally from
those wearing protective masks in healthcare settings
has emerged of FPIs caused by the prolonged wearing of
face masks.
FPIs develop when the skin is indented with the
continuous use of face masks.8 By definition, PIs are a
localised injury to skin or underlying tissue, usually
over a bony prominence, because of prolonged pressure
or shear.9 FPIs can have a devastating effect on staff
who are already overworked and anxious, and place
them at an increased risk of developing an infection,
including COVID-19 itself.10–12 Additionally, single-use
face masks were not originally designed to be worn
continuously for several hours; therefore, the prolonged
use of PPE as seen during the COVID-19 pandemic
further contributes to the incidence of FPIs among
health professionals.4
To address this clear and present problem, the
research team developed an evidence-based care bundle
for use by COVID-19 frontline staff, targeting the
prevention of FPIs, with a resultant evaluation of its
impact on the acquisition of FPIs, pain and ease of use
of the bundle.
Methods
Research question
What is the impact of a care bundle on the development
of FPI among frontline healthcare workers?
Design
The design used adopted a voluntary survey by
questionnaire, supplemented by a qualitative analysis
of interviews from a small purposive sample.
Outcomes
The primary outcome of interest was the incidence of
FPIs. Secondary outcomes of interest were facial pain
while wearing PPE and ease of use of the care bundle.
Site
This study took place in one large Dublin based, public
university teaching hospital, with 800 beds, over the
two-month period March–May 2020.
Access
© 2021 MA Healthcare ltd
Permission to access the staff was provided by the
hospital research audit committee (Ref: CA946).
Population and sample
All staff (n=300) working in COVID-19 wards, ICU and
JOURNAL OF WOUND CARE  VOL 30, NO 3, MARCH 2021
COVID update
the emergency department in the hospital were given a
kitbag containing the elements of the care bundle plus
an information pamphlet. All of these staff were then
invited to participate in the study, by voluntarily
completing the study questionnaire. Further to the
survey, purposive sampling was used to select
14  interview participants who used the bundle. The
14 staff who were selected all had to be working in one
of the COVID-19 clinical areas, wearing PPE and using
the care bundle. This was essential in order for them to
answer the questions asked.
Intervention
The care bundle was developed in line with international
best practice.6,9,13,14 The bundle consisted of five steps
using WaterWipes baby wipes (WaterWipes UC,
Drogheda, Ireland), Eucerin Aquaphor Soothing Skin
Balm (Beiersdorf, Hamburg, Germany) and Mepitac
tape (Mölnlycke Health Care AB, Gothenburg, Sweden).
All staff were provided with WaterWipes baby wipes
to ensure that the facial area was cleansed. The wipes
are made with only two ingredients (99.9% water and
fruit extract). Research on WaterWipes used with babies
has shown that mothers reported a lower incidence of
nappy rash.15 It had not been studied in an FPI context
before, but was readily available for use during what was
a national emergency in Ireland. The manufacturer was
also responsive to the research team’s call for assistance
in developing the care bundle during what was a
national emergency at the peak of the first wave of
COVID-19.
Staff then applied Eucerin Aquaphor Soothing Skin
Balm once the skin was cleansed and dry. Over-the-
counter skin protectants may be an effective, widely
available and inexpensive means of reducing the
frictional forces applied by PPE on facial skin.4 Given
that the balm was a readily available, over-the-counter
product, it was chosen for use in the care bundle.
Similarly to the wipes, the manufacturer was quickly
responsive to helping the research team develop the
care bundle.
Staff then cut Mepitac tape to size and applied it
directly to the bridge of the nose and cheekbones. The
purpose of the tape was to serve as a barrier against the
frictional forces endured by those wearing PPE. The tape
is easy to tear, is breathable and can be applied to
different areas of the face. Personal experience of using
the tape among some members of the research team was
the main reason for the selection of this tape. This was
a pragmatic choice and the tape was readily available to
the research team.
Thus, the five steps to using the bundle are as
follows:
1. Skin protection, using cleansing and moisturisation
2. Selection of a face mask appropriate to the level of
care to be provided
3. Material use, application of tape and face mask
4. Skin and face mask inspection during the clinical
shift as appropriate
16 3
Downloaded from magonlinelibrary.com by 157.051.109.245 on June 3, 2021.
 COVID update

