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. 2022 Dec 19:e13125. Online ahead of print. doi: 10.1111/ijn.13125

Incidence of facial pressure injuries in health‐care professionals during the COVID‐19 pandemic: A systematic review and meta‐analysis

Honghong Su 1, Wenguang Zhou 2, Yue Kong 3,✉, Fangfang Zhu 1, Baoling Xu 1, Xianying Shen 4, Weiqin Zhang 4, Qijun Zhou 5, Qian Lv 1
PMCID: PMC9877937  PMID: 36535903

Abstract

Aim

To evaluate the incidence of facial pressure injuries in health‐care professionals during the COVID‐19 pandemic in a meta‐analysis.

Methods

Related studies were obtained through electronic databases, including PubMed, Embase, Cochrane Library, Web of Science, China National Knowledge Infrastructure (CNKI) Chinese Scientific Journal (VIP) China Biomedical Literature service systems (CBM) and Wanfang Data (from inception to 27 November 2021). The pooled incidence and the 95% confidence interval of facial pressure injuries were calculated with Review Manager v5.4 software.

Results

Overall, 16 studies with 14 430 health‐care professionals were included. Pooled results showed that the pooled incidence of facial pressure injury in health‐care professionals was 58.8% (95% CI: 49.0%–68.7%; p < 0.01). The results of the subgroup analysis showed that the incidence of facial pressure injury in these staff was high, and predominantly stage I pressure injury, in the following cases: in health‐care professionals who wore personal protective equipment for longer than 4 h, in those without any training experience, and on the nose.

Conclusion

Administrators and researchers should pay attention to preventing facial pressure injury related to the wearing of personal protective equipment (PPE) by ensuring all health‐care professionals receive training and by limiting prolonged periods of use.

Keywords: COVID‐19 pandemic, pressure injury, incidence, health‐care professionals, pressure ulcer

Summary statement

What is already known about this topic?

  • Facial pressure injury was one of the most common effects experiencedby health‐care professionals wearing facial PPE during COVID‐19, which seriously affected their facial comfort and self‐image.

  • A number of studies have reported the incidence of facial pressure injury in health‐care professionals, but the evidence is inconsistent.

  • Medical staff are the main force during the COVID‐19.

What this paper adds?

  • This study showed that the pooled incidence of facial pressure injury in health‐care professionals was 56.8% during COVID‐19.

  • This study showed that there was a higher incidence of facial pressure injury in staff who wore PPE for longer than 4 h and in those without any training experience.

  • This study showed that the nose was the most common part of the face with pressure injury, and Stage I pressure injury was the most prevalent injury type in health‐care professionals.

The implications of this paper:

  • This study may provide evidence for managers about the development of guidelines for health‐care professionals to prevent and manage facial pressure injuries and promote the health of health‐care professionals.

1. INTRODUCTION

In December 2019, coronavirus disease 2019 (COVID‐19) broke out in Wuhan, Hubei Province, China. Then, on 30 January 2020, COVID‐19 was defined as a public health emergency of international concern (PHEIC) by the World Health Organization (WHO) (Eurosurveillance Editorial Team, 2020). Subsequent studies have shown that COVID‐19 is a severe, contagious and fast‐spreading infectious disease that is mainly spread by aerosol droplets and personal contact (Jin et al., 2020). Globally, as of 5:03 PM CEST, 17 August 2022, there have been 589 680 368 confirmed cases of COVID‐19, including 6 436 519 deaths, reported to WHO. Close contacts of patients with COVID‐19 and those with invisible infections are the high‐risk COVID‐19 groups (Epidemiology Working Group for NCIP Epidemic Response, Chinese Center for Disease Control and Prevention, 2020; Wang et al., 2020). Among them, health‐care professionals have the closest contact with patients, and the risk of infection is therefore high (Kluytmans‐van den Bergh et al., 2020; Kua et al., 2021). Accordingly, health‐care professionals who are in direct contact with COVID‐19 patients are required to wear personal protective equipment (PPE), which includes hand hygiene, gowns, masks, goggles, face shields and gloves, to reduce the risk of viral transmission (Ağalar & Öztürk Engin, 2020; Woolley et al., 2020). In addition, the Centers for Disease Control and Prevention (CDC) also recommended that health‐care professionals (HCPs) who enter the room of a patient with suspected or confirmed SARS‐CoV‐2 infection should adhere to the standard precautions and use an NIOSH‐approved N95 or equivalent or higher level respirator, gown, gloves and eye protection (Centers for Disease Control and Prevention, 2021). Moreover, studies have shown (Kim et al., 2020; Ueki et al., 2020) that PPE is effective for preventing the spread of COVID‐19.

However, wearing PPE, such as N95 masks and goggles, is associated with the incidence of facial pressure injuries, which can cause pain, redness (erythema), rupture and even secondary infections among HCPs (Zhou et al., 2020).

