Developing the tissue viability seating guidelines

BackgroundCosts for the prevention and management of pressure ulcers have increased significantly with limited published advice from health and social care organisations on seating and preventing pressure ulcers. At the request of the UK Tissue Viability Society the aim of the publication was to develop a practical guide for people, carers and health and social care professionals on how the research and evidence base on pressure ulcer prevention and management can be applied to those who remain seated for extended periods of time.Methods and findingsThe evidence base informing the guidelines was obtained by applying a triangulation of methods: a literature review, listening event and stakeholder group consultation. The purpose was to engage users and carers, academics, clinicians, inspectorate and charities, with an interest in seating, positioning and pressure management to: gather views, feedback, stories, and evidence of the current practices in the field to create a greater awareness of the issue.ConclusionThe new guidelines are inclusive of all people with short and long-term mobility issues to include all population groups. The document includes evidence on where pressure ulcers develop when seated, risk factors, best possible seated position and what seat adjustments are required, the ideal seating assessment, interventions, self-help suggestions and key seating outcomes. The updated TVS CPGs have been informed by the best available evidence, the insights and wisdom of experts, stakeholders and people who spend extended periods of time sitting.     

Exploring repositioning movements in sitting with ‘at risk’ groups using accelerometry and interface pressure mapping technologies

BackgroundDespite high quality guidelines underpinning pressure ulcer care (NPUAP/EPUAP/PPPIA, 2014), pressure ulceration still poses a significant financial impact on health care services in treatment and staff costs as well as having a profound effect on the health and quality of life of individuals experiencing them. Repositioning is a key preventative technique recommended by occupational therapists and other health care professionals. The frequency and quality of repositioning movements performed by individuals, however, can be difficult to determine. This paper explores the use of technology in monitoring repositioning movements in sitting.ObjectiveTo explore the outputs of technologies such as interface pressure mapping systems and accelerometers in enabling the therapist to accurately monitor seated behaviour and enhance practice through targeted interventions to prevent sitting acquired pressure ulceration.MethodReviewing the findings of two recent research studies with ‘at risk’ cohorts (spinal cord injury; elderly orthopaedic), using accelerometry and seated interface pressures, this paper will highlight how useful this technology is in clinical practice to monitor weight shifts and repositioning behaviours.ResultBoth studies illustrated that the majority of individuals did not adhere to the frequency or magnitude of movements currently recommended to redistribute seating interface pressures. When repositioning was performed it was ineffective in reducing seated pressures.ConclusionIn an era of personalised medicine, technology has an important role to play in providing the service user, caregivers and healthcare staff with important biofeedback information about seated behaviours, particularly those that minimise the risk of developing sitting acquired pressure ulcers. This information can augment occupational therapists' clinical decision-making in maximising active pressure ulcer prevention.     

Seated buttocks anatomy and its impact on biomechanical risk

AimThe objective of this study was to describe the amount, types, and shapes of tissue present in the buttocks during sitting (i.e., seated buttocks soft tissue anatomy), and the impact of seated buttocks soft tissue anatomy on biomechanical risk.Materials and methodsThe buttocks of 35 people, including 29 full-time wheelchair users with and without a history of pelvic pressure ulcers were scanned sitting upright on 3” of flat HR45 foam in a FONAR Upright MRI. Multi-planar scans were analyzed to calculate bulk tissue thickness, tissue composition, gluteus maximus coverage at the ischium, the contour of the skin, and pelvic tilt.ResultsBulk tissue thickness varied from 5.6 to 32.1 mm, was composed mostly of adipose tissue, and was greatest in the able-bodied cohort. Skin contours varied significantly across status group, with wheelchair users with a history of pressure ulcers having tissue with a peaked contour with a radius of curvature of 65.9 mm that wrapped more closely to the ischium (thickness at the apex = 8.2 mm) as compared to wheelchair users with no pressure ulcer history (radius of curvature = 91.5 mm and apex thickness = 14.5 mm). Finally, the majority of participants presented with little to no gluteus coverage over their ischial tuberosity, regardless of status group.ConclusionsThis study provides quantitative evidence that Biomechanical Risk, or the intrinsic characteristic of an individual's soft tissues to deform in response to extrinsic applied forces, is greater in individuals at greater risk for pressure ulcers.     

