Hospital Acquired Pressure Injuries (HAPIs) – long a major healthcare problem for hospitalized patients – have the potential to increase with the increasing amount of patients requiring ICU care due to COVID-19. Regardless of primary diagnosis, when immobility, pressure, friction, shear, poor nutrition, and poor profusion plague the hospitalized patient, HAPIs often occur. Each year, more than 2.5 million patients suffer from these injuries, costing the U.S. healthcare system anywhere from $9.1 – 11.6 billion annually.
A pressure injury can manifest itself in many ways, starting from red or purple skin discoloration to more extreme cases where tissue loss can occur. In fact, these injuries which are the second most common lawsuit claim “after wrongful death and greater than falls or emotional distress,” claim the lives of about 60,000 people each year2. Bed surface technology can play a critical role in reducing pressure injuries or their severity.
The onset of COVID-19 has exacerbated the conditions from which HAPIs develop, as many COVID-19 patients require ICU care. Because of severe respiratory problems requiring intubation and ventilators, as well as other equipment used in treatment, injuries can result from an ”intense and/ or prolonged pressure” against a surface or device. More than 30% of all hospital-acquired pressure injuries are the result of pressure placed on the skin from a medical device. In addition to the risk posed by medical devices, the need for patients to be placed in a prone position for long periods of time to help expand the lungs and increase oxygenation, could potentially lead to pressure injuries on parts of the body not usually seen like the face and other soft tissue locations.
Immobility, Length of Stay Exacerbates Risk of Skin Problems Among Covid-19 Patients
In addition to the problems associated with immobility and increased length of stay, COVID-19 causes its own skin problems. In fact, the National Pressure Injury Advisory Panel (NPIAP), says that “the virus itself creates a systemic coagulopathy including hypercoagulation and microvascular occlusion.” Resulting skin changes “appear purpuric and quickly become necrotic.6 The NPIAP goes on to note that these skin changes “mimic” DTPIs (Deep Tissue Pressure Injuries), especially when they occur over tissue exposed to pressure and/or shear forces (e.g., sacrum, buttocks, heels) or under medical devices.” Since DTPIs and COVID-19 skin changes appear to have similar characteristics, it is important that wound care experts involved in the care of these patients have assessment skills that can help differentiate between HAPI and COVID-19 Coagulopathy.
In 2008, the Center for Medicare and Medicaid Services (CMS) stopped reimbursement to hospitals for additional costs related to HAPIs7. If hospitals incorrectly code COVID-19 related skin changes as DTPIs, they will inadvertently penalize themselves. Besides issues of reimbursement, the ability to prevent and treat skin breakdown regardless of the source is critical to hospitalized patients.
The Role of A Well-Designed Support Surface
Part of the prevention and treatment picture for patients at risk for or already experiencing significant and debilitating skin issues includes the appropriate choice of support surfaces on which to place fragile patients. There is an abundance of options available with varying pressure redistribution and microclimate management mediums and making the right choice can seem like a complicated decision.
Amongst the panoply of support surface options, there exist some types that are designed for both treatment and prevention of a wide range of pressure injuries. These support surfaces have much to offer in terms of simplifying the support surface decision for clinicians at the bedside. Great examples of these are support surfaces that utilize technologies like gel and air to redistribute pressure- or constant low pressure (CLP) surfaces. CLP is a desirable option because it can be used for a wide variety of patients of varying acuities and medical situations. From a microclimate standpoint, many support surfaces have Low Air Loss (LAL) technology built right into the surface (such as Stryker’s Isolibrium) and others offer the ease of attaching a pump for use only when indicated on a per patient basis (such as IsoTour). In either situation, using a high quality CLP support surface with optional or built in microclimate management can help dramatically simplify the support surface decision chain within a healthcare facility, while ensuring an appropriate level of protection and treatment for a large portion of the patient population.
It is no secret that the treatment and prevention of pressure injuries encompass so much more than simply selecting the right support surface for a patient, but that understanding should not diminish the clinical impact that an appropriately placed support surface can have on patient outcomes. It is one piece of a complex puzzle, but the puzzle is nonetheless incomplete without all of its pieces.
The vaccines are here, but COVID-19 may still be with us for a long time to come. Critically ill coronavirus patients will face several life-threatening issues up to and including organ failure. Being the largest organ of the body, skin can fail as well. While the pandemic brings new challenges with respect to wound care, bed technology can provide tools that provide support in the prevention of pressure injuries.