During the long‐term pandemic of the disease, increasing numbers of HCPs are suffering from facial pressure injuries related to PPE (People's Daily, 2021). Many factors have been involved in the pressure injury caused by PPE, including pressure, friction, sweating, time and the degree of airtightness between the PPE and the skin (Gefen & Ousey, 2020a, 2020b; Jobanputra et al., 2021). When HCPs wear PPE, their faces are pressed at the fixed part for a long time, which leads to repeated friction on their skin. In addition, movement of N95 masks or goggles will cause friction between the face and the N95 masks/goggles (Gefen & Ousey, 2020b). Due to the long‐term use of the mask and the increased workload and mental pressure, the skin perspires severely, resulting in a humid environment within the mask. Therefore, the long‐term use and fixation of PPE can cause tissue compression. At the same time, because the fixation is unlikely to be noticed or for there to be an opportunity to clean the skin, the interaction of pressure, friction and moisture will synergistically cause the formation of facial pressure injury. All of these factors lead to ischaemia and hypoxia of the local skin tissue and eventually cause facial pressure injuries. A systematic review showed that the PPEs that caused facial pressure injury of HCPs during COVID‐19 were masks, goggles and face shields (Yu et al., 2021). However, there is still a lack of systematic reviews on the incidence of facial pressure injury in HCPs. Similar to previous studies that evaluated the incidence of pressure injuries in patients (Barakat‐Johnson et al., 2019; Jackson et al., 2019; Li, Lin, et al., 2020), it is important to determine the incidence of facial pressure injuries in HCPs during the global COVID‐19 pandemic.

Accordingly, the aim of this review was to estimate the pooled incidence of facial pressure injuries among HCPs during the COVID‐19 pandemic. The results of this study can provide evidence for developing guidelines and clinical implementation for the prevention of facial pressure injuries in HCPs, promoting their health and wellbeing during COVID‐19 and any other pandemics.

2. METHODS

This systematic review was designed and performed following the PRISMA guidelines (see Supporting Information S1).

2.1. Inclusion and exclusion criteria

The inclusion criteria were as follows: (1) observational studies including case–control studies, cohort studies and cross‐sectional studies; (2) studies including HCPs who wore PPE during the COVID‐19 pandemic; (3) studies reporting the incidence of facial pressure injuries; and (4) studies published in Chinese or English. The exclusion criteria were (1) duplicated publications and (2) studies that could not be combined for analysis because the relevant data could not be extracted.

2.2. Search strategy

PubMed, Embase, Cochrane Library, Web of Science, China National Knowledge Infrastructure (CNKI) Chinese Scientific Journal (VIP) China Biomedical Literature service systems (CBM) and Wanfang Data were searched for relevant studies from inception to 27 November 2021. The following Mesh terms and free‐text terms were used: ‘pressure ulcer*’, ‘device related pressure ulcer*’, ‘MDRPI’, ‘MDRPU’, ‘pressure injur*’, ‘personal protective equipment’, ‘PPE personal protective equipment’, ‘masks’, ‘N95 respirator’, ‘N95 face masks’, ‘N95 masks’, ‘eye protective devices’, ‘goggles’, ‘COVID‐19’ and ‘SARS‐CoVvirus‐2’, ‘Coronavirus disease 2019’, ‘prevalence’, ‘incidence’, ‘occurrence’, ‘epidemiology’. Boolean logic operators and truncation symbols were used to group search terms to achieve the purpose of a comprehensive search. The PubMed search strategy is shown in Table 1.

TABLE 1.