5. Skin inspection, cleansing and hydration on removal Data analysis

of the PPE and tape. Survey data were entered onto SPSS version 25 (IBM
The care bundle was available on a smartphone app Corp., US), and analysed using descriptive statistics.
which could be downloaded by all participants, and on a Inferential statistical analysis was undertaken using
poster, many of which were displayed in the PPE donning RevMan Version 5.3. (Cochrane Training), with a forest
and doffing area and the staff room within the selected plot generated displaying the odds ratio (OR) and 95%
clinical areas. The development of the care bundle and CI. Thematic analysis16 was used to reduce and
the supply of the kits were made possible through a staff categorise qualitative data gathered during the
fundraising initiative and support from industry. The semi‑structured interviews.
fundraising element was coordinated by the Development
Office at the Royal College of Surgeons in Ireland (RCSI) Results
University of Medicine and Health Sciences. Survey
Demographics
Data collection A total of 114 staff provided feedback on the use of the
Data were collected between March and May 2020. care bundle. As would be expected, nursing staff
After three consecutive shifts using the care bundle, accounted for the largest group (68%; n=78). However, a
each participant was invited to voluntarily complete range of staff used the care bundle, as shown in Table 1.
the cross-sectional survey, anonymously on their
smartphone. The survey questions elicited Skin injury before use of the care bundle
information pertaining to the individuals’ discipline, In total, 29% (n=33) of the respondents reported that
the incidence of skin injury before and during the use they had a skin injury before using the care bundle.
of the bundle, the nature of the skin injury, pain, Table 2 outlines the type of skin injury experienced, and
comfort and ease of use of the care bundle. The online as can be seen, an abrasion was the most common
survey was hosted on a WordPress website and was (16%; n=18), followed by a skin tear (9%; n=10).
built by an educational technologist using the Smart
forms plugin. Survey data were collected in real time Skin injury during use of the care bundle
on an Excel spreadsheet (Microsoft Corp., US). To assist In total, 8% (n=9) of the respondents reported that they
with the ease of data analysis, the spreadsheet used a had a skin injury while using the care bundle. Table 3
basic tabulation framework to make sense of data. This outlines the type of skin injury experienced, and as can
helped to tabulate data into easily understandable be seen, a skin tear (3.5%; n=4) was the most common.
rows and columns, and this assisted in drawing The mean number of days to skin injury development
parallels between different research parameters. was 2.33 (SD: 0.71; median: 2; range: 1–3).
Qualitative data were also collected via a small
number of one-to-one semi-structured interviews from Table 1. The professional discipline of the staff
using the care bundle
selected staff. These participants were asked to
elaborate further on safety and their overall perceptions Discipline Frequency Percent
of the care bundle. Set interview questions were as
Nurse 78 68
follows, and interspersed within these were
further probing questions that arose from interview Doctor 6 5
to interview:
Physiotherapist 10 9
1. Staff satisfaction: Can you talk to me about your
experience of the care bundle? Healthcare assistant 9 8
2. Can you talk to me about anything else that would
Other 11 10
have benefitted you in terms of the care bundle?
3. Protection: Can you talk to me about your experience Total 114 100
of how the protective tape interacted with the
functioning of the mask? Table 2. Type of skin injury, pre-use of the care
4. Recommendations for practice: Would you bundle
recommend this care bundle to a colleague?
Type of skin injury Frequency Percent
5. Is there anything else you would like to discuss
around the care bundle and your experiences? Abrasion 18 16
Each interview was completed by the same person.
Blister 1 1
Interviews were written from speech to text once
someone completed their third consecutive shift in Deep sore 4 4
© 2021 MA Healthcare ltd

their particular clinical setting. Participants signed

Skin tear 10 9
that the written record was an accurate reflection of
what they said. A further member of the None 81 70
team performed the thematic analysis and no
Total 114 100
disagreements occurred.

16 4 JOURNAL OF WOUND CARE  VOL 30, NO 3, MARCH 2021

Downloaded from magonlinelibrary.com by 157.051.109.245 on June 3, 2021.