Monitoring the biomechanical and physiological effects of postural changes during leisure chair sitting

BackgroundIndividuals with limited mobility can spend prolonged periods in leisure chairs, increasing their risk of developing a seated acquired pressure ulcer. The present study aims to use objective measures of posture and tissue viability to identify the associated risks of leisure chair related pressure ulcers.MethodsHealthy participants (n = 13) were recruited to sit on a leisure chair with either a viscoelastic foam or air cushion. Participants were asked to adopt four different postures for a period of 10 min followed by a 10 min refractory period. Measurements at the leisure chair-participant interface included interface pressure, transcutaneous tissue gas tensions at the ischial tuberosities, accelerometer data collected from the sternum and subjective comfort levels.ResultsResults indicated that interface pressures remained consistent, with peak pressure index values of less than 60 mmHg across all conditions. A proportion of participants exhibited decreased oxygen tensions associated with increased carbon dioxide tensions during one or more test condition. This was particularly prevalent during the right lean posture on the air cushion (46%). In all cases, normal tissue viability was restored during standing. The accelerometer was able to detect significant changes (p < 0.05) in relative trunk angles during slump and right lean when compared to optimal sitting posture.ConclusionCommercially available leisure chairs have little evidence to support their pressure relieving properties. This study revealed that a proportion of healthy individuals demonstrated a compromised tissue viability in specific postures. Further research is required to assess the impact of these sitting conditions in vulnerable individuals.     

Skin blood flow dynamics and its role in pressure ulcers

Pressure ulcers are a significant healthcare problem affecting the quality of life in wheelchair bounded or bed-ridden people and are a major cost to the healthcare system. Various assessment tools such as the Braden scale have been developed to quantify the risk level of pressure ulcers. These tools have provided an initial guideline on preventing pressure ulcers while additional assessments are needed to improve the outcomes of pressure ulcer prevention. Skin blood flow function that determines the ability of the skin in response to ischemic stress has been proposed to be a good indicator for identifying people at risk of pressure ulcers. Wavelet spectral and nonlinear complexity analyses have been performed to investigate the influences of the metabolic, neurogenic and myogenic activities on microvascular regulation in people with various pathological conditions. These findings have contributed to the understanding of the role of ischemia and viability on the development of pressure ulcers. The purpose of the present review is to provide an introduction of the basic concepts and approaches for the analysis of skin blood flow oscillations, and present an overview of the research results obtained so far. We hope this information may contribute to the development of better clinical guidelines for the prevention of pressure ulcers.     

Beware of the toilet: The risk for a deep tissue injury during toilet sitting

A pressure injury (PrI) compromises quality of life and can be life-threatening. The fundamental cause of PrIs is sustained deformations in weight-bearing soft tissues, e.g., during prolonged sitting on inadequate surfaces such as a toilet seat. In nursing homes and geriatric facilities, patients need assistance using the restroom, and patients being left on the toilet for tens-of-minutes is a real-world scenario, unfortunately. Nevertheless, there are no published studies regarding sustained tissue loads during toilet sitting and their effects on tissue physiology. Here, the biomechanical and microcirculatory responses of the buttock tissues to toilet sitting were investigated using finite element modeling and cutaneous hemodynamic measurements, to explore the potential etiology of PrIs occurring on the toilet. We found that prolonged sitting on toilet seats involves a potential risk for PrI development, the extent of which is affected by the seat design. Additionally, we found that specialized toilet seat cushions are able to reduce this risk, by lowering instantaneous tissue exposures to internal stresses (by up to 88%) and maintaining reduced interface pressures. Furthermore, hemodynamic variables were altered during the toilet sitting; in particular, tcPO₂ was decreased by 49% ± 7% (44 ± 2[mmHg] to 22 ± 4[mmHg]) during sitting. The current study confirms that investing in expensive PrI prevention (PIP) products is likely to be ineffective for an immobilized patient who is left to sit on a bare toilet seat for long times. This argument highlights the need for a holistic-care approach, employing PIP devices that span across the entire environment where bodyweight forces apply to tissues.     