Example of PubMed search strategy

Search strategy Result
#1 Search: ‘Personal Protective Equipment’[Mesh] Sort by: Most Recent 35 238
#2 Search: (Equipment, Personal Protective[Title/Abstract]) OR (Protective Equipment, Personal[Title/Abstract]) OR (PPE Personal Protective Equipment[Title/Abstract]) 115
#3 Search: (‘Personal Protective Equipment’[Mesh]) OR ((Equipment, Personal Protective[Title/Abstract]) OR (Protective Equipment, Personal[Title/Abstract]) OR (PPE Personal Protective Equipment[Title/Abstract])) 35 332
#4 Search: ‘Eye Protective Devices’[Mesh] Sort by: Most Recent 1910
#5 Search: (Device, Eye Protective[Title/Abstract]) OR (Protective Device, Eye[Title/Abstract]) OR (Goggles[Title/Abstract]) OR (Safety Lenses[Title/Abstract]) OR (Lenses, Safety[Title/Abstract]) OR (Safety Glasses[Title/Abstract]) OR (Safety Glasses[Title/Abstract]) 1601
#6 Search: (‘Eye Protective Devices’[Mesh]) OR ((Device, Eye Protective[Title/Abstract]) OR (Protective Device, Eye[Title/Abstract]) OR (Goggles[Title/Abstract]) OR (Safety Lenses[Title/Abstract]) OR (Lenses, Safety[Title/Abstract]) OR (Safety Glasses[Title/Abstract]) OR (Safety Glasses[Title/Abstract])) 3185
#7 Search: ‘Masks’[Mesh] Sort by: Most Recent 11 529
#8 Search: (((((((N95 Respirator[Title/Abstract]) OR (N95 Face Masks[Title/Abstract])) OR (N95 Face Mask[Title/Abstract])) OR (N95 Masks[Title/Abstract])) OR (N95 Mask[Title/Abstract])) OR (N95 Filtering Facepiece Respirators[Title/Abstract])) OR (N95 FFRs[Title/Abstract])) OR (N95 FFR[Title/Abstract]) 834
#9 Search: (‘Masks’[Mesh]) OR ((((((((N95 Respirator[Title/Abstract]) OR (N95 Face Masks[Title/Abstract])) OR (N95 Face Mask[Title/Abstract])) OR (N95 Masks[Title/Abstract])) OR (N95 Mask[Title/Abstract])) OR (N95 Filtering Facepiece Respirators[Title/Abstract])) OR (N95 FFRs[Title/Abstract])) OR (N95 FFR[Title/Abstract])) 12 149
#10 Search: ‘Pressure Ulcer’[Mesh] Sort by: Most Recent 12 995
#11 Search: (Pressure Ulcer*[Title/Abstract]) OR (Pressure Sore*[Title/Abstract]) OR (Decubitus Ulcer*[Title/Abstract]) OR (device related pressure ulcer*[Title/Abstract]) OR (MDRPI[Title/Abstract]) OR (MDRPU[Title/Abstract]) OR (medical device related pressure injur*[Title/Abstract]) OR (facial skin injur*[Title/Abstract]) OR (PPE‐related tissue damage*[Title/Abstract]) OR (ear pressure[Title/Abstract]) OR (COVID 19 related pressure injuri*[Title/Abstract]) OR (Skin lesion*[Title/Abstract]) OR (skin reaction*[Title/Abstract]) OR (pressure injur*[Title/Abstract]) OR (medical device related pressure injur*[Title/Abstract]) 54 963
#12 Search: ‘COVID‐19’[Mesh] OR ‘SARS‐CoV‐2’[Mesh] Sort by: Most Recent 122 918
#13 Search: ((((((Coronavirus Disease‐19[Title/Abstract]) OR (COVID‐19 Virus Disease[Title/Abstract])) OR (COVID‐19 Virus Infection[Title/Abstract])) OR (2019‐nCoV Infection[Title/Abstract])) OR (Coronavirus Disease 2019[Title/Abstract])) OR (COVID‐19 Pandemic[Title/Abstract])) OR (SARS CoV 2 Infection[Title/Abstract]) 96 359
#14 Search: (‘COVID‐19’[Mesh] OR ‘SARS‐CoV‐2’[Mesh]) OR (((((((Coronavirus Disease‐19[Title/Abstract]) OR (COVID‐19 Virus Disease[Title/Abstract])) OR (COVID‐19 Virus Infection[Title/Abstract])) OR (2019‐nCoV Infection[Title/Abstract])) OR (Coronavirus Disease 2019[Title/Abstract])) OR (COVID‐19 Pandemic[Title/Abstract])) OR (SARS CoV 2 Infection[Title/Abstract])) 160 535
#15 Search: (((‘Personal Protective Equipment’[Mesh]) OR ((Equipment, Personal Protective[Title/Abstract]) OR (Protective Equipment, Personal[Title/Abstract]) OR (PPE Personal Protective Equipment[Title/Abstract]))) OR ((‘Eye Protective Devices’[Mesh]) OR ((Device, Eye Protective[Title/Abstract]) OR (Protective Device, Eye[Title/Abstract]) OR (Goggles[Title/Abstract]) OR (Safety Lenses[Title/Abstract]) OR (Lenses, Safety[Title/Abstract]) OR (Safety Glasses[Title/Abstract]) OR (Safety Glasses[Title/Abstract])))) OR ((‘Masks’[Mesh]) OR ((((((((N95 Respirator[Title/Abstract]) OR (N95 Face Masks[Title/Abstract])) OR (N95 Face Mask[Title/Abstract])) OR (N95 Masks[Title/Abstract])) OR (N95 Mask[Title/Abstract])) OR (N95 Filtering Facepiece Respirators[Title/Abstract])) OR (N95 FFRs[Title/Abstract])) OR (N95 FFR[Title/Abstract]))) 36 764
#16 Search: (‘Pressure Ulcer’[Mesh]) OR ((Pressure Ulcer*[Title/Abstract]) OR (Pressure Sore*[Title/Abstract]) OR (Decubitus Ulcer*[Title/Abstract]) OR (device related pressure ulcer*[Title/Abstract]) OR (MDRPI[Title/Abstract]) OR (MDRPU[Title/Abstract]) OR (medical device related pressure injur*[Title/Abstract]) OR (facial skin injur*[Title/Abstract]) OR (PPE‐related tissue damage*[Title/Abstract]) OR (ear pressure[Title/Abstract]) OR (COVID 19 related pressure injuri*[Title/Abstract]) OR (Skin lesion*[Title/Abstract]) OR (skin reaction*[Title/Abstract]) OR (pressure injur*[Title/Abstract]) OR (medical device related pressure injur*[Title/Abstract])) 58 785
#17 Search: (((‘COVID‐19’[Mesh] OR ‘SARS‐CoV‐2’[Mesh]) OR (((((((Coronavirus Disease‐19[Title/Abstract]) OR (COVID‐19 Virus Disease[Title/Abstract])) OR (COVID‐19 Virus Infection[Title/Abstract])) OR (2019‐nCoV Infection[Title/Abstract])) OR (Coronavirus Disease 2019[Title/Abstract])) OR (COVID‐19 Pandemic[Title/Abstract])) OR (SARS CoV 2 Infection[Title/Abstract]))) AND ((((‘Personal Protective Equipment’[Mesh]) OR ((Equipment, Personal Protective[Title/Abstract]) OR (Protective Equipment, Personal[Title/Abstract]) OR (PPE Personal Protective Equipment[Title/Abstract]))) OR ((‘Eye Protective Devices’[Mesh]) OR ((Device, Eye Protective[Title/Abstract]) OR (Protective Device, Eye[Title/Abstract]) OR (Goggles[Title/Abstract]) OR (Safety Lenses[Title/Abstract]) OR (Lenses, Safety[Title/Abstract]) OR (Safety Glasses[Title/Abstract]) OR (Safety Glasses[Title/Abstract])))) OR ((‘Masks’[Mesh]) OR ((((((((N95 Respirator[Title/Abstract]) OR (N95 Face Masks[Title/Abstract])) OR (N95 Face Mask[Title/Abstract])) OR (N95 Masks[Title/Abstract])) OR (N95 Mask[Title/Abstract])) OR (N95 Filtering Facepiece Respirators[Title/Abstract])) OR (N95 FFRs[Title/Abstract])) OR (N95 FFR[Title/Abstract]))))) AND ((‘Pressure Ulcer’[Mesh]) OR ((Pressure Ulcer*[Title/Abstract]) OR (Pressure Sore*[Title/Abstract]) OR (Decubitus Ulcer*[Title/Abstract]) OR (device related pressure ulcer*[Title/Abstract]) OR (MDRPI[Title/Abstract]) OR (MDRPU[Title/Abstract]) OR (medical device related pressure injur*[Title/Abstract]) OR (facial skin injur*[Title/Abstract]) OR (PPE‐related tissue damage*[Title/Abstract]) OR (ear pressure[Title/Abstract]) OR (COVID 19 related pressure injur*[Title/Abstract]) OR (Skin lesion*[Title/Abstract]) OR (skin reaction*[Title/Abstract]) OR (pressure injur*[Title/Abstract]) OR (medical device related pressure injur*[Title/Abstract]))) 70
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2.3. Study selection and data extraction