 COVID update

Fig 1. Forest plot: odds ratio of skin injury development, care bundle versus usual care
Study or Pre-care bundle Post-care bundle Weight Odds ratio Odds ratio
subgroup
Events Total Events Total M–H, fixed [95% Cl] M–H, fixed (95% Cl)

Study group 2020 33 114 9 114 100.0% 4.75 [2.15, 10.49]

Total 114 114 100.0% 4.75 [2.15, 10.49]

Heterogeneity: not applicable

0.01 0.1 0 10 100
Test for overall effect: Z=3.86 (p<0.0001)
Favours [usual care] Favours [care bundle]
M–H—Mantel–Haenszel; CI—confidence interval

Odds ratio of skin injury development, PPE was removed. As can be seen in Table 5, the mean
care bundle versus usual care pain score was 1.73 (SD: 2.11; median: 1; range: 0–9).
Fig 1 outlines the forest plot of the odds ratio of skin
injury development. In the pre-care bundle group 29% How easy was the care bundle to use?
(n=33) of the respondents reported that they developed Staff rated, on a scale of 0–10, how easy they found the
a skin injury, whereas in the post-care bundle group care bundle to use. As can be seen in Table 6, the mean
8% (n=9) of the respondents reported that they score was 7.76 (SD: 3.06; median: 9; range: 0–9).
developed a skin injury. The OR of skin injury
development is 4.75 (95% CI: 2.15–10.49; p=0.0001), Would you recommend this care bundle to a colleague?
meaning that after the care bundle was issued, Staff rated, on a scale of 0–10, how likely they would be
respondents were almost five times less likely to to recommend the care bundle to a colleague. As can be
develop a skin injury. seen in Table 7, the mean score was 8.25 (SD: 2.61;
median: 10; range: 0–10).
Pain while wearing PPE with the care bundle
Staff rated their pain on a scale of 0–10 while using PPE Interviews
with the care bundle. As can be seen in Table 4, the mean One-to-one semi-structured interviews (n=14) were
pain score was 3.18 (SD: 2.44; median: 3; range: 0–10). completed, where participants were asked to elaborate
further on safety and their overall perceptions of the
Pain once the PPE was removed care bundle. The majority of respondents were nurses
Staff also rated their pain, on a scale of 0–10, once the (64.2%; n=9) (Table 8).
Following thematic analysis using the approach
Table 3. Type of skin injury while using the care designed by Attride-Sterling,16 three themes emerged
bundle from the data:
Type of skin injury Frequency Percent 1. The care bundle maintained my safety
2. The care bundle and its effect on my mask
Abrasion 2 2
3. Ease of use of the care bundle.
Blister 2 2
Theme 1: The care bundle maintained my safety
Deep sore 1 1 Each of the 14 respondents (N1 to N14) commented
Skin tear 4 3 on how the care bundle prevented further FPIs. The
particular FPIs mentioned were pressure sores,
None 105 92 blisters and redness. The following participants
Total 114 100 summed up the sentiments expressed by all
interview participants.

Table 4. Pain while wearing personal protective

It was so good I didn’t have any marks coming out but I
equipment (PPE) with the care bundle
usually mark so easily. I felt like it really helped alleviate
Scale: 0=no pain, 10=worst pain imaginable the pressure as well. (N2)
Mean 3.18
It definitely prevented a pressure sore on my nose. I had
Median 3 what looked like an abrasion when this all started
© 2021 MA Healthcare ltd

(Covid). Now I don’t even get redness. (N6)

Standard deviation 2.44

Minimum 0 It is clear from the quotes that participants felt that

using the care bundle in its entirety helped prevent a
Maximum 10
new FPI.

16 6 JOURNAL OF WOUND CARE  VOL 30, NO 3, MARCH 2021

Downloaded from magonlinelibrary.com by 157.051.109.245 on June 3, 2021.

