Influencing factors of medical device-related pressure ulcers in medical personnel during the COVID-19 pandemic: A systematic review and meta-analysis

Abstract

Objective

To determine the influencing factors of medical device related pressure injury (MDRPU) in medical staff by meta-analysis.

Methods

A comprehensive literature search was conducted by PubMed, Embase, Cochrane Library, Web of Science, CNKI, VIP, CBM, and WanFang Data (from inception to July 27, 2022). Two researchers independently performed literature screening, quality evaluation and data extraction, and meta-analysis was conducted with RevMan 5.4 and Stata12.0 software.

Results

Total of 11215 medical staff were included in 9 articles. Meta analysis showed that gender, occupation, sweating, wearing time, single working time, department of COVID-19, preventive measures, and level 3 PPE were the risk factors for MDRPU in medical staff (P < 0.05).

Conclusion

The outbreak of COVID-19 led to the occurrence of MDRPU among medical staff, and the influencing factors should be focused on. The medical administrator can further improve and standardize the preventive measures of MDRPU according to the influencing factors. Medical staff should accurately identify high-risk factors in the clinical work process, implement intervention measures, and reduce the incidence of MDRPU.

1. Introduction

Coronavirus Disease 2019 (COVID-19) is a new respiratory disease caused by SARS CoV-2 virus. It first appeared in Wuhan, China, in December 2019, and then quickly spread around the world. So far, it has caused more than 150 million cases and 3 million deaths [1]. It is well known that the virus is highly infectious and can be transmitted from SARS CoV-2 infected persons to others by coughing, sneezing and speaking or by contacting saliva droplets [2]. The front-line medical staff are considered to be the population with high infection risk, because they have been in close contact with infected patients for a long time [3]. The use of personal protective equipment (PPE) has become critical to the safety of front-line medical staff in fighting against viruses. PPE mainly includes medical protective masks (N95 masks and surgical masks), goggles, protective face screens, protective clothing, etc. [4,5], which are preventive measures taken to minimize the risk of virus transmission. However, long working hours and long-term use of PPE will increase the risk of PPE related pressure ulcers among medical staff [6].

Medical Device Related Pressure Ulcer (MDRPU) is a local injury to the skin and/or subcutaneous tissue (including mucous membrane) caused by the continuous compression of external medical devices [7]. The shape of the injury is consistent with the shape of the Device, and it is common in the parts with less subcutaneous fat [7]. A systematic evaluation showed that [8], the incidence of MDRPU among medical staff during the COVID-19 period was 30%∼92.8%. Once MDRPU occur, they may damage the skin barrier and promote the coronavirus to invade the blood circulation, increasing the risk of infection for medical personnel [9]. At home and abroad, the pressure sore assessment scale is used to assess the risk of patients, objectively judge the possibility of stress injury, thus reducing the pain of patients and the consumption of medical resources [10]. Timely assessment and identification of high-risk patients is the key to prevent MDRPU.

At present, many scholars have discussed the influencing factors of MDRPU among medical staff, but due to different researchers, regions and tools, the research conclusions are different. A recent systematic evaluation showed that [8], the occurrence of MDRPU was mainly related to factors such as female medical staff, sweating, long-term use of PPE, chronic skin diseases, and allergic history, but only English databases were searched, and Chinese literature was lacking, and all were descriptive studies. In addition, there is another systematic evaluation on the stress injury of COVID-19 patients and medical staff [11], but the participants are COVID-19 patients and medical staff, not specific medical staff. In our systematic evaluation, the participants are all medical personnel. In order to more comprehensively retrieve relevant studies, we searched Chinese and English databases, including Chinese and English studies. Therefore, the purpose of this system evaluation is to explore the influencing factors of MDRPU among medical personnel at home and abroad, identify the overall influencing factors of MDRPU among medical staff, and provide basis for early intervention.

2. Methods

This systematic review was conducted according to the PRISMA guidelines.

2.1. Inclusion and exclusion criteria

The inclusion criteria were as follows: (1) Medical staff with MDRPU during COVID-19; (2) Influencing factors of MDRPU; (3) Cohort study, cross-sectional study; (4) In the original study, the statistical method is the logistic regression model and provides odds ratio (OR) and 95% confidence interval (CI), or documents that can convert the estimated value and standard error of the logistic regression coefficient; (5) The study language is Chinese or English.We excluded: (1) Full text study cannot be obtained; (2) Study where relevant data cannot be extracted; (3) Repeated publication of literature; (4) Review or conference paper.