Two authors independently screened the titles and abstracts of the retrieved studies according to the inclusion and exclusion criteria (excluded studies that obviously did not meet the inclusion criteria). Then, the full text of any potentially eligible study was screened to determine whether it could be finally included. If a disagreement occurred, it was resolved by discussion with the third author. Data were extracted using a unified table. The data collected were as follows: (1) basic information, such as title, author, publication date and country; (2) study characteristics, such as sample size, gender and age; (3) type of study design; and (4) incidence of facial press injuries, location and stage of facial pressure injury.

2.4. Quality appraisal

Two authors independently evaluated the quality of the included studies. A cross‐sectional survey study recommended by the Agency for Healthcare Research and Quality (United States) was used as an evaluation tool (Rostom et al., 2004), which contained 11 items, with a maximum score of 11, and 0–3, 4–7 points and 8–11 points, respectively, representing low quality, medium quality and high quality. The judging criteria options were yes, no or unclear as answers. After the evaluation was completed for each author, a cross‐check was performed to validate the results. If there was a disagreement, it was resolved by discussion with the third author.

2.5. Data extraction and synthesis

Review Manager v5.4 software was used to calculate the pooled incidence of facial pressure injuries and its 95% confidence interval (CI). The heterogeneity of the included studies was evaluated by calculating the I 2 and P values of Cochran's Q‐test. I 2  > 50% and p < 0.1 suggested significant heterogeneity, and the random‐effects model was adopted to pool the results; otherwise, the fixed‐effects model was applied. Subgroup analyses were used to evaluate the pooled incidence of facial pressure injury according to the differences in the effects of PPE wearing time, training experience, injured part and stage of the injury. Sensitivity analysis was conducted to determine the stability of the results. A funnel plot was used to analyse potential publication bias. p < 0.05 was considered statistically significant.

3. RESULTS

A total of 259 studies were retrieved in an initial database search, and all the studies were imported into the Endnote X9 software. After excluding duplicated studies, 167 studies were obtained. Based on the inclusion and exclusion criteria of this study, 95 studies were excluded after reading the titles and abstracts of the studies. After reading the full text, a further 56 studies were excluded from the remaining 72 studies, and thus 16 studies were finally included for analysis. The PRISMA flow diagram of the study screening is shown in Figure 1.

FIGURE 1.

FIGURE 1

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Flow chart of study selection

3.1. Characteristics and quality evaluations of the included studies

The characteristics of the included studies are shown in Table 2. Among the 16 included studies, 10 were published in Chinese, and 6 were in English. The total sample size of the included studies was 14, 430, and the year of publication was 2020 or 2021. All the studies were cross‐sectional studies. The main locations of the injuries were the bridge of the nose, cheeks, forehead and ears. The main injury stages were Stage 1, Stage 2, Stage 3 and deep tissue pressure injury (DTPI). The results for the study's methodological evaluation are shown in Table 3. All the included studies described the research objective in detail, and the methods for data analysis were appropriate; however, the 5th, 9th and 11th items of the criteria were the main points missing in the quality evaluation. The fifth item was ‘Indicate if evaluators of subjective components of study were masked to other aspects of the status of the participants’. The 9th item was ‘If applicable, explain how missing data were handled in the analysis’. The 11th item was ‘Clarify what follow‐up, if any, was expected and the percentage of patients for which incomplete data or follow‐up was obtained’.

TABLE 2.