 COVID update

Theme 2: The care bundle and its effect on my mask Table 5. Pain once the PPE was removed
One of the issues that the research team was wary of
Scale: 0=no pain, 10=worst pain imaginable
prior to the use of the care bundle was that it may affect
the efficacy of the face mask seal. Each participant Mean 1.73
expressed that the elements of the care bundle did not Median 1.00
compromise the protective nature of the face mask. The
quotes from the following participants represent those Standard deviation 2.11
of the whole group.
Minimum 0

No not at all, the dressings we were using before the Maximum 9

bundle affected the seal but the tape as part of the
bundle didn’t. It definitely helped a lot. (N2)
Table 6. Ease of use of the care bundle
No it didn’t interfere with the seal on my mask like some Scale: 0=difficult, 10=easy
other dressings did. (N5)
Mean 7.76

Mask functioned well. I didn’t notice a difference in the Median 9

seal. (N9)
Standard deviation 3.06
Initial concerns held by the research team were not Minimum 0
realised because the care bundle elements did not
reduce or interfere with the efficacy of the face mask as Maximum 10
an item of PPE. The education contained in the
smartphone touch-app given to every participant Table 7. Recommendations for using the care bundle
assisted in this.
Would you recommend this care bundle to a colleague?
(0=least likely, 10=very likely)
Theme 3: Ease of use of the care bundle
The research team deemed it important to ascertain if Mean 8.25
the care bundle was easy to use. This was important
Median 10
considering the intense nature of providing COVID-19
care and treatment. Participants talked about the ease Standard deviation 2.61
with which they used the care bundle, forming the view
that it was not a chore to use it. The comments made Minimum 0

by these two participants were a representation of what Maximum 10

every participant expressed.

The poster was easy to follow. (N7)

Table 8. The professional discipline of interview
respondents
The poster was easy to follow and I found the bundle
easy to use. (N1) Interview participants

Doctor 2
An easy-to-use care bundle ensured that participants
used the bundle every day before fitting their face mask Healthcare assistant 2
and at the end of the shift.
Nurse 9

Discussion Physiotherapist 1
The COVID-19 outbreak is challenging for all healthcare
Total 14
professionals on a collective and individual level.17 The
need for this study was borne out of the fact that the
safety of frontline staff was of paramount importance safe PPE for frontline staff is vital in order to ensure the
during the COVID-19 emergency. A clear and present health and wellbeing of staff and to ensure safe staffing
threat to staff safety was the emergence of FPIs because of COVID-19 care areas.21
of the prolonged wearing of protective face masks and This study involved the development of an easy-to-
goggles. Skin tears or friction lesions as a result of use, evidence-based, five-step care bundle for use by
© 2021 MA Healthcare ltd

intensive and prolonged use of PPE have been reported
and photographed extensively in the general media
worldwide since the COVID-19 outbreak began. FPIs
have also been recently reported in dermatology
literature.18–20 The importance of training and providing
COVID-19 staff. The key elements of the bundle included
face wipes, moisturiser and protective tape, with each
element acting in synergy. Thus, the bundle emerged as
an all-in-one protector for staff against FPIs. This is of
particular importance, given the negative impact that

