The Use of Personal Protective Equipment and The Risk of Facial Pressure Sores among Nurses in Covid Isolation Rooms

This study aimed to determine the relationship between the use of personal protective equipment and the risk of facial pressure injury among nurses in the Raudhah 5 room of Muhammadiyah Hospital Bandung (RSMB). This study is a quantitative correlation study with a cross-sectional research design. The research population is 15 COVID-19 isolation nurses in RSMB with a total sampling technique. Bivariate analysis used is the contingency coefficient correlation test. Nurses that used personal protective equipment or more than 50% had a moderate risk of pressure injury as experienced by ten nurses (66.7%). The correlation coefficient test of personal protective equipment obtained a p-value= 0.537. There is no relationship between the use of personal protective equipment to the risk of facial pressure injury on nurses in RSMB. Nurses who use level 3 of PPE, especially in the facial area, should use dressings to prevent the risk of facial pressure injury.

The transmission of COVID-19 is effortless because it can be transmitted from one individual to another through droplets when sneezing, coughing, or even talking [3]. The impact on health workers, especially nurses at the frontline, is the increased workload of COVID-19 patients, weakness, and susceptibility to exposure to COVID-19. Nurses exposed to or positive for COVID-19 will experience symptoms such as cough, sore throat, fever, myalgia or arthralgia, fatigue, and headache. Nurses who are exposed to COVID- 19  sweating, which results in redness, pain, itching, and increased friction on the skin surface [6].
Therefore, all of these induce a risk of facial injuries among nurses.
To Prevent the transmission of COVID-19, nurses must wear PPE when providing nursing care to infected patients. PPE level 3 is disposable, and the maximum use time is four hours [5]. Incidence of shortness of breath, blurred vision, nausea, fainting, vomiting, diarrhoea, and risk of pressure sores are noted among nurses wearing PPE for a prolonged period.  the PPE according to the required usage period, and provide a cool work environment so that health workers can reduce discomfort in using PPE [9].
In connection with the phenomenon of pressure sores risk that occurs in nurses and the importance of nurses preventing the risk of facial pressure sores in the fight against COVID-19, and the absence of those who have conducted research in Indonesia on this, the Author is interested in running a study with the title "the relationship between the use of personal protective equipment and the risk of facial pressure sores in nurses in room 5 of Muhammadiyah Hospital Bandung".

Literature Review
PPE is a standard of vigilance in preventing and controlling infections in all health facilities. The purpose of using PPE is to protect health workers and patients from exposure to diseases and pathogenic microbes. The type of PPE for health workers is divided into three levels of protection: [10] head protection, 3-layer surgical masks, N95 masks, goggles, face shields, gloves, protective clothing, and foot protection boots [5].

Methodology
This quantitative correlational research will examine and explain the relationship between variables using cross-sectional research methods/designs [14]. The researchers intend to study the relationship between the use of PPE and the onset of the risk of facial pressure sores in nurses. The data was obtained from filling out the respondent's questionnaire sheet. Based on Table 1, the characteristics of respondents are most dominated by the age of 31 -40 years old or nine respondents (60%), female or 11 respondents (73.3%), and the education category is more nurses with D-III graduates of Nursing as many as nine respondents (60%).   Table 2 shows the results of PPE use in nurses based on the number of research questionnaire statements and the number of respondents who answered 'Yes' in each statement. The score of the PPE use questionnaire was divided into three according to the number of 'Yes' answers in the PPE use questionnaire statement. The result of the average score of PPE use in nurses in the Raudhah room 5 with the help of the MS Excel application is 80%. Table 3 shows the frequency distribution of the risk of facial pressure wounds among nurses in Raudhah 5 th Room of Muhammdiyah Hospital Bandung.   Based on Table 4, the score of 6 PPE usage against the onset of the risk of facial pressure sores was low at nine at 0 for one person at 11.1%, medium risk for seven people at 77.8%, and high risk for one person at 11.1%. Score 7 PPE use against the onset of low risk of facial pressure sores as much as 0 or none 0%, medium risk two people 50%, and high risk two people 50%. Score 8 PPEuse against the onset of low risk of facial pressure sores as much as 0 or none 0%, medium risk one person 50%, and high risk one person 50%.