Characteristics of the included studies

Author (year) Country Sample size Sex (male/female) Age (years) Study design Setting Overall incidence % (N) Location of injury Stage
Chen et al. (2020) China 391 79/312 21–56 A cross‐sectional survey study The General Hospital of Central Theater Command of PLA 213 (54.48%) Nasal bone Not reported
Dai YJ et al. (2020) China 998 107/891 20+ A cross‐sectional survey study Three designated hospitals, one square cabin hospital and one fever clinic in Beijing, Wuhan and Chengdu 574 (57.51%) Nasal bridge, cheek, retroauricular, forehead Stage1, Stage2, Stage4, DTPI
Feng and Chen (2020) China 45 8/37 28–45 A cross‐sectional survey study Ningbo Huamei Hospital, University of Chinese Academy of Sciences (Ningbo Second Hospital) 40 (89.9%) Nasal bridge, cheek, auricle, forehead Stage1, Stage2
Jiang et al. (2020) China 2901 214/2687 21–61 A cross‐sectional survey study 145 hospitals in 21 provinces and municipalities 771 (26.58%) Nasal bridge, cheek, auricle, forehead Stage1, Stage2, Stage3, DTPI
Yu et al. (2020) China 174 4/170 22–50 A cross‐sectional survey study A tertiary first‐class hospital in Wuhan City, Hubei Province 138 (79.31%) Nose, cheek, forehead, retroauricular Stage1, Stage2, Stage4, unstageable
Li, Zhang, et al. (2020) China 144 45/99 24–45 A cross‐sectional survey study Huangpo Hospital of Traditional Chinese Medicine, Huangpo District, Wuhan City, Hubei Province 124 (86.11%) Not reported Not reported
Lu et al. (2021) China 56 8/48 24–56 A cross‐sectional survey study Jingjiang City People's Hospital, Jiangsu Province 18 (32.14%) Nasal bridge, periorbital, ear, forehead Stage1, Stage2,
Wang et al. (2021) China 126 19/107 20+ A cross‐sectional survey study A provincial‐level designated prevention and control hospital for COVID‐19 in Anhui Province 78 (61.9%) Nose, cheek, ear, occipital Stage1, Stage2,
Yang and Yang (2020) China 184 33/151 29.97 ± 5. 26 A cross‐sectional survey study The front line of anti‐epidemic during the new crown: isolation ward, fever clinic, shelter hospital, infectious disease department 100 (54.35%) Retroauricular, nasal bridge, cheek, forehead, occipital Stage1, Stage2,
Zheng et al. (2020) China 64 8/56 20+ A cross‐sectional survey study Prevention hospitals in Huangshi, Hubei Province 30 (47.9%) Nose, cheek, forehead, ear, lower jaw Stage 1, Stage 2, Stage 3/4, DTPI
Bambi et al. (2021) Italy 266 85/181 22–59 A cross‐sectional survey study Critical care units in Italy 205 (77.1%) Nose, ear, forehead Stage1, Stage2, Stage3, unstageable
Coelho et al. (2020) Brazil 1106 181/925 34.08 A cross‐sectional survey study Ceará, Brazil 768 (69.4%) Forehead, nasal bone, nasal wing, zygomatic, ear, cheek Stage pressure injury1, stage pressure injury 2, DTPI
Jiang et al. (2021a) China 1761 290/1471 20–60 A cross‐sectional survey study 60 hospitals of 145 designated medical institutions located across 12 provinces in China 1043 (59.2%) Bridge of nose, cheeks, auricle Stage 1, Stage 2, Stage 3, DTPI
Jiang, Liu, et al. (2020) China 4306 516/3790 32.51 ± 7.13 A cross‐sectional survey study 28 provinces, autonomous regions and municipalities in China 1293 (30.03%) Bridge of nose, cheeks, auricle, forehead, zygoma, mandible, eyebrow arch Stage 1, Stage 2, Stage 3, DTPI
Xia et al. (2020) China 297 91/206 25–55 A cross‐sectional survey study Not reported 173 (58.3%) Nose, cheek, forehead, retroauricular Not reported
Jiang et al. (2021b) China 1611 271/1340 32.8 ± 6.9 A cross‐sectional survey study 145 hospitals in China 911(56.5%) Nasal bridge, cheek, overhead, ear Stage 1, Stage 2, Stage 3, DTPI
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DTPI, deep tissue pressure injury.

TABLE 3.

Studies' quality evaluation results

Studies Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Q10 Q11 Total score
Chen et al. (2020) Yes No Yes Yes No Yes Yes Yes No Yes No 7
Dai et al. (2020) Yes Yes Yes Yes No Yes Yes Yes No Yes No 7
Feng and Chen (2020) Yes No Yes Yes No Yes No Yes No Yes No 6
Jiang, Zhu, et al. (2020) Yes No Yes Yes No Yes No Yes No Yes No 6
Yu et al. (2020) Yes Yes Yes Yes No Yes No Yes No Yes No 7
Li, Zhang, et al. (2020) Yes Yes Yes Yes No No No Yes No Yes No 6
Lu et al. (2021) Yes Yes Yes Yes No Yes Yes Yes No Yes No 8
Wang et al. (2021) Yes Yes No Yes No Yes Yes Yes No Yes No 7
Yang and Yang (2020) Yes Yes No Yes No Yes No Yes No Yes No 6
Zheng et al. (2020) Yes Yes Yes Yes No Yes Yes Yes No Yes No 8
Bambi B et al. (2021) Yes Yes No Yes No Yes Yes Yes No Yes No 7
Coelho et al. (2020) Yes Yes Yes Yes No Yes No Yes No Yes No 7
Jiang et al. (2021a) Yes Yes Yes Yes No Yes No Yes No Yes No 7
Jiang, Liu, et al. (2020) Yes Yes Yes Yes No Yes Yes Yes No Yes No 8
Xia et al. (2020) Yes No Yes Yes No Yes No Yes No Yes No 6
Jiang et al. (2021b) Yes Yes No Yes No Yes No Yes No Yes No 6
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Note: Q1. Define the source of information (survey, record review) Q2. List inclusion and exclusion criteria for exposed and unexposed subjects (cases and controls) or refer to previous publications Q3. Indicate time period used for identifying patients Q4. Indicate whether or not subjects were consecutive if not population‐based Q5. Indicate if evaluators of subjective components of study were masked to other aspects of the status of the participants Q6. Describe any assessments undertaken for quality assurance purposes (e.g., test/retest of primary outcome measurements) Q7. Explain any patient exclusions from analysis Q8. Describe how confounding was assessed and/or controlled Q9. If applicable, explain how missing data were handled in the analysis Q10. Summarize patient response rates and completeness of data collection Q11. Clarify what follow‐up, if any, was expected and the percentage of patients for which incomplete data or follow‐up was obtained.