Decubitus ulcers: a review of the literature

Decubitus ulcers are a worldwide health care concern affecting tens of thousands of patients and costing over a billion dollars a year. Susceptibility to pressure ulcers comes from a combination of external factors (pressure, friction, shear force, and moisture), and internal factors (e.g. fever, malnutrition, anaemia, and endothelial dysfunction). Often, enough damage is done to create the basis for a decubitus ulcer after as little as 2 h of immobility, a situation which may be difficult to avoid if the patient must undergo prolonged surgery or remain bedridden. Damage owing to pressure may also occur hours before the patient receives medical attention, especially if the patient falls or becomes immobilized owing to a vascular event. Several classification systems for decubitus ulcers have been described, based on where injury first occurs. The histologic progression of decubitus ulcers is a dynamic process involving several stages, each having characteristic histologic features. A team-focused approach integrating all aspects of care, including pressure relief, infection control, nutrition, and surgery, may improve healing rates. With accurate risk assessment and preventative care, we can hope to minimize complications and mortality owing to decubitus ulcers.     

Lessons learned from patients with spinal cord injury in managing pressure ulcers: A qualitative study

ObjectivesTo explore how individuals with spinal cord injury self-manage the prevention and treatment of pressure ulcers and to provide insight into experiences with self-management support.DesignQualitative study using semi-structured interview and a deductive thematic analysis.SettingCommunity.ParticipantsTwelve of the 14 participating adults with a spinal cord injury had experience with pressure ulcers, and eight of these had a current pressure ulcer.ResultsRespondents suggested to tailor treatment of pressure ulcers to patients’ individual wishes and capabilities of patients. Patients and caregivers need to be aware of the importance of determining the cause of pressure ulcers to prevent deterioration. Patients often depend on informal caregivers for follow-up and prevention, and healthcare professionals in non-SCI specialties often lack the knowledge needed to manage pressure ulcers in this specific patient group. Tailored education and peer support are important for patients to set boundaries, be assertive, and cultivate a positive attitude when dealing with pressure ulcers. It is difficult to combine treatment of severe pressure ulcers and preventive measures with work roles. Managing the social impact of pressure ulcers requires more coordination with caregivers.ConclusionsTo support self-management of pressure ulcers in patients with a spinal cord injury, they must find out which preventive measures and treatments suit them best. Healthcare professionals play an important role in the self-management of pressure ulcers and can help patients deal with the emotional and social impact of pressure ulcers. To know patient's needs and tailor their education, healthcare professionals of non SCI organizations need to have knowledge of pressure ulcers management of this specific patient group.     

Preventing pressure ulcers among wheelchair users: preliminary comments on the development of a self-administered risk assessment tool

The prevalence of pressure ulcers among permanent wheelchair users remains high. While many risk factors for pressure ulcer development in this group have been identified only a minority of these have been evaluated scientifically and it is generally acknowledged that existing risk assessment tools are inadequate for predicting risk in seated persons who use a wheelchair for mobility. A 2-year prospective study is underway to design a new self-administered pressure ulcer risk indicator to be used by non-ambulant wheelchair users and their carers in conjunction with professionals. This instrument will be designed as a result of triangulation of methods. A systematic review of available evidence Latest professional opinion A qualitative study exploring the issues from the perspective of seated persons with a history of pressure ulcers (n = 10) undertaken by one of the authors (JW) A 2-year prospective study identifying key risk factors in a sample of 160 seated persons. This paper offers an insight into the findings on the recruitment of the 160 individuals into the prospective study, which is currently collecting a large amount of data on the health, degree of disability and integrity of skin of all the participants. The paper offers an overview of the medical diagnosis, degree of physical disability, issues pertaining to continence and prevalence of pressure ulcers in this group on recruitment. Early findings suggest that the new risk indicator should include measures of degree of physical disability and ability to transfer as an integral part of self-assessment and therefore prevention of pressure ulcers. The study was due for completion in the autumn of 2002. It is envisaged that early work on the development of the tool should be complete by the summer of 2003.     

The prevalence,management, equipment provision and outcome for patients with pressure ulceration identified in a wound care survey within one English health care district