2.2. Search strategy

We searched English and Chinese databases, including PubMed, Embase, Cochrane Library, Web of Science, CNKI, VIP, CBM, and WanFang Data.The retrieval time limit was from inception to July 27, 2022. The following Mesh terms and free-text terms included “MDRPU/pressure ulcer*/device related pressure ulcer*/MDRPI/pressure injur*” “personal protective equipment/PPE personal protective equipment/masks/N95 respirator/N95 face masks/N95 masks/eye protective devices/goggles” “COVID-19/SARS-CoV-2/coronavirus disease 2019” “relevant factor*/influence factor/risk factor*/reason*“.

2.3. Data extraction

Two researchers independently screened the literature according to the criteria for inclusion and exclusion, extracted the data and cross checked them. If there was a dispute, it will be resolved through negotiation or decided by the third researcher. All the literatures retrieved were imported into Endnote X9 software, and two researchers read the title and abstract for preliminary screening. After the preliminary screening, the full text of the literature was screened again to determine the final included literature. The following information was extracted from the included literature: author, publication time, country, sample size, research type, risk factors involved, etc.

2.4. Quality appraisal

The quality evaluation of the cross-sectional study used the Agency for Healthcare Research and Quality (US) [12] as the evaluation tool, which included a total of 11 items and answered with “yes”, “no” and “unclear”. The full score was 11 points. 0–3 points, 4–7 points and 8–11 points represent low quality, medium quality and high quality respectively. The cohort study was evaluated using the Newcastle Ottawa Scale (NOS) [13] recommended by Cochrane. Each part included three categories of study population selection, inter group comparability, exposure or result evaluation. There were eight items in total, with a full score of 9 points. If the score was ≥7, the literature was of high quality, and if the score was<7, the literature was of low quality.

2.5. Statistical analysis

Statistical analysis was completed by RevMan5.3 and Stata12.0 software, and the effect was described by odds ratio (OR) value and 95% CI. If P > 0.1, I ²<50%, it indicated that the heterogeneity between studies was acceptable, and the fixed effect model was used for consolidation analysis; If P ≤ 0.1, I ² ≥ 50%, it meant that the heterogeneity between studies was large, and the random effect model was used for analysis. Sensitivity analysis was used to test the stability of meta analysis results. The publication bias was evaluated by Egger's test. Inspection level α = 0.05。

3. Results

3.1. Study selection

A total of 404 relevant studies were retrieved. All the studies were imported into Endnote X9 software. 333 related studieswere obtained after removing the duplicate studies. Based on the inclusion and exclusion criteria of this study, 263 studies were excluded after reading the title and abstract of the studies. 61 studies were excluded after full text reading of the articles that might meet the inclusion criteria, and finally 9 studies were included [[14], [15], [16], [17], [18], [19], [20], [21], [22]], including 5 Chinese studies and 4 English literatures. Among the 9 studies included, 1 was a retrospective study [19], and 8 were a cross-sectional study [[14], [15], [16], [17], [18],[20], [21], [22]]. The specific process and results of literature screening are shown in Fig. 1 .

Fig. 1.

Flow chart of studies screening.

3.2. Characteristics and quality evaluations of the included studies

Nine papers [[14], [15], [16], [17], [18], [19], [20], [21], [22]] were included, published from 2020 to 2022, with a total of 11215 subjects in three countries, including China, Brazil and Turkey. AHRQ was used to evaluate the cross-sectional studies, including 11 items. Eight cross-sectional studies were more consistent with the quality requirements of the included literature in terms of inclusion criteria formulation, outcome index evaluation, quality control, etc. The methodological quality evaluation scores of eight papers [[14], [15], [16], [17], [18],[20], [21], [22]] were all ≥6 points, which were of medium and high quality. Among them, five were of high quality [[16], [17], [18],21,22], and three were of medium quality [14,15,20]. The retrospective study was evaluated by NOS, and the quality evaluation score of one retrospective study [19] was 7, which was high-quality literature. See Table 1 for the basic characteristics and methodological quality evaluation of the included literature.

Table 1.

Basic characteristics of the included studies.

