PPE And Related Skin Reactions
Overview
Healthcare workers, who played a vital role during the pandemic, faced various challenges related to the use of personal protective equipment (PPE), resulting in skin issues. This study aimed to identify and understand these skin problems experienced by nurses working in intensive care units within a hospital.
The study followed a cross-sectional survey design and involved nurses from three intensive care units in Ankara, Turkey. Data were collected through an online questionnaire developed by researchers between December 2021 and June 2022.
Out of 120 nurses, 82 (68.33%) participated in the survey. On average, nurses used PPE, including goggles, N95 masks, bonnets, face shields, gloves, boots/shoe covers, and coveralls, for approximately 3.76 hours per use. A significant proportion of nurses, 74 out of 82 (90.24%), reported experiencing skin problems related to PPE, often with multiple issues such as pressure sores, acne, skin reactions like allergic dermatitis or contact urticaria, and regional pain, affecting between 4.9% and 79.3% of respondents.
Approximately 53.66% of nurses applied protective measures to prevent skin problems. Among these measures, the use of pressure-reducing surfaces was the most common. The application of protective measures, particularly for goggles, bonnets, and face shields, was found to be effective in reducing PPE-related skin problems.
Introduction
During the pandemic, health authorities recommended the highest level of protective measures for healthcare workers to prevent occupational exposure and transmission of infections. Personal protective equipment (PPE), including medical masks, N95/3M/FFP2 masks, non-sterile gloves, goggles, face shields, bonnets, coveralls, shoe covers, and boots, was extensively utilized. However, various complications, such as skin issues, headaches, sweating, breathing difficulties, vision problems, dry mouth, fatigue, communication challenges, anxiety, and fear, were reported due to the use of PPE.
Among these issues, skin problems gained significant attention, with prevalence rates ranging from 47% to 75.13% in meta-analyses. Different manufacturers produced PPE with varying qualities, leading to a wide array of skin problems, as observed in various studies. Expert associations in the field of healthcare, such as the National Pressure Injuries Panel and Canadian Wound, Ostomy, and Continence Nursing, have highlighted this issue.
Healthcare institutions sourced PPE from different manufacturers, resulting in qualitative differences in the PPE used by each institution. Identifying facility-specific variations in PPE can help assess the challenges faced by the critical care workforce and impact the delivery of healthcare services. This research aimed to contribute to the global literature by reporting skin problems associated with PPE use. Unlike previous studies that focused on individual PPE elements like masks, goggles, or gowns, this study comprehensively examined the skin problems caused by each type of PPE used by healthcare professionals during the pandemic. It also explored protective measures employed to mitigate these skin issues.
Methods
Inclusion Criteria
– Health care workers in three ICUs within one hospital service.
– Nurses actively providing health care in the ICU.
– Nurses using Level 3 PPEs during the study period.
– Participants who provided informed consent for the study.
Exclusion Criteria
– Health care workers not involved in direct patient care.
– Nurses not using Level 3 PPEs.
– Participants who did not provide informed consent for the study.
This cross-sectional survey aimed to investigate skin problems related to the use of personal protective equipment (PPE) among healthcare workers in three intensive care units (ICUs) within one hospital service. The study spanned from December 2021 to June 2022 and included nurses actively engaged in healthcare delivery in the ICU. Level 3 PPEs, comprising goggles, N95 masks, face shields, bonnets, gloves (up to the elbow), boots or shoe covers, and coveralls, were used. The study aimed to answer several research questions, including the proportion of skin problems related to PPE use, the influence of socio-demographic characteristics and working conditions on skin problems, and the effectiveness of protective applications in preventing these issues.
Data were collected through an online questionnaire that covered socio-demographic details, working conditions, and skin problems experienced by the nurses. Protective measures employed to mitigate skin problems were also assessed. Ethical considerations were adhered to, with voluntary participation and written consent from participants. Data analysis included percentages, means, the Shapiro-Wilk test for normality, chi-square tests (or Fisher’s Exact test), correlation tests, and multivariate logistic regression. A significance level of p < 0.05 was used for statistical analysis.
