British Journal of Nursing - Pressure ulcers and the prone position

The prevention of pressure ulcers (PU) is an important consideration for nurses and allied health professionals. To reduce PU incidence, health professionals are guided by National Institute for Health and Care Excellence (NICE) guidelines (2014). However, the guidelines do not refer to proning, prone nursing or nursing patients with acute respiratory distress syndrome (ARDS). Although this position has been used within critical care settings for patients with ARDS, the use of proning has seen a recent upsurge in the care of patients with COVID-19 (Zhu et al, 2020). Critical care clinicians treating these patients have reported good responses to ventilation in the prone position, leading to this being recommended in international guidelines (Bamford et al, 2020). Proning in these circumstances, usually for more than 16 hours per day, leads to an increased risk of pressure ulcers. A survey of their members by the Intensive Care Society (ICS) and the Faculty of Intensive Care Medicine (FICM) (2019) identified pressure ulcers as the most cited complication.

The Tissue Viability Society (TVS) (2020a) has compiled guidance from the latest evidence that includes:

Equipment

Patient positioning

Protecting specific areas of the body

Wound-care products.

The guidance (2020a) also refers clinicians to the ICS guidance for prone positioning in adult critical care (2019).

Prone

The prone position is defined as lying in a horizontal position with the front of the body facing downwards. It is used to improve short-term oxygenation and lung compliance (BACCN, 2018).

Treating patients with ARDS, with its high mortality rate, is a clinical challenge for critical care units. The COVID-19 pandemic has seen the number of critical care units treating patients with ARDS increase (Bamford et al 2020). In 2014, a meta-analysis concluded that mechanical ventilation in the prone position significantly reduces mortality in patients with moderate to severe ARDS when used early and for more than 16 hours per day (Sud et al, 2014). This was further supported by a Cochrane review (Bloomfield et al, 2015), which recommended prone ventilation for 16 or more hours to be actively considered in patients with severe hypoxaemia within 48 hours of mechanical ventilation. This has also been effective in the management of COVID-19 patients with moderate to severe ARDS (Meng et al, 2020).

The general points to note with respect to the latest guidelines are as follows.

Equipment: if using an alternating-air mattresses/powered mattress, ensure it is flat and in static mode for proning and repositioning, ensuring mode is changed after any procedure. Ensure any lines or devices are working, positioned carefully and are not trapped

Skincare: the TVS (2020b) has compiled a skincare checklist for proning. In summary, the important principles are to cleanse and moisturise the skin, ensuring any lines, tubing or devices are working, secure and positioned carefully. Catheters should lie freely between the legs, the eyes should be taped closed, and ears should not be bent over or trapped. Barrier protection should be considered to protect from moisture, especially the mouth area. Silicone padding, re-application of ECG dots should be considered. Bony prominences should be protected, supported and off-loaded. Skin condition should be monitored and documented, and any redness addressed

Dressing recommendations: film barrier products are easy to apply, protect the skin from moisture, may reduce friction but do not provide pressure relief or pressure reduction. Manufacturer's instructions for application and use should be followed. Thin hydrocolloid dressings are low profile and waterproof, and available in a range of sizes. They are good in areas of higher friction due to their low profile surface. They offer varying degrees of transparency, facilitating skin inspection, but provide little, if any, padding and no pressure relief. Multilayer silicone foam products are available as adhesive and non-adhesive. The adhesive is very ‘skin friendly’, reducing skin stripping. They have good absorbency, but may not fit into very narrow or small areas. They can reduce pressure, shear and friction. It is important to ensure they are removed at regular intervals (at least once per shift) to check and record skin condition. Silicone gel padding materials offer good extra padding, redistribute pressure well and are available in a wide range of shapes and sizes. They are not dressings and do not offer any absorbency. Care is needed to prevent maceration. They can be cost effective as they can be cleaned and repositioned; however, they are for single-patient use only.

Summary

The principles of pressure ulcer prevention should be used in a systematic and thorough way. Recording the patient's skin integrity is essential to help understand and respond to changes in the skin in a timely manner. While it is recognised that ARDS is a critical illness with a high mortality rate, mitigating against the risk of PU damage should still be a fundamental part of nursing patients in the prone position.