First author	country	sample size	Research type	Influencing factors	Quality score (points)
					NOS	AHRQ
Coelho, MMF, 2020 [14]	Brazil	1106	Cross-sectional study	1,5,6		7
Tang, J, 2020 [15]	China	102	Cross-sectional study	5,13		5
Jiang, Q(a), 2020 [16]	China	4306	Cross-sectional study	2,4,5,14		8
Aksoy, M, 2022 [17]	Turkey	1465	Cross-sectional study	1–3,4,5,13		8
Dai, Y, 2020 [18]	China	998	Cross-sectional study	7–10		8
Xia, J, 2020 [19]	China	89	Cohort study	5,6,16	7
Yang, X, 2020 [20]	China	184	Cross-sectional study	6,7,12,13		6
Zheng, J, 2020 [21]	China	64	Cross-sectional study	6,11		8
Jiang, Q (b), 2020 [22]	China	2901	Cross-sectional study	3–5,14,15		8

Note: 1. Age; 2. Gender; 3. Occupation; 4. Sweating; 5. Wearing time; 6. Take preventive measures; 7. Single working time; 8. Total working hours; 9. Frequency of skin protection; 10. Whether to receive pre job training; 11. Sensitive skin; 12. Number of patients managed; 13. Department of COVID-19; 14. Level 2 PPE; 15. Level 3 PPE; 16. Whether to wear protective clothing.

3.3. Results of meta-analysis

In this study, 9 influencing factors that can be combined in 9 articles were analyzed by meta-analysis, including general factors, work factors and protective factors of medical staff. Meta analysis results show that gender, occupation, sweating, wearing time, single working time, department of COVID-19, preventive measures and level 3 PPE were all the influencing factors of MDRPU of medical staff. There was no significant correlation between age and MDRPU of medical staff. Male medical personnel can have a risk of MDRPU as high as 1.5 times. Occupation of medical personnel can have a risk of MDRPU as high as 1.65 times.Sweating medical staff is 23.15 times that of non sweating medical staff. Wearing time of medical personnel can have a risk of MDRPU as high as 1.73 times. Single working time of medical personnel can have a risk of MDRPU as high as 1.6 times. Department of COVID-19 can have a risk of MDRPU as high as 9.03 times. Taking preventive measures of medical personnel can have a risk of MDRPU as high as 4.68 times. Level 3 PPE can have a risk of MDRPU as high as 1.89 times. See Table 2 for the results of Meta analysis of each influencing factor. Because some influencing factors cannot be combined quantitatively or only one article was reported, only descriptive analysis will be conducted for these influencing factors. Dai et al. [18] reported that the total working time was a risk factor for MDRPU, and the frequency of skin protection and pre job training for skin protection are protective factors. Zheng et al. [21] found that sensitive skin was the influencing factor of MDRPU, and logistic regression analysis showed that compared with normal skin, the risk of crush injury of sensitive skin was significantly increased by 6.676 times. Other studies have found that whether to wear protective clothing [19], the number of patients under management [20], and level 2 PPE [22] were also factors affecting MDRPU.

Table 2.

Meta analysis results of influencing factors of MDRPU in medical staff.

Influencing factors	Heterogeneity test		Effects model	Meta analysis results				Number of studies
	I2（%）	P		Z	P	OR	95%CI
general factors
Age	93	<0.01	Random-effects model	1.27	0.20	0.87	0.70–1.08	2 [14,17]
Gender (male)	0	1.00	Fixed-effects model	3.76	<0.01	1.50	1.21–1.85	2 [16,17]
work factors
Occupation(doctor, nurse)	0	0.75	Fixed-effects model	2.96	<0.01	1.65	1.18–2.31	2 [17,22]
Sweating	96	<0.01	Random-effects model	35.88	<0.01	23.15	19.50–27.48	3 [16,17,22]
Wearing time	96	<0.01	Random-effects model	9.84	<0.01	1.73	1.55–1.92	6 [[14], [15], [16], [17],19,22]
Single working time	0	0.89	Fixed-effects model	5.59	<0.01	1.60	1.35–1.88	2 [18,20]
Department of COVID-19	42	0.19	Fixed-effects model	8.09	<0.01	9.03	5.30–15.39	2 [15,17]
protective factors
Take preventive measures	63	0.04	Random-effects model	17.91	<0.01	4.68	3.95–5.54	4 [14,[19], [20], [21]]
Level 3 PPE	94	<0.01	Random-effects model	6.30	<0.01	1.89	1.55–2.30	2 [16,22]

Note: Some influencing factors of studies cannot be combined quantitatively.

