Pressure injuries in mechanically ventilated COVID-19 patients utilising different prone positioning techniques - A prospective observational study

Objectives: To compare the incidence and distribution of pressure injuries (PIs) with two approaches to prone positioning for mechanically ventilated COVID-19 patients, and to determine the prevalence of these PIs on intensive care unit (ICU) and hospital discharge. Design: A prospective observational study. Setting: Adult patients admitted to a quaternary ICU with COVID-19-associated acute lung injury, between September 2021 and February 2022. Main Outcome Measures: Incidence and anatomical distribution of PIs during ICU stay for "Face Down" and "Swimmers Position" as well as on ICU and hospital discharge. Results: We investigated 206 prone episodes in 63 patients. In the Face Down group, 26 of 34 patients (76 %) developed at least one PI, compared to 10 of 22 patients (45 %) in the Swimmers Position group (p = 0.02). Compared to the Swimmers Position group, the Face Down group developed more pressure injuries per patient (median 1 [1, 3] vs 0 [0, 2], p = 0.04) and had more facial PIs (p = 0.002). In a multivariate logistic regression model, patients were more likely to have at least one PI with Face Down position (OR 4.67, 95 % CI 1.28, 17.04, p = 0.02) and greater number of prone episodes (OR 1.75, 95 % CI 1.12, 2.74, p = 0.01). Over 80 % of all PIs were either stage 1 or stage 2. By ICU discharge, 29 % had healed and by hospital discharge, 73 % of all PIs had healed. Conclusion: Swimmers Position had a significantly lower incidence of PIs compared to the Face Down approach. One-quarter of PIs had healed by time of ICU discharge and three-quarters by time of hospital discharge. Implications for Clinical Practice: There are differences in incidence of PIs related to prone positioning approaches. This study validates and helps better inform current prone position guidelines recommending the use of Swimmers Position. The low prevalence of PIs at hospital discharge is reassuring.