3.2. Meta‐analysis results

3.2.1. Incidence of facial pressure injuries in health‐care professionals

Significant heterogeneity was observed among the 16 studies (I 2  = 99%, p < 0.01), so a random‐effects model was used to pool the results. The results of the meta‐analysis showed that the incidence of facial pressure injuries among HCPs during the COVID‐19 pandemic was 58.8% (95% CI: 49.0%–68.7%; p < 0.01). The meta‐analysis forest plot is shown in Figure 2.

FIGURE 2.

FIGURE 2

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Forest plot of the incidence of facial pressure injuries among HCPs during the COVID‐19 pandemic

3.2.2. Results of subgroup analysis

Wearing time

Pooled results of seven studies (Dai et al., 2020; Jiang et al., 2021a; Jiang, Liu, et al., 2020; Jiang, Zhu, et al., 2020; Lu et al., 2021; Xia et al., 2020; Zheng et al., 2020) showed that the incidence of facial pressure injuries in HCPs wearing PPE < 4 h was 44.1% (95% CI: 13.6%–74.7%), whereas the pooled results of 12 studies (Bambi et al., 2021; Coelho et al., 2020; Dai et al., 2020; Feng & Chen, 2020; Jiang et al., 2021a, 2021b; Jiang, Liu, et al., 2020; Jiang, Zhu, et al., 2020; Li, Zhang, et al., 2020; Xia et al., 2020; Yang & Yang, 2020; Zheng et al., 2020) showed that the incidence of facial pressure injuries for those wearing PPE for more than 4 h was 66.5% (95% CI: 49.4%–83.5%; Figure 3).

FIGURE 3.

FIGURE 3

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Subgroup analysis according to the duration of wearing personal protective equipment (PPE)

Training experience

Pooled results of three studies (Dai et al., 2020; Li, Zhang, et al., 2020; Yu et al., 2020) showed that the incidence of facial pressure injuries in HCPs with training experience was 31.3% (95% CI: 8.2%–54.4%), whereas pooled results of 15 studies (Bambi et al., 2021; Chen et al., 2020; Coelho et al., 2020; Dai et al., 2020; Feng & Chen, 2020; Jiang et al., 2021a, 2021b; Jiang, Liu, et al., 2020; Jiang, Zhu, et al., 2020; Li, Zhang, et al., 2020; Lu et al., 2021; Wang et al., 2021; Yang & Yang, 2020; Yu et al., 2020; Zheng et al., 2020) indicated that the incidence of facial pressure injuries in HCPs without training was 61.9% (95% CI: 47.5%–76.3%; Figure 4).

FIGURE 4.

FIGURE 4

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Subgroup analysis according to whether the health‐care professionals had training experience

Location of facial injury

A total of 11 studies (Bambi et al., 2021; Coelho et al., 2020; Dai et al., 2020; Feng & Chen, 2020; Jiang et al., 2021a, 2021b; Jiang, Liu, et al., 2020; Jiang, Zhu, et al., 2020; Lu et al., 2021; Wang et al., 2021; Zheng et al., 2020) reported the incidence of nasal pressure injury among HCPs—40.5% (95% CI: 34.5%–46.4%); 10 studies (Bambi et al., 2021; Dai et al., 2020; Feng & Chen, 2020; Jiang et al., 2021a, 2021b; Jiang, Liu, et al., 2020; Jiang, Zhu, et al., 2020; Lu et al., 2021; Wang et al., 2021; Zheng et al., 2020) reported the incidence of pressure injury on cheeks—23.6% (95% CI: 17.5%–29.7%); six studies (Bambi et al., 2021; Dai et al., 2020; Feng & Chen, 2020; Jiang et al., 2021a, 2021b; Zheng et al., 2020) reported the incidence of forehead pressure injury—10.3% (95% CI: 7.0%–13.7%); 10 articles (Bambi et al., 2021; Dai et al., 2020; Feng & Chen, 2020; Jiang et al., 2021a, 2021b; Jiang, Liu, et al., 2020; Jiang, Zhu, et al., 2020; Lu et al., 2021; Wang et al., 2021; Zheng et al., 2020) reported the incidence of ear pressure injuries—20.0% (95% CI: 16.0%–24.1%); and six studies (Dai et al., 2020; Feng & Chen, 2020; Jiang, Liu, et al., 2020; Lu et al., 2021; Wang et al., 2021; Zheng et al., 2020) reported the incidence of other stress injuries—7.3% (95% CI: 3.6%–18.1%; Figure 5).

FIGURE 5.