The prevalence of pressure ulceration within the population receiving health care in Bradford, UK was 0.74 people with a pressure ulcer per 1000 population (95% CI 0.6–0.8). This prevalence includes a number of tertiary referrals and if these are removed the prevalence falls to 0.71 people with a pressure ulcer per 1000 population. Of the pressure ulcers encountered 195 (53.7%) were classed as grade 2 pressure ulcers with 80 grade 3 wounds and 40 grade 4 pressure ulcers. Forty-eight pressure ulcers were identified as grade 1 wounds but the accuracy of this classification may be in doubt given that 24 apparent grade 1 pressure ulcers were reported to have visible wound beds with common reports of slough and granulation tissue. Severe pressure ulcers differed from less severe partial thickness wounds – grade 3 and 4 pressure ulcers tended to be larger, of longer duration, with greater coverage of the wound bed with necrotic tissue and less granulation and epithelial tissue. Wound exudate was heavier where people presented with severe pressure ulcers while there was a greater probability of wound infection (37.5% of grade 4 pressure ulcers were infected). Given these challenges it was perhaps unsurprising that people with severe pressure ulcers were more likely to have been risk assessed, to have had a critical incident form completed (although only 35% of grade 4 pressure ulcers were identified as having been reported on a critical incident form), to be provided with a powered PR mattress in bed and to be dressed with an antimicrobial dressing. The time to treat each severe pressure ulcer tended to be longer than was the treatment times for less severe wounds. Only 40 people with pressure ulcers (11%) as their most serious wound were located in hospital, suggesting that current pressure ulcer epidemiology and costs may be understated given their reliance on previous hospital based surveys of pressure ulcers. Another potential confounder of pressure ulcer epidemiological studies may be the number of nursing home beds in the surveyed population. On breaking down the Bradford audit data by postcode the pressure ulcer prevalence ranged between 0.13 and 1.39 people with a pressure ulcer per 1000 population with the higher prevalence proportions found in postcodes with large numbers of nursing home beds. It would appear to be prudent to record the number of nursing home beds within community based populations where pressure ulcers (and potentially other wounds) are being recorded.     

Evaluating the effects of sedentary behaviour on plantar skin health in people with diabetes

BackgroundDiabetes-Related Foot Ulcers (DRFUs) are a common and devastating consequence of Diabetes Mellitus and are associated with high morbidity, mortality, social and economic costs. Whilst peak plantar pressures during gait are implicated cited as a major contributory factor, DRFU occurrence has also been associated with increased periods of sedentary behaviour. The present study was designed aimed to assess the effects of sitting postures on plantar tissue health.MethodsAfter a period of acclimatisation, transcutaneous oxygen tensions (T_CPO₂) and inflammatory cytokines (IL-1α and IL-1RA) were measured at the dorsal and plantar aspects of the forefoot before, during and after a 20-min period of seated-weight-bearing in participants with diabetes (n = 11) and no diabetes (n = 10). Corresponding interface pressures at the plantar site were also measured.ResultsDuring weight-bearing, participants with diabetes showed increases in tissue ischaemia which were linearly correlated proportional to plantar pressures (Pearson's r = 0.81; p < 0.05). Within the healthy group, no such correlation was evident (p > 0.05). There were also significant increases in post seated weight-bearing values for ratio for IL-1α and IL-1RA, normalised to total protein, post seated weight-bearing in participants with diabetes compared to healthy controls.ConclusionThis study shows that prolonged sitting may be detrimental to plantar skin health. It highlights the need to further examine the effects of prolonged sitting in individuals, who may have a reduced tolerance to loading in the plantar skin and soft tissues.     

A study to evaluate factors for inclusion in a new self-assessed risk indicator for persons who use a wheelchair for mobility

A preliminary analysis of a 2-year prospective study of the health, degree of physical disability and skin integrity of 160 permanently seated persons is presented in this paper. The study was undertaken to inform the development of a self-managed risk assessment tool for the prevention of pressure ulcers in permanently seated individuals. The results of this study offer further insight into the challenges of pressure ulcer prevention and the role of education and self management in achieving this.     

