Prophylactic Dressings for Maintaining Skin Integrity of Healthcare Workers When Using N95 Respirators While Preventing Contamination Due to the Novel Coronavirus: A Quality Improvement Project

Abstract

Purpose: Extended use of N95 respirator masks is far more prevalent during the coronavirus disease 2019 (COVID-19) pandemic. As WOC nurses, we were tasked with formulating procedures for protecting the facial skin integrity of healthcare workers (HCWs) using personal protective devices when caring for patients with suspected or active COVID-19, while avoiding contamination when the masks are donned or doffed. This quality improvement project describes how we approached this project within the limited time frame available as we cared for patients with established and suspected COVID-19.

Participants and setting: This project focused on HCW use of N95 respirator masks and dressings currently available in our facility. The 4 WOC nurses acted as quality improvement project directors and as participants. The setting for our project was our facility's simulation laboratory.

Approach: We evaluated 6 topical products (an alcohol-free liquid acrylate, thin film dressing, thin hydrocolloid dressing, hydrocolloid blister care cushion, thin foam transfer dressing, and thick foam dressing) applied to skin in contact with 3 N95 respirators; all are available on our facility's formulary and all are in widespread clinical use. After the product was applied to the face and nose, the N95 respirator was donned and evaluated for fit. Participants then wore the devices for 10 hours and doffed the mask using established facility procedures. In order to evaluate for potential contamination including possible aerosolization, we applied a commercially available fluorescent lotion to simulate the presence of infectious particles. Contamination was assessed using an ultraviolet light for all dressings except for the alcohol-free liquid acrylate. We also evaluated cutaneous responses (skin integrity, irritation, comfort) during this period.

Outcomes: We found that contamination of the simulated pathogen did not occur with removal of any of the protective products. No skin irritation was noted with any of the tested products after a 10-hour wear time underneath the N95 respirator masks, but mild discomfort was experienced with 3 of the dressings (thin film dressing and both hydrocolloid dressings).

Conclusion: Based on these experiences, we recommend application of an alcohol-free liquid acrylate film to prevent facial skin injury associated with friction from the extended use of an N95 respirator mask. We further recommend performing a fit test and user-performed seal check with the use of any topical dressing and especially those that add cushion. For the duration of the COVID-19 pandemic, we recommend use of protective dressings to maintain skin integrity and protection from coronavirus infection as HCWs continue to provide care to all of patients under their care.

Figure 1.

N95 respirator mask 1.

Figure 2.

N95 respirator mask 2 with goggles.

Figure 3.

N95 respirator mask 3.

Figure 4.

(A, B) Thin hydrocolloid dressing and N95 respirator mask 1. (A) Thin hydrocolloid dressing applied to the bridge of the nose and cheekbones. (B) Appearance of thin hydrocolloid dressing after mask 1 is applied and checked for fit.

Figure 5.

(A, B) Thin hydrocolloid dressing with N95 respirator mask 2. (A) Thin hydrocolloid dressing applied to the bridge of the nose and cheekbones. (B) Appearance of thick hydrocolloid dressing after N95 respirator mask 2 is applied and checked for fit.

Figure 6.

(A-D) Alcohol-free liquid acrylate film skin barrier. (A) Alcohol-free liquid acrylate film skin barrier applied starting at the right side of the cheeks. (B) Application of alcohol-free liquid acrylate film skin barrier continued to dotted areas of bilateral cheeks and the bridge of the nose. (C) Application of alcohol-free liquid acrylate film skin barrier continued to dotted area on the chin. (D) Application of alcohol-free liquid acrylate film skin barrier continued to dotted areas of the forehead and behind the ears.

Figure 7.

(A-D) Silicone-based thin foam transfer dressing. (A) Germ-simulating lotion as seen under UV light applied on the surface of the silicone-based thin foam transfer dressing; the dressing was applied from one side of the cheek to the other side across the bridge of the nose. (B) Removal of the silicone-based thin foam transfer dressing started at the right side of cheek. (C) Removal of the silicone-based thin foam transfer dressing ending toward the left side of cheek, with no visible contamination of facial skin. (D) Silicone-based thin foam transfer dressing completely removed with no contamination on facial skin.

Figure 8.

(A-D) Hydrocolloid blister care cushion. (A) Germ-simulating lotion as seen under UV light applied to the surface of hydrocolloid blister care cushion dressing; the dressing was applied to the bridge of the nose. (B) Removal of dressing started at one side of the hydrocolloid blister care cushion dressing. (C) Removal of hydrocolloid blister care cushion dressing is completed. (D) Hydrocolloid blister care cushion dressing is completely removed with visible skin contamination intended by the wearer to simulate infectious particles but no aerosolization noted.

Figure 9.

(A-D) Thin film dressing. (A) Germ-simulating lotion as seen under UV light applied to the surface of thin film dressing that was applied to the bridge of the nose. (B) Removal of thin film dressing started at one side and then across the bridge of the nose. (C) Removal of thin film dressing continued across the bridge of the nose. (D) Removal of thin film dressing ended with difficulty noted from the wearer with tactile cues provided by the WOC nurses observing the removal; no visible contamination of facial skin.

Figure 10.

(A-D) Silicone-based transfer dressing. (A) Germ-simulating lotion as seen under UV light applied to the surface of silicone-based transfer dressing—dressing applied to the bridge of the nose. (B) Removal of silicone-based transfer dressing started at one side and then across the bridge of the nose. (C) Removal of silicone-based transfer dressing continued across the bridge of the nose. (D) Silicone-based dressing is completely removed, with no visible contamination of facial skin; noted transfer of germ-simulating lotion onto glove from skin side of silicone-based transfer dressing.

Figure 11.

(A-D) Hydrophilic polyurethane membrane matrix with a semipermeable polyurethane plus thin hydrocolloid. (A) Germ-simulating lotion as seen under UV light applied to the surface of thin hydrocolloid dressing securing the hydrophilic polyurethane membrane matrix with a semipermeable polyurethane—dressing applied across the bridge of the nose and from one side of the cheek to the other. (B) Removal of dressing started at the right cheek and proceeded across the bridge of the nose. (C) Removal of dressing continued across the bridge of the nose toward the left cheek. (D) Hydrophilic polyurethane membrane matrix with a semipermeable polyurethane plus thin hydrocolloid as a secondary dressing is completely removed. Difficulty was noted during removal, but no visible contamination of the facial skin was observed.