Reducing Facial Hospital-Acquired Pressure Injuries Related to Prone Positioning in the Intensive Care Unit

The purpose of this quality improvement (QI) initiative was to evaluate the effects of a repositioning intervention bundle on the occurrences and severity of hospital-acquired pressure injuries (HAPIs) of the face in patients with COVID-19-related acute respiratory distress syndrome (ARDS) managed by ventilation and placed in a prone position.

Eighteen critically ill, ventilated patients were placed in a prone position for extended periods (range, 1-13 days). The study setting was critical care units in a 504-bed nonprofit teaching hospital located in the Northeastern United States.

Standard of care for the prevention of pressure injury (PI) in ventilated patients placed in a prone position at our facility included use of foam dressings over bony prominences on the face and the application of tape to secure the endotracheal (ET) tube as compared to commercial ET tube securement devices. We also placed a fluidized pillow with pillowcase wrapped with an absorbent pad under the head to absorb secretions. We added 2 interventions to our facility's existing HAPI prevention bundle. The first was a repositioning strategy; ventilated and prone patients were lifted by their shoulders by critical care RNs while their ET tube was stabilized by a respiratory therapist every 6 hours. The RNs then repositioned the patient's head and arms to the opposite side into a swimmer's position (head lying to the side with one cheek in contact with the fluidized pillow). The second intervention was micromovement of the head performed by an RN every 4 hours.

Prior to implementation of the QI initiative, data collected during the early pandemic demonstrated that multiple patients developed facial PIs secondary to prone positioning; a majority were full-thickness or unstageable PIs, whereas a minority were partial-thickness PIs (stage 2). Following implementation of the QI initiative, data indicated that 5 of 18 (28%) patients placed in a prone position had HAPIs of the face; 4 (22%) of the HAPIs were stage 1 or 2 and 1 was unstageable. Patients were placed in a prone position from 1 to 13 days. All facial HAPIs developed within the first 2 days of placement in a prone position.

The addition of an RN and a respiratory therapist repositioning intervention and micromovements of the head every 4 hours by the RN to an existing pressure prevention bundle during prone positioning led to a clinically relevant reduction in the severity of facial HAPIs. As a result, care for these patients has been changed to incorporate the repositioning interventions implemented during this QI project.