Prevalence of pressure ulcers in africa: A systematic review and meta-analysis

BackgroundA recent global review of pressure ulcers contained no studies from Africa.ObjectiveTo identify the prevalence and incidence of pressure ulcers in Africa.Data sourcesBibliographic databases, African specific databases, grey literature.Study eligibility criteriaStudies with prevalence or incidence data of pressure ulcers from Africa since the year 2000.ParticipantsAny age, including children, in any setting, specifically including hospital patients from any clinical area but not restricted to hospital settings.Study appraisal and synthesis methodsHoy score for bias, Joanna Briggs Institute Critical Appraisal Instrument.MethodWe followed the PRISMA guideline for systematic reviews. We searched Embase, Medline, Scopus, CINHAL, Google Scholar, specialist African databases and grey literature for studies reporting incidence or prevalence data.ResultsNineteen studies met the inclusion criteria and were included in the study. Point prevalence rates varied from 3.4% to 18.6% for medical/surgical and other general hospital units with a pooled prevalence of 11%, for grades II-IV 5%. For spinal injury units the pooled prevalence was 44%.Limitationsrestricted to English, French and Arabic.ConclusionPrevalence of pressure ulcers in Africa reported here is similar to figures from a recent review of prevalence in Europe and two recent global reviews of hospitalised patients. Prevalence of pressure ulcers in spinal cord injury patients is similar to figures from a review of developing countries. The reporting of prevalence is lacking in detail in some studies. Studies using an observational design employing physical examination of patients showed higher prevalence than those relying on other methods such as medical notes or databases.Implications of key findingsFurther prevalence and incidence studies are needed in Africa. Reporting of such studies should ensure items in the “Checklist for Prevalence Studies” from Joanna Briggs Institute (or similar well regarded resources) are addressed and the PICOS model and PRISMA guidelines are employed.Systematic review registration numberProspero registration number CRD42020180093     

Understanding the association between pressure ulcers and sitting in adults what does it mean for me and my carers? Seating guidelines for people,carers and health & social care professionals

The aim of the publication was to develop a practical guide for people, carers and health and social care professionals on how the research and evidence base on pressure ulcer prevention and management can be applied to those who remain seated for extended periods of time. This publication was developed at the request of the Tissue Viability Society in order to revise the original seating guidelines from 2008 as evidence and subsequent care has moved forward in relation to this area. Since 2008, the costs for the prevention and management of pressure ulcers have increased significantly and there is limited published advice from health and social care organisations on seating and preventing pressure ulcers. These guidelines have been written for:

• •People
• •Carers
• •Health and Social Care professionals
• •Education and training staff
• •Independent sector.

Who live or work in primary, secondary, and tertiary settings.     

Using a case-mix-adjusted pressure sore incidence study in a surgical directorate to improve patient outcomes in pressure ulcer prevention

The Glasgow Acute Clinical Audit Sub-Committee on Pressure Sores has previously carried out studies of incidence of pressure ulcers in the medical directorates and case-mix-adjusted the figures for length of hospital stay and risk assessment score. Case-mix classification is 'classification of people or treatment placed into groups using characteristics associated with condition, treatment or outcome that can be used to predict need, resource, use of outcomes'. In this instance, crude pressure ulcer incidence figures may be adjusted for length of hospital stay and pressure sore risk assessment score, and stratified into groups, which allows like to be compared with like. The value in case-mix-adjusted figures lies in repeating the exercise, thus determining the trend for individual areas and assessing whether improvement in the quality of care is being achieved. This is more positive than creation of 'league tables' comparing simultaneous studies in a number of areas. The figures showed that there was no statistically significant difference between surgical directorates in trusts with regard to risk assessment scores and length of hospital stay. Gathering data on the incidence of pressure ulcer development allows us to identify where new sores are occurring, but does not critically analyse the nursing intervention taken in individual cases, which identifies preventive strategies. The Glasgow group's primary aim was to gather data on case-mix-adjusted incidence of pressure damage; the secondary objectives were to scrutinize the data to gather more general information on intrinsic and extrinsic factors which may predispose to pressure ulcer development. The study was carried out in the surgical directorate. Findings showed that incidence was low (1.1%), with the majority of sores being superficial. There was a correlation between pressure ulcer development and incontinence, evidence of under-utilization of moving and handling aids for prevention of pressure ulcers, and a need for greater collaboration between nursing staff and dietitians. All patients had access to pressure-reducing surfaces, with cut-foam pressure-reducing mattresses with vapour-permeable covers on all beds. Dynamic systems were available if the primary nurse identified a need for them.     

Pressure ulcer/injury classification today: An international perspective

There has been an ongoing debate in the healthcare community about what pressure ulcers/injuries are, and how to name, define and classify them. The aim of this discussion paper is to provide a brief theoretical background about pressure ulcer/injury classification, to explain the approach the Guideline Governance Group has taken during the 2019 update of the International Guideline for ‘Prevention and Treatment of Pressure Ulcers/Injuries’ and to share views on how to best implement pressure ulcer/injury classification. First formal pressure ulcer/injury classifications were introduced in the 1950s and today various pressure ulcer/injury classification systems are used worldwide. Dissimilarities between commonly used classification systems may be considered a limitation that impedes clinical and scientific communication. However, the conceptual meaning of pressure ulcer/injury categories described within the various classification systems is comparable and the current evidence does not indicate that one classification is superior to another. Therefore, the Guideline Governance Group created a crosswalk of the major pressure ulcer/injury classifications in common use across different geographic regions. Clinicians are encouraged to use the classification system adopted by their healthcare setting in the most consistent way. The validity of pressure ulcer/injury classification is closely linked to its intended purpose. Studying measurement properties of pressure ulcer/injury classification systems must follow state-of-the-art methods. Structured educational interventions are helpful for improving diagnostic accuracy and reducing misclassification of pressure ulcers/injuries. Implementation of innovative skin and soft tissue assessments and revised pressure ulcer/injury classifications are only worth implementing, when the diagnostic information improves clinical care.     