JOURNAL OF WOUND CARE  VOL 30, NO 3, MARCH 2021 167

Downloaded from magonlinelibrary.com by 157.051.109.245 on June 3, 2021.
 COVID update
FPIs have in terms of the risk of pain, discomfort and
infection, including that of COVID-19 itself.10–12 The
systematic education touch-app available on the
smartphones of participants ensured ready access and
ease of use. Nonetheless, only 38% of those who received
the care bundle responded to the survey. It was presumed
that everyone installed the touch-app, but this may not
have been the case. Indeed, some participants may have
used the bundle but not installed the app. Another
possible reason for the response rate was that all staff
were working in COVID-19 facing areas during the worst
of the pandemic and may simply not have had the time,
energy or inclination to respond to the survey.
In this study, the research team determined the
incidence of FPIs among staff who responded to the
survey, working in COVID-19 clinical areas within an
800-bed, public university teaching hospital in Dublin,
Ireland. The use of the bundle was associated with a
reduction in the incidence of skin injury from 29% to 8%
among those who responded. It is important to highlight
the incidence of this problem among staff as the growing
use of FPIs in COVID-19 care areas has been extensively
reported across social media platforms. However, this
incidence figure is below the 42% reported by Jiang et al.5
The reason for this difference may be that the study by
Jiang et al.5 was reported as the first cross-sectional survey
completed by COVID-19-facing medical staff early in the
pandemic. By the time the current study took place, the
application and wearability of PPE may have been better.
Furthermore, the study by Jiang et al.5 took place across
161 hospitals in China, whereas the present study took
place in one Irish hospital, and as such may reflect a
different context to data collection. Additionally, in a
recently published practical tip sheet on maintaining
skin health and integrity for staff wearing PPE for
prolonged periods of time, a recommendation for future
research in this area was to determine the incidence of
FPIs among healthcare workers wearing PPE in order to
evaluate the maintenance of integrity of mask function
when a prophylactic dressing is applied.22 In the present
study, the impact of a specially designed care bundle on
the development of FPIs among frontline healthcare
workers wearing PPE has been examined, partially
addressing this gap in the literature. However, previously
employed skin protection methods used by participants
and how this may have affected the outcomes was
not addressed.
Crucially, this study sought to ascertain if the care
bundle reduced the chances of staff acquiring an FPI and
if the care bundle enhanced comfort. It is important to
emphasise the association between pain and discomfort
with infection control measures. A study carried out in
Italy reported that even mild facial skin abrasions,
itching or burning sensation, instinctively resulted in
users touching masks, respirators or goggles in order to
adjust their position to reduce the level of discomfort or
pain.20 In the current study, survey data demonstrate
that using the care bundle made it less likely that staff
would develop an FPI, while survey data also showed
16 8
that the bundle reduced pain. Interview data augmented
this with participants paying particular attention to the
ease of use of the bundle, specifically how it did not
interfere with the protective mask, and how it was not a
burden for them to use. The interaction between the
chosen protective tape and mask functioning was of
importance in the present study. Whether applying
prophylactic dressings onto sensitive facial sites may
compromise the seal of a medical face mask is an ongoing
debate among clinicians and researchers alike. In the
present study, interview data clearly demonstrated that
the protective tape did not affect the seal or functioning
of face masks as reported by healthcare providers.
Limitations
More critically, some elements of bias could have affected
the study. For example, the staff who took part in the
study did so voluntarily by receiving and using the care
bundle pack, and thus staff were not randomly selected.
However, not everyone responded to the survey. Had the
nonresponders completed the survey then findings may
have been different. Also, the responses of those who
completed the survey were based solely on self-response
with no validation of injury, such as photographs of
injury or whether those who sustained an FPI were
already susceptible to skin injury or used additional
skincare strategies. Additionally, the improvement in
