COVID-19 patients in prone position: validation of instructional materials for pressure injury prevention

	Variável
Sex n(%)
Male	4 (15.4)
Female	22 (84.6)
Age, Med (IQR)	36.5 (10.3)
Current professional activity n(%)
Assistance	13 (50)
Teaching	10 (38)
Research	3 (11)
Management	6 (22)
Highest degree n(%)
Specialization	8 (30.8)
Master's degree	10 (38.5)
Doctoral degree	7 (26.9)
Postdoctoral student	1 (3.8)
Area of expertise n(%)
Cardiology	4 (15.4)
Stomatherapy/dermatology	7 (26.9)
Intensive care	14 (53.8)
Time of experience (years), Med (IQR)
Care, Med (IQR)	12.00 (9.8)
Research, Med (IQR)	6 (13)
Teaching, Med (IQR)	5.0 (12.8)
Institution n(%)
Public	21 (80.76)
Private	5 (19.2)

Step described in checklist	Judges' suggestions
Step 1. Four actions before positioning patients in prone position: adequate dressing, supervision, protection of critical areas for the development of PI in the anterior region of the body and removal of electrodes in the anterior region of the chest.	Include other critical areas such as shoulders, back of foot and nose, and other materials used for protection.
Step 2. Nine actions related to the body segment of the head, positioning of the bed in reverse Trendelenburg at 30º, importance of lateralization of the head and its rotation, care with the auricular pavilion and eyes and adequate positioning of probes and catheters.	Changes in the description of the actions and the inclusion of other protection devices.
Step 3. Five actions referring to the upper limb positioning (UULL) in "swimmer position" and their rotation, protection of critical areas, such as shoulders, elbows and hands, and attention to vascular devices.	Removal of the word "swimmer", more detailed description of the UULL positioning, changes in the frequency of rotation of the limbs and better description in relation to the neutral position of the hands.
Step 4. Four actions to prevent PI in the thoracic region: positioning of the electrodes, pad at the height of the scapular region and attention of the catheters and drains.	Greater detail on the electrode positioning and care for drains and catheters regarding traction and inclusion of breast care.
Step 5. Six actions in relation to the abdomen/hip region: positioning the cushion in the pelvic girdle region, care to avoid drainage traction, care for the genitalia and bladder catheters and extensions.	Changes in the description of the actions, inclusion of other devices that may increase the risk of pressure injury in this region and in terms of the location of the indwelling bladder catheter.
Step 6. Care of the lower limbs (LLLL): positioning the cushion in the patellar region and keeping the feet in a free position.	Improve the description of the location of the cushion, protection of the knees with polyurethane foam and assessment of the dorsum of the foot

PI prevention actions	Pert	Cla	Rel
1a. The entire team was dressed in cap, goggles, N95 mask, disposable apron and procedure gloves.	1	1	1
1b. The pressure points in the anterior region of the body (frontal region of the face, zygomatic, mentonian, thoracic, iliac crest, genital, patellar and pre-tibial) were assessed for the presence of hyperemia and/or injuries.	1	1	1
1c. Critical areas were protected with silicone devices or hydrocolloid plates: frontal region of the face, zygomatic, mentonian, iliac crest, patellar and pre- tibial.	1	1	1
1d. The monitoring electrodes were removed from the anterior region of the chest.	1	1	1
2a. The bed was positioned in reverse Trendelenburg at 30º.	0.92	0.96	0.96
2b. Head lateralized to the same side of the elevated upper limb.	0.96	0.96	0.96
2c. The head was lateralized and positioned under a cushion.	0.96	0.96	0.96
2d. Head rotation was prescribed every 2 hours.	0.96	1	1
2e. The eyes were lubricated and the eyelids closed with microporous tape in the horizontal direction). (ATTENTION: eye lubrication must be performed according to institutional protocol).	1	1	1
2f. The pinna is not folded.	1	1	1
2g. The orotracheal cannula is not pressing on the labial mucosa and is not pulled.	1	1	1
2h. The tongue is positioned inside the mouth.	0.96	0.96	0.96
2i. The gastric/enteric (oro/naso) catheter is not pressing on the nasal/labial mucosa and is not pulled.	1	1	1
3a. The upper limbs were positioned in the swimmer position (one upper limb elevated and the other extended along the body).	1	0.96	1
3b. Rotation of the upper limb positioning was prescribed every 2 hours.	0.96	0.96	0.96
3c. The shoulders are not rotated and the elbows are free of pressure.	1	1	1
3d. The hands are in a neutral position and free from pressure.	0.96	0.96	1
3e. No vascular devices (peripheral or arterial venous) or extensions are under the upper limbs.	0.96	0.96	0.96
4a. The monitoring electrodes are positioned in the posterior region of the chest.	1	1	1
4b. A cushion was positioned at the height of the shoulder girdle.	1	1	1
4c. The central venous catheter is not pressing on any region of the chest and is not pulled.	1	1	1
4d. The chest drain(s) is(are) not pressing on any region of the chest and is not being pulled.	1	1	1
5a. A cushion was placed at the height of the pelvic girdle.	1	1	1
5b. Ostomy pouches kept empty.	1	1	1
5c. The abdomen drain (s) is not pressing on any region of the abdomen and is not pulled.	0.96	0.92	0.96
5d. The male genitalia is positioned between the lower limbs.	1	1	1
5e. The closed urine collector extension is not pressing on the thigh region.	0.96	1	1
6a. A pad was positioned below the patellar region.	0.96	0.96	0.96
6b. The cushion positioned below the knees keeps the feet free of pressure.	1	1	1