Pressure relief, cold foam or static air? A single center, prospective, controlled randomized clinical trial in a Dutch nursing home

Objective

At present, the evidence regarding the type of mattress that is the best for preventing pressure ulcers is not convincing. In a single center, prospective, controlled trial we compared a static air overlay mattress (no electric pump needed) on top of a cold foam mattress with a cold foam mattress alone on pressure ulcer incidence in nursing home residents.

Methods

83 Patients were included in the study with a score lower than 12 points on the Norton scale and no pressure ulcer at the start of the study. 42 Patients received a cold foam mattress and 41 patients received a static air overlay on top of that cold foam mattress. Out of bed we standardized the pressure reduction in sitting position by using a static air cushion in both groups. Patients were checked weekly in both groups for pressure ulcers.Only when there were signs of developing a pressure ulcer grade 2 or higher, repositioning by our nursing home pressure ulcer protocol (PU protocol) was put into practice.

Results

Seven patients (17.1%) on a cold foam mattress and two (4.8%) on a static air mattress developed a pressure ulcer grade 2 or more. There was no difference regarding pressure ulcer incidence between patients with a high risk (Norton 5-8) and patients with a medium risk (Norton 9-12). In 5 out of 7 patients who developed a pressure ulcer on a foam mattress the ulcers showed no healing using our PU protocol. In the static air group all pressure ulcers healed by regular treatment according to our PU protocol.

Conclusions

In this study, static air overlay mattresses provided a better prevention than cold foam mattresses alone (4.8% versus 17.1%). The Norton scores of the patients in both groups did not change during the 6 month trial period. Our decision to use repositioning only when there were signs of a pressure ulcer seems to be acceptable when a static air overlay is in position. However, the score of 17.1% development (incidence) of pressure ulcers in the foam group may stress the need of repositioning when using only this type of mattress.     

Protective equipment-related pressure ulcers in healthcare workers during COVID-19 pandemic: A systematic review

AimThis systematic review was carried out to examine pressure ulcers in healthcare staff due to the use of protective equipment during COVID-19 pandemic and the precautions taken to prevent these injuries.MethodRelevant studies were retrospectively searched. Seven English keywords identified from MESH were used while searching. The search was carried out in five international databases by trying various combinations of these words during February 15–25, 2021. This systematic review was updated by rescanning databases on December 20, 2021 and a total of 611 studies were attained.Results17 studies which met the study inclusion criteria, which were conducted mostly through online survey method in different study designs and which included a total of 24,889 healthcare professionals were examined. The incidence of PPE-related pressure ulcers was found to be between 30% and 92.8%. Grade I pressure ulcers were the most common (44.1%–82%). The incidence of skin problems except PPE-related pressure ulcers such as itching, redness and dry skin was found to be between 42.8–88.1%. Risk factors that frequently played a role in the development of PPE-related pressure ulcers and other skin problems were longer use of PPE and sweating. PPE-related pressure ulcers and other skin problems were more frequent over the nose (nasal bone/nasal bridge), ears, forehead and cheeks. PPE-related itching, redness and dry skin mostly occurred. Several dressing applications were found to be effective in the prevention of PPE-related pressure ulcers and other skin problems that might develop especially on the facial region.ConclusionPPE-related pressure ulcers and other skin problems were found to be higher among healthcare professionals. Data regarding the sealing of dressing applications against viral transmission in the prevention of PPE-related pressure ulcers and other skin problems are limited. It is estimated that future studies will be performed to prevent device-related pressure ulcers in healthcare workers. It is suggested that there is a need to conduct studies with larger samples where expert researchers make observations for pressure ulcers in order to determine the prevalence and incidence of PPE-related pressure ulcers.