3.4. Sensitivity analysis

The stability of the meta-analysis results was checked through the conversion effect model and the removal of documents with high weight or low quality. The sensitivity analysis of each influencing factor was conducted separately. If the analysis results of each influencing factor before and after the analysis were basically consistent, the meta-analysis results were stable and reliable. See Table 3 for details.

Table 3.

Sensitivity analysis results.

Influencing factors	Before sensitivity analysis		After sensitivity analysis		Stability
	OR(95%CI)	P	OR(95%CI)	P
Age	0.87(0.70–1.08)	0.20	–	–	–
Gender (male)	1.50(1.21–1.85)	<0.01	–	–	–
Occupation(doctor, nurse)	1.65(1.18–2.31)	<0.01	–	–	–
Sweating	23.15(19.50–27.48)	<0.01	12.38(9.73–15.75)	<0.01	stable
Wearing time	1.73(1.55–1.92)	<0.01	2.06(1.65–2.57)	<0.01	stable
Single working time	1.60(1.35–1.88)	<0.01	–	–	–
Department of COVID-19	9.03（5.30–15.39）	<0.01	–	–	–
Take preventive measures	4.68(3.95–5.54)	<0.01	4.84(4.08–5.74)	<0.01	stable
Level 3 PPE	1.89(1.55–2.30)	<0.01	–	–	–

3.5. Publication bias

Using Stata12.0 software to conduct the Egger's test, it was found that there was publication bias in the wearing time, and the bias of other factors was less likely. See Table 4 for details.

Table 4.

Test for publication bias of influencing factors of MDRPU in medical staff.

Influencing factors	Egger's test		Influencing factors	Egger's test
	t	P		t	P
Age	–	–	Department of COVID-19	–	–
Gender (male)	–	–	Level 3 PPE	–	–
Sweating	7.52	0.084	Single working time	–	–
Wearing time	3.45	0.026	Occupation(doctor, nurse)	–	–
Take preventive measures	1.37	0.305

4. Discussion

4.1. General factors

Meta analysis of general factors such as gender and age showed that gender (male) was the influencing factor of MDRPU in medical staff. The study [17] showed that the incidence of MDRPU was 58.6% in 563 female, and the incidence of MDRPU was 64.3% in 324 male. Tezcan et al. [23] found that male were the influencing factors of MDRPU. This study shows that due to gender factors, male medical personnel can have a risk of MDRPU as high as 1.5 times. It may be related to the following factors: hormonal differences between genders, female hormones have a protective effect on skin; Compared with female, male do not pay attention to skin care, and their skin tolerance is poor; Male medical personnel have more work activities. The research of Wang et al. [24] showed that there was no significant correlation between age and MDRPU of medical staff, which was the same as the conclusion of this study, indicating that age had no difference in the prevalence of MDRPU of medical staff. However, research [25] reported that, with the growth of age, cell renewal gradually slows down, skin barrier function decreases, permeability increases, skin was more vulnerable to external factors, and the risk of stress injury may increase. Meta analysis of this study shows that there is no significant difference in the age of MDRPU among medical staff, which may be related to the fact that there are two articles included. In the future, it is necessary to further explore the impact of age on the occurrence of MDRPU.

4.2. Working factors

The results shows that occupation is the influencing factor of MDRPU in medical staff. In the past, most studies on stress injury were related to hospitalized patients [[26], [27], [28]]. With the outbreak of COVID-19, people gradually realized that medical staff were also victims of stress injury. The study [17] showed that the incidence of MDRPU was 63.3% in 679 nurse, and the incidence of MDRPU was 58.6% in 157 doctor. The analysis of the occurrence of MDRPU among medical staff may be due to the fact that medical personnel are in a high intensity, high load, long-term treatment and rescue work environment, and are often subject to the combined effects (pressure, shear force and friction) of N95 respirator, goggles and protective face screens.The study showed that use of dressing cuts for padding under a KN95 respirator considerably reduced localized forces and did not worsen the thermal and SEM readings at the skin-device contact sites [29].Therefore, it is recommended to place a dressing between the PPE and the skin. The use of dressings on vulnerable areas of the face can greatly reduce direct pressure, shear or friction [30].