FIGURE 5

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Subgroup analysis according to the locations of the facial pressure injuries

Injury stage

Pooled results of 10 studies (Bambi et al., 2021; Dai et al., 2020; Feng & Chen, 2020; Jiang et al., 2021a, 2021b; Jiang, Liu, et al., 2020; Jiang, Zhu, et al., 2020; Lu et al., 2021; Wang et al., 2021; Zheng et al., 2020) showed that the incidence of Stage 1 facial pressure injury in HCPs was 68.4% (95% CI: 49.3%–87.4%). The incidence of Stage 2 facial pressure injury was 22.7% (95% CI: 14.4%–30.9%) based on 10 studies (Bambi et al., 2021; Dai et al., 2020; Feng & Chen, 2020; Jiang et al., 2021a, 2021b; Jiang, Liu, et al., 2020; Jiang, Zhu, et al., 2020; Lu et al., 2021; Wang et al., 2021; Zheng et al., 2020); the incidence of Stage 3 injury was 0.4% (95% CI: 0.1%–0.8%) based on seven studies (Bambi et al., 2021;Dai et al., 2020; Jiang et al., 2021a, 2021b; Jiang, Liu, et al., 2020; Jiang, Zhu, et al., 2020; Zheng et al., 2020), and the incidence of facial pressure injuries in deep tissues was 0.5% (95% CI: 0.2%–0.8%; Figure 6) based on six studies (Dai et al., 2020; Jiang et al., 2021a, 2021b; Jiang, Liu, et al., 2020; Jiang, Zhu, et al., 2020; Zheng et al., 2020).

FIGURE 6.

FIGURE 6

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Subgroup analysis according to the stage of the facial pressure injuries

3.3. Publication bias and sensitivity analysis

The funnel plots were not concentrated or asymmetric on visual inspection, indicating the possible risk of publication bias (Figure 7). Sensitivity analysis showed that the combined prevalence rate of the fixed‐effect model was 100%, and the results were similar. Excluding any one article had no significant effect on the overall results.

FIGURE 7.

FIGURE 7

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Funnel plot for the meta‐analysis of the pooled incidence of facial pressure injuries among HCPs

4. DISCUSSION

To the best of our knowledge, this is the first systematic review and meta‐analysis evaluating the incidence of facial pressure injuries in HCPs during the COVID‐19 pandemic. A total of 16 studies were included in the meta‐analysis, and the results showed that the pooled incidence of facial pressure injuries in HCPs during the COVID‐19 pandemic was 58.8%, which is significantly higher than the incidence among patients (Jackson et al., 2019). The results of the meta‐analysis call for attention and efforts to reduce the incidence of facial pressure injuries among HCPs.

At present, the COVID‐19 global pandemic remains active, and PPE is still the most effective measure for preventing the spread of the disease (Mahmood et al., 2020). The higher incidence of pressure injuries among HCPs may be due to the following factors (Alves et al., 2020; Jobanputra et al., 2021; Smart et al., 2020). The first is direct pressure and friction, which cause skin depression. The second is that HCPs need to compress the metal nose clip on the nose of the mask and use a tight elastic rope to ensure airtightness. This kind of material with a small contact area and hard texture increases the pressure on local tissues. The third reason is the long‐term use of PPE by HCPs. Under high‐intensity work with N95 masks, sweating of the skin causes the skin surface to be very moist in a confined environment. As a result, the elasticity of the skin is decreased, and the pH is changed, which in turn affects the barrier function of the stratum corneum and further increases the burden of the pressure on the skin.

The European Pressure Ulcer Advisory Panel (EPUAP) recommends the use of liquid skin protectants for attenuating friction, but the use of mineral oil, petroleum jelly or any other compound is not recommended, probably because these materials may cause the PPE to slip off the face (European Pressure Ulcer Advisory Panel (EPUAP), 2021). In view of the high incidence of facial pressure injuries in HCPs, administrative and research efforts should be made based on evidence‐based nursing procedures, such as mandatory work breaks, time limits with PPE use and the number of consecutive shifts. This can prevent facial pressure injuries related to PPE in HCPs.

Significant heterogeneity was observed among the included studies. Considering the results of the subgroup analysis, we assumed that heterogeneity may be primarily caused by sociodemographic differences among the research population. The sample size, inclusion and exclusion criteria, age, gender, stage and location of injury were quite different among the HCPs included in the study, which may have led to large variations in the incidence of pressure injuries.

Studies have shown (Pittman et al., 2015) that the risk of pressure injuries related to PPE is significantly correlated with the time the PPE is used. The results of this study found that the incidence of facial pressure injuries in health‐care professionals who wore PPE for more than 4 h was higher than that of HCPs who wore PPE for <4 h, which is consistent with the results of a systematic review (Yu et al., 2021). The longest time that the skin can withstand during capillary occlusion pressure is 2 to 4 h, and a longer period of ischaemia may lead to injury. This may be why facial pressure injuries among HCPs are more common in patients with facial pressure injuries (Jackson et al., 2019). According to WHO, wearing N95 masks for more than 4 h can cause discomfort; hence, wearing PPE for longer than 4 h should be avoided (World Health Organization, 2020). Moreover, hospital managers should design appropriate policies, procedures and guidelines and arrange shift times reasonably. Accordingly, the 4 h shift is most in line with the physiological characteristics and requirements of the human body.

The results of the subgroup analyses also showed that the incidence of facial pressure injuries among untrained HCPs was higher than that of those who had been trained. In the early stages of the COVID‐19 pandemic, most HCPs had no training in PPE wearing, and accordingly, these HCPs had a higher prevalence of facial pressure injuries, which adversely affected their mental health (Hu et al., 2020). It has been shown (Hu et al., 2021) that HCPs have a more positive attitude towards preventing stress injuries, but they have insufficient knowledge about prevention. Thus, it is crucial for HCPs to master the airtightness inspection procedure for N95 masks. The procedure is used to check the airtightness of masks, which is the minimum safety standard to ensure effective protection. However, most HCPs cannot perform the airtightness inspection procedure correctly, which exposes them to a higher risk of infection. Of concern, that study by Beam et al. (2018) showed that only 2% of nurses performed airtightness checks correctly (Beam et al., 2018). HCPs cannot guarantee airtightness, so they choose to compress the metal nose clip on the nose of the mask and use a tightened elastic cord in attempts to make their mask airtight (Jobanputra et al., 2021), which will increase the pressure on local tissues. It can be seen that during a major infectious disease pandemic, the lack of knowledge and anxiety of HCPs can eventually cause facial pressure injuries. Therefore, it is important for hospital managers to train health‐care professionals to wear PPE correctly (Padula et al., 2021). They should also strengthen education about the facial pressure injuries of HCPs while regularly carrying out airtightness checks on staff wearing N95 masks during training to enable them to master the standard operating procedures for airtightness testing.

