SPECIAL FOCUS: WOUND CARE
Skin health in the ICU during the COVID-19 pandemic By Corey Heerschap s concern regarding Canadian ICU beds filling due to the expanding number of COVID-19 pandemic cases continues to grow, healthcare facilities and decision makers must consider and prepare for the increased level of care these additional critical patients will require. Take the skin health of COVID-19 patients for example. Nurses Specialized in Wound, Ostomy and Continence Canada released best practice recommendations for skin health among critically ill patients with an emphasis on individuals suffering from COVID-19. These best practice recommendations, released in May of 2020, provide an overview of prevention and management of common skin issues found among critically ill patients including skin tears, moisture associated skin damage, medical adhesive related skin injuries, pressure injuries and device related pressure injuries, among others. As the case count within Canada continues to rise these recommendations will assist front-line clinicians and administrative decision-makers working with the critically ill population to provide safe and effective skin care to their patients. As of January 11th, 2021 COVID-19 patients within Canada filled 881 ICU beds, with 6,854 individuals being admitted to the ICU up to this point. At this same time, out of 72.8 per cent of report data provided to the Government of Canada, there are 464 COVID-19 patients ventilated nationally, with 1,310 individuals having required mechanical ventilation to date. The age group representing over 50 per cent of those admitted to the ICU in Canada as of January 15th, 2021 has been individuals between the ages of 60 and 79. This age group is also at the highest risk for pressure injury development within an acute care hospital. One pressure injury study identified that 73 per cent of pressure injuries occur in patients over 65 during their acute care stay.
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In individuals that are bed or chair bound related to critical or chronic illness, it has been well-established that they are at increased risk for development of pressure injuries, skin tears, and other wounds such as moisture associated skin damage. Many of those admitted to the ICU with COVID-19 experience severe weakness leading to prolonged time in bed and/or chair or worsening of a pre-existing condition. As a result of the increased time spent lying or sitting, patients become more at risk for developing pressure injuries, localized skin damage caused by pressure or a combination of pressure and shear. Another form of pressure that must be considered as well, especially in an acute environment such as the ICU, is pressure caused by medical devices such as endotracheal tubes, monitoring equipment, catheters, intravenous lines, among others. The inclusion of prevention and management strategies such as pressure redistribution, routine turning and repositioning, implementation of a skin care routine, appropriate choice of wound dressing and optimized nutritional intake are important to prevent these injuries from manifesting and for managing pressure injuries when present. The need for increased pressure offloading equipment for patients at risk of pressure injuries has been recognized at the management level. Jennifer Kluszczynski, manager of the ICU at Royal Victoria Regional Health Centre (RVH) in Barrie, Ontario recognizes the importance, “of ensuring available offloading equipment, especially to support patient care when patients require proning.” Kaitlyn Hemphill, a Registered Nurse in the ICU at RVH notes an increase in pressure injuries, especially to the ears” of patients suffering from COVID-19 due to the increased pressures when proning the patient. Proning, as a treatment to manage acute respiratory distress syndrome
Patients in the “proning” position as part of COVID-19 treatment have an increased risk for a number of wounds. as a result of COVID-19, can lead to increased risks for a number of wound types including pressure injuries. To reduce pressure, patients should be placed on a pressure redistribution surface, possibly using pillows, wedges, or other offloading equipment to reduce pressure in high-risk areas. A dense foam can also be considered for offloading of areas such as the head, face, and ears. Soft silicone multi-layer dressings may also be considered to assist with offloading areas of pressure. Placement of any medical devices, tubing, and wiring should be considered to provide stabilization and offloading to not cause increased areas of pressure. Other wounds, often less recognized as compared to pressure injuries in the acute care setting, can also cause significant skin damage, increase costs, and are time consuming to manage by the care team. One of these wound types includes moisture associated skin damage (MASD). COVID-19 patients are “often diaphoretic, causing head to toe moisture” according to Marta Siembida a Registered Nurse in the ICU. MASD occurs with prolonged over hydration of the skin leading to tissue erosion. This moisture can come in many forms including urine, stool, and sweat as examples. Ensuring patients have access to a complete skin care program which includes pH balanced skin cleansers, moisture barriers, and equipment to
manage moisture such as moisture wicking pads when in bed, is important to the prevention of skin damage in this population. Ensuring the patient remains hydrated and provided with appropriate nutrition will also assist with protecting the patient’s skin and reduce the risk of MASD. Patients suffering from COVID-19 also may experience “increased edema due to organ shutdown and lack of movement” according to ICU Registered Nurse Brenda Hughes. Increased edema, along with other co-morbidities and medical adhesive use, are associated with increased risk for skin tear development. To assist with skin tear prevention, use of a hypoallergenic moisturizer, once or twice daily, will reduce the risk of trauma during positioning and ambulation, and avoiding use of adhesives on fragile skin is important. Dressings to manage these wounds should reduce trauma on removal, provide moist wound healing, and assist the patient with managing pain. Skin tears, as with other skin health complications in COVID-19 patients, must be considered when caring for and planning for patients entering the ICU to ensure availability of equipment and recognition of monitoring and caring for patient’s skin health. To read more about skin health in critically ill patients and how to prevent and manage complications with an emphasis on COVID-19, please H visit www.nswoc.ca. ■
Corey Heerschap, MScCH, BScN, RN, NSWOC, WOCC(C), IIWCC is a Clinical Nurse Specialist for Wound and Ostomy. 20 HOSPITAL NEWS FEBRUARY 2021
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