The results shows that the wearing time is the influencing factor of MDRPU in medical staff. The study [17] showed that the incidence of MDRPU was 74.1% (n = 887) when PPE was used for ≥4 h, and the incidence of MDRPU was 15.1% (n = 887) when PPE was used for <4 h. The maximum time that the skin can withstand capillary closure pressure is 2–4 h, and beyond this time, skin damage of different degrees will be caused. The longer the PPE is worn, the higher the risk of MDRPU [31], and significantly shorter than the time that patients have MDRPU. The reason may be related to the heavy workload of medical staff, friction and sweating caused by continuous medical work [32]. Lan et al. [33] showed that the occurrence of MDRPU among medical staff was related to the time of wearing PPE>6 h. Then, study [34] showed that the occurrence of MDRPU in medical staff was mainly related to the working days per week.Therefore, it is necessary to further study the impact of PPE wearing time on the occurrence of MDRPU in medical staff. The World Health Organization said that wearing N95 masks for more than 4 h would cause discomfort [35], which suggests that hospital managers should arrange shifts reasonably according to human physiological characteristics and arrange intervals for rest. At the same time, it is recommended that medical staff evaluate their proper daily wearing time of PPE, limit the daily wearing time of PPE to 4 h as much as possible, and evaluate the head and face skin every day to prevent the occurrence of MDRPU.

This study shows that sweating is the biggest influencing factor of MDRPU among medical staff, and the risk of MDRPU among sweating medical staff is 23.15 times that of non sweating medical staff. The study [17] showed that the incidence of MDRPU among sweating medical staff was 73.4%, and the incidence of MDRPU was 16.4% among non sweating medical staff. Sweating will change the skin microenvironment, weaken the skin protection ability, increase the friction between skin and PPE, and increase the risk of MDRPU. The research [36] also showed that wearing N95 masks and goggles will not increase the risk of MDRPU if you did not sweat, so controlling sweating may be an effective way to prevent DRPI. The practice guide [37]recommended to use silicone foam dressing to absorb sweat and reduce pressure when using PPE to reduce the occurrence of MDRPU. Some people think that the use of preventive dressings will affect the airtightness and protective effect of PPE, but some studies show that the use of hydrocolloid dressings or foam dressings on the head and face will not affect the airtightness, but also can effectively reduce the occurrence of MDRPU [38]. A literature [21] included in this study shows that taking preventive measures is a risk factor for MDRPU. A large amount of sweating in a closed environment will lose the protective effect of hydrocolloid dressing, and increase the risk of skin damage. Therefore, further research is needed on the use of preventive dressing.

The results shows that long working time is the influencing factor of MDRPU in medical staff. Similar to the investigation results of Yang et al., the shortest working time of each shift is 6 h and the longest is 13 h, which is an important risk factor for medical personnel to have MDRPU [20]. The study [18] showed that the incidence of MDRPU was 90.69%, 93.91%, 96.27% and 100% when working time of each shift was 4 h, 5–8 h, 9–12 h and>12 h. The reason is, on the one hand, due to the serious shortage of medical staff at the initial stage of the epidemic, and the shortage of protective equipment, medical staff can not replace the pressure parts at will in order to save protective equipment, extend working hours and avoid infection. Under the pressure of protective equipment for a long time, combined with poor permeability of protective clothing, the skin is easy to be soaked by sweat, which leads to MDRPU. On the other hand, medical staff wear goggles, protective masks, protective face screens and other protective equipment for a long time. The skin barrier function is weakened due to the compression of facial skin tissues and the loss of skin moisture. In addition, sweat immersion and other reasons lead to reduced skin pressure resistance [39]. Indentation, skin damage and obvious pain often occur. The longer the single working time is, the longer the medical personnel need to wear protective equipment, and the more times they wear protective equipment, the negative impact of protective equipment will increase, and the skin damage rate will also increase. Therefore, in order to better solve the problem of skin damage, if conditions permit, reasonable arrangement of working hours, reduction of single and cumulative working hours, increase of skin protection frequency and strengthening pre job training are effective means to reduce the occurrence of skin damage.