skin condition attributed by the authors to the care
bundle may have been due to other factors, such as
differing lengths of time wearing PPE or the particular
ward setting in which participants worked, a factor
which may have affected the mean length of skin damage
of 2.33 days. Wear time is a factor that should be
addressed in future studies as it may differ from person
to person or ward to ward. Changes in staff wellbeing, or
the fact that they were part of the study and received
training, is something that could also have been explored
in greater detail. These are all important factors that
require exploration in future studies on the bundle, in
order to enhance the validity of what was found in this
study and to reduce possible bias. Allied to this point is
that while the care bundle consisted of five steps to be
completed sequentially, it is not clear what the critical
step, or steps, were; again, this needs to be validated in
future studies, perhaps leading to a more refined process
of application, wear and removal of the bundle elements.
Despite this, it has been highlighted that when using
care bundles in clinical practice, it is the consistent
application of all the elements of the bundle that yields
success.23 Thus, we have followed this guidance, and as
such the purpose was not to explore the impact of one
element of the bundle over another, rather it was to
explore the effect of the bundle as a whole.
© 2021 MA Healthcare ltd
Conclusion
This study has demonstrated that it is possible to
reduce the incidence of FPIs and reduce pain. However,
more needs to be done to ensure the prevention of FPIs
and associated pain from prolonged wearing of PPE.
JOURNAL OF WOUND CARE  VOL 30, NO 3, MARCH 2021
Downloaded from magonlinelibrary.com by 157.051.109.245 on June 3, 2021.
 COVID update
Clinical colleagues are working in circumstances that
are challenging and research suggests that frontline
staff are experiencing anxiety, depression and insomnia
during the COVID-19 outbreak.24 It is of the utmost
importance that researchers stand in solidarity with
clinical colleagues on the frontline, providing evidence-
based solutions to problems they are encountering
during these unprecedented times. This study has
provided an intervention that can help prevent the
emergence of FPIs that compromise staff safety when
they are providing care to COVID-19 patients in acute
care settings. However, it does require further
investigation to ensure that the products used directly
affected the outcomes.
Protection of frontline healthcare workers is a priority,
to ensure that staff may work without harm from the
use of equipment that is meant to be, in the first
instance, protective in nature. Throughout the
Acknowledgements
The study was supported by a fundraising campaign led by RCSI,
University of Medicine and Health Sciences, Dublin.
References
1 Health Protection Surveillance Centre. Epidemiology of COVID-19 in
Ireland: daily infographic. 2021. https://tinyurl.com/140zh11v (acessed 15
February 2021)
2 World Health Organization. Rational use of personal protective
equipment (PPE) for coronavirus disease (COVID-19): interim guidance, 19
March 2020. https://apps.who.int/iris/handle/10665/331498 (accessed 1
July 2020)
3 World Health Organization (2020b) Advice on the use of masks in the
community, during home care, and in health care settings in the context of
COVID-19: interim guidance, 19 March 2020. https://apps.who.int/iris/
handle/10665/331493 (accessed 20 June 2020)
4 Gefen A, Ousey K. Update to device-related pressure ulcers: SECURE
prevention. COVID-19, face masks and skin damage. J Wound Care 2020;
29(5), 245–259. https://doi.org/10.12968/jowc.2020.29.5.245
5 Jiang Q, Song S, Zhou J et al. The prevalence, characteristics, and
prevention status of skin injury caused by personal protective equipment
among medical staff in fighting COVID-19: a multicenter, cross-sectional
study. Adv Wound Care 2020; 9(7):357–364. https://doi.org/10.1089/
wound.2020.1212
6. Alves P, Moura A, Gefen A et al. Prevention of skin lesions caused by
personal protective equipment (face masks, respirators, visors and
protection glasses). 2020. Associação Portuguesa de Tratamento de
Feridas 2020. ISBN 978-989-54770-4-3. https://tinyurl.com/3yz4oh57
(accessed 15 July 2020)
7 Foo CCI, Goon ATJ, Leow YL, Goh CL Adverse skin reactions to
personal protective equipment against severe acute respiratory syndrome:
a descriptive study in Singapore. Contact Dermatitis 2006; 55(5), 291–294.
https://doi.org/10.1111/j.1600-0536.2006.00953.x
8 Sivamani RK, Goodman J, Gitis NV, Maibach HI Coefficient of friction:
tribological studies in man: an overview. Skin Res Technol 2003;
9(3):227–234. https://doi.org/10.1034/j.1600-0846.2003.02366.x