CARE BEFORE PRONE POSITIONING
Step 1. Preparation	( )	1a. Perform hand hygiene and dressing with disposable apron, N95 mask, goggles, hat and procedure gloves.
	( )	1b. Assess the presence of hyperemia and/or lesions at the following pressure points: frontal face, zygomatic, mentonian, shoulders, elbows, chest, iliac crest, genitalia, patella, pre-tibial and dorsum of the foot.
	( )	1c. Apply silicone device or extra thin hydrocolloid plates in the following regions: frontal face, zygomatic, mentonian, nose, shoulders, iliac crest, patella, pre tibial and instep.
	( )	1d. Remove the monitoring electrodes from the anterior chest area and place them on the limbs.
	( )	1e. Position the cushions at the height of the shoulder girdle and the other at the pelvic girdle.
CARE AFTER PRONE POSITIONING
Step 2. Head	( )	2a. Position the bed in reverse Trendelenburg at 30º if there is no contraindication.
	( )	2b. Position the head to the same side where the upper limb was raised.
	( )	2c. Lateralize the head and place on a cushion.
	( )	2d. Rotate the lateralization of the head every 2 hours.
	( )	2e. Lubricate the eyes and keep the eyelids closed with microporous tape horizontally.
	( )	2f. Check that the pin is not folded.
	( )	2g. Check that the orotracheal cannula does not press on the labial mucosa and the fixation is not pulled.
	( )	2h. Position the tongue inside the oral cavity.
	( )	2i. Check that the gastric/enteric (oro/naso) catheter is not pressing on the nasal/labial mucosa and is not pulled.
Step 3. Upper limbs	( )	3a. Position the upper limbs in the swimmer position (one limb in extension with shoulder abduction and elbow flexion and the other along the body).
	( )	3b. Rotate the upper limb positioning every 2 hours OR every 1 hour in case of skin lesions in the upper limbs.
	( )	3c. Check that the shoulders are not rotated and the elbows are free of pressure.
	( )	3d. Place the hand of the upper limb that is positioned along the body on a cushion.
	( )	3e. Check that the devices are not pressing on the upper limbs and are not pulled or bent.
Step 4. Chest	( )	4a. Position the monitoring electrodes on the posterior chest.
	( )	4b. Check the location of the cushion at the height of the shoulder girdle, paying attention to the accommodation of the breasts.
	( )	4c. Check that the devices are not pressing on the thoracic region and are not pulled or bent.
Step 5. Hip and Abdomen	( )	5a. Check the location of the cushion at the height of the pelvic girdle.
Step 5. Hip and Abdomen	( )	5b. Check that the ostomy pouch (s) for elimination are being kept relatively empty and their closure system is not pressing on the abdomen, pelvis, and limbs.
	( )	5c. Position the male genitalia between the lower limbs.
	( )	5d. Check that the extension of the closed urine collector and any other device is not pressing on the thigh region.
Step 6. Lower limbs	( )	6a. Position a cushion along the tibial region allowing the instep to be free of pressure.

[TFN1] Note: Med: median; IQR: interquartile range

COVID-19 patients in prone position: validation of instructional materials for pressure injury prevention

Pacientes con COVID-19 en decúbito prono: validación de materiales instructivos para la prevención de lesiones por presión

ABSTRACT