COVID-19 has Amplified the Need to Establish Unavoidable Pressure Injury Criteria in Acute Care

With the onset of the COVID-19 pandemic, there has been increased confusion regarding the diagnostic clarity of some skin lesions, especially in the critical care population. These lesions can be challenging to differentiate from other dermatological conditions seen in this population, including skin failure and deep tissue pressure injuries. During severe SARS-CoV-2 infection, endothelial dysfunction and hypercoagulability¹occur, and COVID-19 patients are at increased risk for ischemic lesions that mimic the appearance of deep tissue pressure injuries. In addition, similarities in underlying pathophysiologic mechanisms of these skin conditions can cause diagnostic overlap.

Skin failure occurs in critical care populations due to disease severity and shunting of blood to vital organs. Nearly every year, and sometimes multiple times per year, a new skin failure definition is published.²There is also quite a variability in the definition of skin failure across fields. In dermatology, skin failure is usually defined as extensive dermatologic conditions that compromise the homeostatic functions of the skin to the extent that it requires clinical intervention.²For the wound care community, who are typically the experts consulted to differentiate the etiology of skin lesions that are suspected to be pressure injuries in the critical care population, skin failure is more closely defined by hypoperfusion of the skin resulting in tissue death which can occur in the setting of failure of other organ systems.^2,3This definition is sometimes attributed to the rationale for developing some unavoidable hospital pressure injuries4 and can encompass some dermatologic lesions that are seen at the end of life.² 

The clinical course of deep tissue pressure injury can mimic COVID ischemic lesions, and the viral endothelial dysfunction present in patients with COVID-19 decreases tissue tolerance. This results in an increased risk of hospital-acquired pressure injury. The National Pressure Injury Advisory Panel (NPIAP) quickly released white papers regarding skin manifestations of COVID-19 and unavoidable pressure injuries in this population.^5,6The white papers reference the proclivity of COVID-19 ischemic lesions to mimic the appearance and even clinical course of deep tissue pressure injuries. They also discuss the increased risk of pressure injury development and the possibility that a pressure injury was unavoidable in patients with COVID-19. The increased risk of pressure injury formation in patients with COVID-19 extends beyond critical care and even the acute care treatment period.⁶

The Centers for Medicare and Medicaid Services (CMS) had defined unavoidable pressure injuries for long-term care facilities as pressure injuries that occurred in patients that had met several of the criteria. These criteria included receiving reasonable care with their clinical conditions individualized and risk factors evaluated. Interventions that adhered to patient needs, care goals, and standards of care also had to be defined and implemented. In addition to correct risk stratification, careplan development, and intervention implementation, outcomes also must be monitored and evaluated with modifications made as indicated.^6,7In acute care within the COVID-19 pandemic, verifying that these criteria have been met can be challenging. If a team can verify these criteria have been met, formal recognition of unavoidable pressure injuries in the acute care environment by benchmarking and quality organizations has not been implemented. In addition, the potential for deep tissue pressure injuries to evolve is not recognized by many quality and documentation departments due to a lack of clarity in ICD-10 coding guidelines regarding pressure ulcers that worsen during a hospital stay and deep tissue injuries that eventually evolve as expected to a staged lesion.

Extrinsic factors can also complicate diagnostic clarity of cutaneous lesions in patients with COVID-19, including disaster charting, staffing, hospital volumes, supply chain, and resource availability. Disaster charting is the terminology used to define reduced charting input requirements due to the extreme patient and staffing conditions present during disastrous situations, including the COVID-19 pandemic. Without thorough charting, root cause analysis of skin lesion clinical presentation and disease course can be difficult to perform adequately. A high proportion of understaffed units and undertrained and temporary staff during the COVID-19 pandemic also contributes to the risk of hospital-acquired pressure injury development and lack of diagnostic clarity through documentation root cause analysis review.

The NPIAP is correct in which the increased hospital volumes and pressure injury risk of patients during the COVID-19 pandemic have amplified the need for establishing the criteria for unavoidable pressure injuries in the acute care setting, which is long overdue. It is needed for accurate reflection of patient safety and nursing quality indicators.

References

1. Piazza G, Morrow DA. Diagnosis, management, and pathophysiology of arterial and venous thrombosis in COVID-19. JAMA. 2020;324(24):2548-2549. doi:10.1001/jama.2020.23422
2. Dalgleish L, Campbell J, Finlayson K, et al. Understanding skin failure: a scoping review. Adv Skin Wound Care. 2021;34(10):542-550. doi:10.1097/01.ASW.0000755844.87283.20
3. Langemo DK, Brown G. Skin fails too: acute, chronic, and end-stage skin failure. Adv Skin Wound Care. 2006;19(4):206-211. doi:10.1097/00129334-200605000-00014
4. Nowicki JL, Mullany D, Spooner A, et al. Are pressure injuries related to skin failure in critically ill patients?. Aust Crit Care. 2018;31(5):257-263. doi:10.1016/j.aucc.2017.07.004
5. Black J, Cuddigan J; National Pressure Injury Advisory Panel Board of Directors. Skin manifestations with COVID-19: the purple skin and toes that you are seeing may not be deep tissue pressure injury. National Pressure Injury Advisory Panel. 2020. Accessed January 31, 2021. https://cdn.ymaws.com/npiap.com/resource/resmgr/white_papers/COVID_Skin_Manifestations_An.pdf
6. Black J, Cuddigan J, Capasso V, et al; National Pressure Injury Advisory Panel. Unavoidable pressure injury during COVID-19 crisis: a position paper from the national pressure injury advisory panel. National Pressure Injury Advisory Panel. 2020. Accessed January 31, 2021. https://cdn.ymaws.com/npiap.com/resource/resmgr/white_papers/Unavoidable_in_COVID_Pandemi.pdf
7. Department of Health and Human Services. CMS Manual System. Centers for Medicare and Medicaid Services guidance to surveyors for long-term care facilities. Transmittal 4. DHHS Pub. 100-07. November 12, 2004. Accessed January 31, 2021. https://www.hhs.gov/guidance/document/guidance-surveyors-long-term-care-facilities