The Effect of COVID-19 on the Pressure Injury Reporting Gap

Public health officials in the United States recognized early in the domestic course of the COVID-19 pandemic that a lack of resources, namely the existing supply of ventilators and hospital personnel, would be the primary insufficiency in addressing the country’s needs if cases continued to accelerate, thereby resulting in the need to ration care.^1–7 Although centralized health care rationing has not been required as of the time of this writing, the overwhelming effects of the pandemic on the health care system, frontline providers, and traditional aspects of care are measurable.

The expectations and responsibilities placed on health care workers were significantly increased during the COVID-19 crisis and hindered their ability to screen for certain aspects of care that are traditionally monitored.^8,9 Heart failure, myocardial infarction, and stroke are among the conditions identified thus far with a drastic reduction in incidence during the pandemic.^8,10 A primary obligation of nursing staff is to regularly assess for and prevent the development of HAPIs in severely ill and immobilized patients owing to the far-reaching adverse effects of HAPIs on patient morbidity and resulting disproportionate cost to the health care system.¹¹ Anecdotal evidence from hospital staff suggests that care and monitoring of HAPIs, among many other aspects of care, were necessarily deferred secondary to these unprecedented circumstances in favor of more critical patient needs during the pandemic. As a result, the authors of this retrospective review hypothesized that a decrease in HAPI reporting would be observed despite maximum hospital capacity across much of the United States.

A retrospective review of the electronic medical records of patients admitted to the YNHH System from December 2017 through February 2021 was performed to identify and analyze those with HAPIs, defined as a PI of any area not documented upon admission but subsequently present during the patient’s hospital stay. As at many other institutions, patient acuity and admission rates at YNHH System facilities during the pandemic were elevated to an unprecedented level.^12,13 The Yale University Joint Data Analytics Team helped identify patients from the electronic medical record based on formal HAPI coding. An independent HAPI-specific database maintained by nursing staff was reviewed as well to confirm congruence of documentation. The data were divided into 2 time periods: prepandemic (December 2017 through February 2020) and mid-pandemic (March 2020 through February 2021). To strengthen the power of the study and generate an accurate baseline for average PI frequency at the authors’ institution, the prepandemic period consists of 2 years of data rather than a single year, which could be a relative outlier. Monthly HAPI counts in the prepandemic period were averaged and compared by calendar month with HAPI counts in the mid-pandemic period using the paired t test.

A total of 1660 patients were identified as having experienced a documented HAPI during the selected time period. Direct monthly comparison between calendar years revealed a significantly lower number of reported incidents during the mid-pandemic period than during the prepandemic baseline (P <.0001) (Figure).

Pressure injury documentation is unique owing to mandated state reporting laws and required rigorous documentation by hospitals, both of which remained in place during the pandemic.^14–19 Thus, the data reported herein directly reflect the understandable difficulty nurses and other health care workers experienced in delivering the traditional aspects of care expected of them.

Although the effect of the COVID-19 pandemic on HAPI reporting has been widely discussed, to the authors’ knowledge this analysis is the first to highlight it. Several limitations were noted during data collection that necessitate further investigation, including PI characteristics (eg, stage) that were incompletely described at the time of data collection.

Although nationwide data collection is incomplete, YNHH is the most extensive health care system in New England, and the results reported herein may be indicative of how Tier 1 hospitals across the country have performed during this time. These performance metrics could influence surgical decision-making for PIs, because postoperative monitoring and care may be affected by any future exacerbations of the pandemic. To optimize patient outcomes and uphold institutional expectations, interdisciplinary clinician-led teams must continue to monitor for HAPIs and congruous conditions to minimize reporting gaps and progression in PI severity despite COVID-19 pandemic-related conditions and additional related responsibilities.