9. European Pressure Ulcer Advisory Panel, National Pressure Injury
Advisory Panel, Pan Pacific Pressure Injury Alliance. Prevention and
treatment of pressure ulcers/injuries: clinical practice guideline. The
international guideline 2019. https://guidelinesales.com (accessed 15
July 2020)
10 Peko-Cohen L, Ovadia-Blechman Z, Hoffer O, Gefen A. Dressings cut
to shape alleviate facial tissue loads while using an oxygen mask. Int
Wound J 2019; 16(3):813– 826. https://doi.org/10.1111/iwj.13101
11 Recalcati S. Cutaneous manifestations in COVID-19: a first
perspective. J Eur Acad Dermatol Venereol 2020; 34(5):e212–e213. https://
doi.org/10.1111/jdv.16387
12 Moreno RA, Villa E, Moreno VA et al. Cutaneous manifestation of
COVID-19 in images: a case report. J Eur Acad Dermatol Venereol 2020;
34(7):e307–e309. https://doi.org/10.1111/jdv.16531
13 Gefen A. Skin tears, medical face masks, and Coronavirus. J Wound
Manag Prev 2020; 66(4):6–7
14 Moore Z, Webster J. Dressings and topical agents for preventing
pressure ulcers. Cochrane Database Syst Rev 2018; 12(12):CD009362.
https://doi.org/10.1002/14651858.CD009362.pub3
17 0
COVID‑19 pandemic, it has become apparent that staff
have experienced FPIs from the prolonged use of PPE.
In response to this, the research team quickly developed
an easy to use five-step care bundle. In the sample
responding to the survey, the use of the care bundle was
associated with a reduction in the incidence of facial
pressure injury from 29% to 8%, and the bundle was
reported as being easy to use, safe and effective.
Consistent with evidence from the international
literature, when skincare is prioritised, and a systematic
preventative care bundle approach is adopted, there are
clear benefits for the individuals involved. Furthermore,
reaching out to frontline staff to provide support has
the added benefit of enhancing wellbeing. This has
never been more important than during the current
pandemic, where clinical colleagues are facing
unprecedented safety challenges in their day-to-day
work.  JWC
15 Price AD, Lythgoe J, Ackers-Johnson J et al. The BaSICS (Baby Skin
Integrity Comparison Survey) study: a prospective experimental study
using maternal observations to report the effect of baby wipes on the
incidence of irritant diaper dermatitis in infants, from birth to eight weeks
of age. Pediatr Neonatol 2020. https://doi.org/10.1016/j.
perneo.2020.10.003
16 Attride-Stirling J. Thematic networks: an analytical tool for qualitative
research. Qualitative Research 2001; 1(3):385-405. https://doi.org/10.1177
%2F146879410100100307
17 Zhang Y, Sun Z, Latour JM et al. Hospital response to the Covid-19
outbreak: the experience in Shangai, China. J Adv Nurs 2020; 76(7):1483–
1485. http://doi.org/10.1111/jan.14364
18 Darlenski R, Tsankov N. Covid-19 pandemic and the skin: what should
dermatologists know? Clin Dermatol 2020; 38(6):785–787. https://doi.
org/10.1016/j.clindermatol.2020.03.012
19 Gheisari M, Araghi F, Moravvej H et al. Skin reactions to non-glove
personal protective equipment: an emerging issue in the COVID-19
pandemic. J Eur Acad Dermatol Venereol 2020; 34(7):e297–e298. https://
doi.org/10.1111/jdv.16492
20 Atzori L, Ferreli C, Atzori MG, Rongioletti F. COVID-19 and impact of
personal protective equipment use: from occupational to generalized skin
care need. Dermatol Ther 2020; 33(4):e13598. https://doi.org/10.1111/
dth.13598
21 Bagnasco A, Zanini M, Hayter M et al. Covid-19 – a message from Italy
to the global nursing community. J Adv Nurs 2020; 76(9):2212–2214.
https://doi.org/10.1111/jan.14407
22 Coyer F, Coleman K, Hocking K et al. Maintaining skin health and
integrity for staff wearing personal protective equipment for prolonged
periods: a practical tip sheet. Wound Practice & Research 2020;
28(2):75–83 https://doi.org/10.33235/wpr.28.2.75-83
23 Chaboyer W, Bucknall T, Webster J et al. The effect of a patient centred
care bundle intervention on pressure ulcer incidence (INTACT): a cluster
randomised trial. Int J Nurs Stud 2016; 64:63–71. https://doi.org/10.1016/j.
ijnurstu.2016.09.015
24 Pappa S, Ntella V, Giannakas T et al. Prevalence of depression, anxiety,
and insomnia among healthcare workers during the COVID-19 pandemic:
a systematic review and meta-analysis. Brain Behav Immun 2020;
88:901–907. https://doi.org/10.1016/j.bbi.2020.05.026
Reflective questions
● How can facial pressure injuries be prevented by a skin
protection care bundle?
© 2021 MA Healthcare ltd
● How can staff safety be enhanced in COVID‑19 wards by
using a skin protection care bundle?
● What are the steps in developing a skin protection care
bundle?
JOURNAL OF WOUND CARE  VOL 30, NO 3, MARCH 2021
Downloaded from magonlinelibrary.com by 157.051.109.245 on June 3, 2021.