The nose was shown to be the main location of facial pressure injuries among staff in this meta‐analysis, followed by the cheeks, forehead and ear (auricle), which is similar to the results of a systematic review (Barnawi et al., 2021). The possible explanation is that the nose beam is located at the bone carina, which has less subcutaneous tissue and thin skin. The cheek lacks the protection of soft tissue. In addition, HCPs are in a high‐intensity, high‐load, long‐term and psychologically stressful work environment. The bridge of the nose and cheeks is often damaged by the combined action of pressure, shear force, friction and sweating of PPE. Facial pressure injuries occur when straps are too tight or when rough, hard or sharp parts contact the skin. Therefore, to alleviate this pressure, it is recommended to place a thin layer of silicone foam dressing between the PPE and the skin. HCPs can cut the dressing into pieces of appropriate size according to the area and shape of the compressed part; stick it on the forehead, cheek, nose and ear; and place it between the PPE and the skin (EPUAP).

As for the stage of the injury, our subgroup analysis results showed that the most prevalent stage of facial pressure injuries among health‐care professionals is Stage 1 injury, followed by Stage 2 injury. These results are consistent with a systematic review summarizing the incidence of stress injury in hospitalized adult patients globally, which also showed that Stage 1–2 injuries were the most prevalent type of injury (Li, Lin, et al., 2020). However, because there is less subcutaneous fat on the head and face (except cheeks), Stage 1–2 injuries in HCPs wearing PPE are prone to progress to deep tissue damage and serious pressure injuries. However, there is no validated assessment tool for facial equipment‐related pressure injuries in HCPs. Accordingly, future studies are needed to develop a risk prediction model suitable for PPE‐related pressure injuries among these staff.

In view of the continuous pandemic of COVID‐19 and the adverse influences of the facial pressure injuries caused to HCPs, to ensure the safety of these staff, it is recommended that tools be developed for evaluating pressure injuries related to facial equipment. A standardized method to report the incidence of facial pressure injuries among HCPs worldwide should also be developed and validated to minimize the heterogeneity of research results.

4.1. Study limitations

First, significant heterogeneity was observed among the included studies, which is likely related to differences in training experience, duration of wearing PPE, location of pressure injuries and injury stage among the included studies. Second, the included studies were mainly performed in China, which may not accurately reflect the results of studies from other countries. Third, the study describes the characterization of the population but did not describe the health‐care personnel and settings. Finally, publication bias may exist in the meta‐analysis, which should be considered when interpreting the results.

5. CONCLUSION

This meta‐analysis showed the pooled incidence of facial pressure injuries among HCPs during the COVID‐19 pandemic. However, due to the relatively low quality of the research found in the meta‐analysis, we recommend that higher quality research be carried out in the future to better determine the incidence of facial pressure injuries in these staff.

In the future, managers need to take interventional measures, such as reasonable shift scheduling and strengthening training, to improve the facial pressure injuries of HCPs during COVID‐19. Moreover, we encourage future studies to explore and develop evaluation and measurement tools, management mechanisms, risk prediction models and best evidence on facial PPE‐related pressure injuries and to develop a standardized method to report the incidence of facial pressure injuries of health‐care professionals worldwide. These efforts should reduce the incidence of facial pressure injuries so that HCPs can better respond to emerging pandemic infectious diseases.

CONFLICT OF INTEREST

The authors declare that they have no conflicts of interest.

AUTHORSHIP STATEMENT

HS, WZ and YK conceptualized the study. HS and WZ wrote the first version. YK reviewed and revised it critically for important intellectual content. HS, WZ and FZ searched the database and collected the data. HS, FZ and XS analysed and interpreted the data. BX, WZ, QZ and QL conducted the meta‐analysis. HS and WZ contributed equally to this study.

Supporting information

Data S1. Supporting information

Click here for additional data file. (26.2KB, docx)

ACKNOWLEDGMENTS

We thank Medjaden Inc. for their scientific editing of this manuscript.

Su, H. , Zhou, W. , Kong, Y. , Zhu, F. , Xu, B. , Shen, X. , Zhang, W. , Zhou, Q. , & Lv, Q. (2022). Incidence of facial pressure injuries in health‐care professionals during the COVID‐19 pandemic: A systematic review and meta‐analysis. International Journal of Nursing Practice, e13125. 10.1111/ijn.13125

Honghong Su and Wenguang Zhou contributed equally to this work.

Funding Information This study was supported by the Fujian Science and Technology Planning Project (2020Y0080) and the Special Plan for Military Biosafety Research (20SWAQK48) in China.

DATA AVAILABILITY STATEMENT

All data generated or analysed during this study are included in this published article, and further inquiries can be directed to the corresponding author.

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Associated Data

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Supplementary Materials

Data S1. Supporting information

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Data Availability Statement

All data generated or analysed during this study are included in this published article, and further inquiries can be directed to the corresponding author.

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