Results
In this study, 82 out of 120 (68.33%) nurses participated, with an average age of 28.93 ± 4.21 years. The majority of the participants were female (64.63%), and 81.71% held bachelor’s degrees. On average, they had worked in the ICU for approximately 8.82 ± 5.89 months and attended to around 12.71 ± 3.88 patients daily.
The nurses reported an average duration of PPE usage per session, including goggles, N95 masks, bonnets, face shields, gloves, boots/shoe covers, and coveralls, of 3.76 ± 1.36 hours.
Skin problems related to PPE use were prevalent among the nurses, with 90.24% experiencing at least two or more such issues. The most common skin problems were associated with goggles (79.3%) and N95 masks (89.0%), followed by bonnets (34.1%), face shields (22.0%), gloves (34.1%), and boots/shoe covers (30.5%).
Protective applications were employed by some nurses to prevent skin problems, with varying proportions using them for different PPE components. Notably, 31.7% used protective applications for goggles, 28.0% for N95 masks, 6.1% for bonnets, and 13.4% for face shields.
Gender played a role in the development of skin problems related to goggles, with females experiencing more acne issues. Applying protective applications was associated with a reduced incidence of pressure sores. For N95 masks, an increase in protective application correlated with more reports of regional pain. Bonnets and face shields showed higher rates of skin problems in individuals who did not use protective applications. Protective applications reduced skin reactions for gloves and boots/shoe covers.
Correlation analysis indicated no significant links between skin problems (except for goggles and gloves) and age, working duration in the ICU, number of patients cared for daily, and duration of PPE usage per session. However, caring for more patients was associated with a reduction in skin problems related to goggles and gloves.
Multivariate logistic regression analysis did not reveal any significant relationships between age, working duration in the ICU, duration of PPE usage per session, number of patients cared for daily, and skin problems related to PPEs.
Conclusion
Various issues, including skin problems due to the use of personal protective equipment (PPE), have been observed among healthcare professionals providing intensive services during health crises, such as epidemics and pandemics. Despite their prevalence, these skin problems were not prioritized during such crises, although they adversely affected the performance and work quality of healthcare personnel. This cross-sectional survey aimed to identify the specific skin problems related to each type of PPE, associated factors, and protective measures employed during the pandemic.
The research revealed that a substantial 90.24% of nurses reported experiencing at least one skin problem associated with PPE usage. This prevalence exceeded that reported in previous studies, possibly due to variations in PPE materials, usage duration, and user demographics.
Skin problems related to goggles, N95 masks, and face shields were particularly common, affecting a significant proportion of the participants. These issues included pressure sores and regional pain. In comparison to a meta-analysis reporting a skin problem prevalence range of 47%-66%, this study identified a higher frequency (90.24%). This difference may be attributed to various factors, including PPE material, usage duration, and the age and gender of the users.
Skin problems linked to bonnets were less frequently studied, but in this research, one out of every five nurses reported issues, mainly affecting areas behind the ears, the face, and the scalp. Previous studies have reported various skin problems associated with gloves, such as eczema, chapped skin, excessive sweating, allergic contact dermatitis, and more. In this study, approximately one in four nurses experienced one or more skin problems, including pressure sores, acne, skin reactions, and regional pain.
When examining the impact of various factors such as age, gender, PPE usage duration per session, number of patients cared for daily, and protective applications on skin problems, it was found that age did not significantly correlate with skin issues. Gender only played a significant role in acne related to goggles, pressure sores associated with bonnets, and skin reactions linked to face shields. Generally, gender did not significantly affect skin problems.
Duration of PPE usage per session was previously associated with increased skin problems. However, in this study, the relationship was not as pronounced, possibly due to the relatively shorter average duration of PPE usage. Conversely, caring for more patients daily was linked to a lower incidence of skin problems related to goggles and gloves. This could be because nurses changed their PPE for each patient, reducing prolonged pressure on the skin.
Protective applications, such as hydrogel and hydrocolloid dressings, were found to significantly reduce skin problems related to various PPE components by reducing friction between the PPE and the skin. While the results suggested that gender and age-specific modifications in PPE production may not be necessary, they emphasized the importance of encouraging protective practices, especially among female healthcare professionals, to prevent skin problems effectively.
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