The result of this study shows that the department of COVID-19 is the influencing factor for the occurrence of MDRPU in medical staff. The department where COVID-19 belongs, including outpatient and intensive care unit [16], is the place where medical staff are most likely to appear in MDRPU. The study [17] showed that the incidence of MDRPU in COVID-19 intensive care was 87.3% (n = 887), and the incidence of MDRPU in COVID-19 clinic was 85.7% (n = 887). The high incidence of MDRPU among medical staff in COVID-19's department may be due to the use of N95 masks, goggles and face screens [40,41]: firstly, the pressure and friction caused by N95 masks, goggles and face screens themselves; Secondly, medical staff should press the metal nose clip on the nose of the mask and use a tightened elastic rope to ensure the sealing of the mask. This kind of material with small contact area and hard texture will increase the pressure on local tissues.Thirdly, medical personnel wear N95 masks, goggles and face screens for a long time to work with high intensity. It is difficult to drain the sweat from the skin, which causes moisture on the skin surface, causing MDRPU.Therefore, It was suggest that kitbag containing the elements of the care bundle medical staff working could be given in COVID-19 wards, ICU and the emergency department in the hospital [42,43]. The key elements of the bundle included the face wipe, moisturiser and protective tape, and each element acted in synergy [42,43]. Thus, the bundle emerged as an all-in-one protector for staff against MDRPU.

4.3. Protective factors

The result of this study shows that preventive measures are the influencing factors for medical staff to have MDRPU, which is consistent with the research results of Smart et al. [41]. The study [19] showed that the number of cases with MDRPU who not taking preventive measures was higher than those who taking preventive measures (66.67% vs 33.33%, P < 0.05). The parts where medical personnel have MDRPU, such as the bridge of the nose, cheek, forehead [44], are the parts with the largest vertical pressure on PPE. No preventive measures are taken on the face, and the skin contact parts are rough, hard sharpness and small area of skin contact are the possible causes of pressure injury in these parts. The use of preventive dressings can reduce MDRPU [11], but a literature [21] included in this study shows that taking preventive measures is a risk factor for MDRPU, and relevant research needs to be carried out in the future. In addition, this study shows that the level 3 PPE is the influencing factor of MDRPU for medical personnel. The study [16] showed that the number of cases with MDRPU who wore level 3 PPE was higher than those who wore level 2 PPE (63.97% vs 13.75%, P < 0 .001). As an acute respiratory infectious disease, COVID-19 strictly implements level 3 PPE when treating and nursing suspicious or confirmed patients in the early outbreak period. Medical staff are required to wear N95 medical protective masks, goggles, protective face screens, etc. in addition to protective clothing and isolation clothing. In particular, the facial protection measures are the most strict. The face is squeezed by masks, goggles and protective face screens for a long time. The masks, goggles and protective face screens are made of rough, hard, sharp materials, and the area of skin contact is small, which will lead to poor blood pressure circulation of the face skin, reduced skin resistance, and skin depression in the early stage. In serious cases, the skin may even become swollen, broken, or even infected [39]. This suggests that medical staff should further improve the materials of masks, goggles and protective face screens to reduce the risk of MDRPU on the premise of ensuring the protection effect for posts that must wear level 3 PPE.

5. Limitations

① Although this study has developed a strict retrieval strategy and carried out a comprehensive retrieval, it only retrieves Chinese and English documents, and does not retrieve gray documents. The number of documents eventually included is limited, which may have an impact on the comprehensiveness of the results. ② Most of the included studies are from China, and only two are from Brazil and Turkey, which are not representative. ③ Most of the factors in the meta analysis were only included in 2 articles, and the authenticity and reliability of the results need to be discussed. ④ Some influencing factors are heterogeneous after the merger, which may cause a certain degree of bias to the conclusions of this study. ⑤ Among the 9 studies included, most of them are cross-sectional studies from China, with few retrospective studies and no prospective studies, and some of the samples included in the literature are small. Therefore, a large sample, multi center, high-quality prospective study should be carried out in the future to deeply explore the influencing factors of MDRPU in medical staff, so as to obtain comprehensive and scientific research results.

6. Conclusions

Medical staff are the main force in the prevention and control of COVID-19. However, during the COVID-19 period, medical staff suffered from MDRPU. The occurrence of these stress injuries is related to gender, occupation, sweating, wearing time, single working time,the department of COVID-19, preventive measures and level 3 PPE. This study benefits medical staff and helps medical institutions better understand the MDRPU of medical staff during the COVID-19 pandemic. The medical administrator can further improve and standardize the preventive measures for crushing injuries related to protective equipment according to the influencing factors. Medical staff should accurately identify high-risk factors in the clinical work process and implement intervention measures to avoid MDRPU. At present, the use of preventive dressings is controversial, and researchers need to further study the effectiveness and airtightness of preventive dressings for medical personnel. Due to the large difference in the sample size of the studies included this time and the heterogeneity among the studies, a large sample, multi center prospective study is needed in the future.

Funding

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

Declaration of competing interest

The authors declare that they have no conflict of interest.