Discussion
The characteristics of respondents in this study were seen from the demographic data of respondents. Based on the Table, most of the respondents aged 31-40 years were nine people 60%, 11 were female, 73.3% and had D-III Nursing education. Ref. [6] shows the results of her research that most nurses experience the prevalence of skin injuries with undergraduate education levels and nursing professions of the female sex, with an average age range of 32-40 years who use PPE level 2 and level 3 as well as a daily PPE use time of 4 hours and more tha 4 hours. Logistic regression analysis showed that PPE levels, daily PPE use time, and gender could lead to the presence of excessive sweating, which increases the risk of skin injury significantly. This is in line with research that conducted a survey using questionnaires to 65 health workers in China who are at the forefront of fighting COVID-19 with an average age of 30 -39 years. The results of the 61 respondents who filled out the questionnaire showed that most were female, and as many as 56 people were 91.8% [8].
Based on the results of the bivariate analysis in Table 4, the results of p-value was 0.537 higher than 0.05, which means that H0 is accepted or there is no relationship between the use of personal protective equipment and the risk of facial pressure sores in nurses in room 5 of Muhammadiyah Hospital Bandung.
Based on the analysis results, there is no relationship between the use of personal protective equipment and the onset of the risk of facial pressure sores from the time of use of PPE, especially in the facial area. The frequency of PPE use time is at most 3 hours and 30 minutes for as many as seven people, 46.7%. This is in contrast to the research stating that the duration of using PPE for > 6 hours is the main factor that causes pressure sores on the skin of the nurse's face. The results of other studies show that the duration of continuous use of PPE in health workers is more than 6 hours a day [15].
In addition, other possible factors support the study's results that there is no relationship between the use of PPE and the risk of pressure sores in nurses, namely by using foam dressings before using PPE, especially when using PPE on the face area states that [16] dressing precautions can minimize or even eliminate pressure and shearing at the site of pressure sore risk. The dressing serves to absorb sweat, can redistribute pressure, and this dressing does not cause a pruritus effect. Using such dressings reduces pressure injuries from more than 80% to 10% [17].
Using personal protective equipment for nurses or other health workers is an important thing that must be used to protect nurses or patients from the transmission of nosocomial infections and healthcare-associated infections. At the beginning of the emergence of a new virus variant known as COVID-19, controlling and breaking the spread chain became the main goal of care providers or health services. Nurses in charge of handling or caring for COVID-19 patients are required to use complete PPE, commonly called level 3 PPE consisting of coveralls and aprons, head coverings, N95 masks, google and Faceshield glasses, disposable sterile gloves, and protective shoes. This is done to minimize the transmission of COVID-19 either from patients or the nurses themselves. This is in line with the study's results, which stated that nurses' compliance in using PPE when providing care to COVID-19 patients who produce aerosols was 97.5%.
The use of personal protective equipment PPE according to Chinese regulatory regulations, every health worker needs to change PPE every 4 hours. But this is not in line with the facts on the ground. Nurses and other health workers sometimes have to work beyond the existing rules of about 8-12 hours, causing inconvenience to their users [6].
One of the effects caused by the prolonged use of PPE is the onset of pressure sores on the facial skin area caused by the use of PPE in face areas such as head caps, goggle glasses, face shields and N95 masks. This is in line with the study that out of 61 health workers, as many as bones [9].
The risk of facial pressure sores can be assessed using the Norton scale, which has three classification scores: a score lower than 15: high risk, 16 -18: medium risk, and higher than 19: low risk. The results of the analysis in this study were more nurses who experienced moderate risk of ten people (66.7%), high risk (26.7%), and low risk of 1 person (6.7%) [19]. Although the results showed that there was no relationship between the use of PPE and the onset of the risk of facial pressure sores because the duration of using PPE 3 nurses at most was 3 hours and 30 minutes. This still affects the risk of pressure sores for 3 hours because when the nurse provides nursing care for COVID-19 patients, they cannot touch PPE (especially those used in the facial area) even though it feels uncomfortable and painful [17].

Conclusion
The conclusion of the study entitled "The Relationship Between the Use of Personal Protective Equipment against the Risk of Facial Pressure Wounds Among Nurses in Raudhah Room 5 Muhammadiyah Hospital" is based on the contingency or physical correlation test, namely 0.537 higher than 0.05, the result decision shows that there is a moderate risk ( no relationship between) in the use of personal protective equipment and the risk of facial pressure sores in nurses in Raudhah 5 th Room of Muhammadiyah Hospital Bandung.