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Surveillance for Pressure Injuries on Admission to Inpatient Rehabilitation Hospitals During the COVID-19 Pandemic

      Abstract

      Objective

      To determine if the incidence of pressure injuries (PIs) on admission to an inpatient rehabilitation hospital (IRH) system of care was increased during the early coronavirus disease 2019 (COVID-19) pandemic period.

      Design

      Retrospective survey chart review of consecutive cohorts. Admissions to 4 acute IRHs within 1 system of care over the first consecutive 6-week period of admitting patients positive for COVID-19 during the initial peak of the COVID-19 pandemic, April 1-May 9, 2020. A comparison was made with the pre–COVID-19 period, January 1-February 19, 2020.

      Setting

      Four acute IRHs with admissions on a referral basis from acute care hospitals.

      Participants

      A consecutive sample (N=1125) of pre–COVID-19 admissions (n=768) and COVID-19 period admissions (n=357), including persons who were COVID-19–positive (n=161) and COVID-19–negative (n=196).

      Main Outcome Measures

      Incidence of PIs on admission to IRH.

      Results

      Prevalence of PIs on admission during the COVID-19 pandemic was increased when compared with the pre–COVID-19 period by 14.9% (P<.001). There was no difference in the prevalence of PIs in the COVID-19 period between patients who were COVID-19–positive and COVID-19–negative (35.4% vs 35.7%). The severity of PIs, measured by the wound stage of the most severe PI the patient presented with, worsened during the COVID-19 period compared with pre–COVID-19 (χ2 32.04%, P<.001). The length of stay in the acute care hospital before transfer to the IRH during COVID-19 was greater than pre–COVID-19 by 10.9% (P<.001).

      Conclusions

      During the early part of the COVID-19 pandemic time frame, there was an increase in the prevalence and severity of PIs noted on admission to our IRHs. This may represent the significant burden placed on the health care system by the pandemic, affecting all patients regardless of COVID-19 status. This information is important to help all facilities remain vigilant to prevent PIs as the pandemic continues and potential future pandemics that place strain on medical resources.

      Keywords

      List of abbreviations:

      CMI (case mix index), DTI (deep tissue injury), HA (health care–acquired), IRH (inpatient rehabilitation hospital), LOS (length of stay), PI (pressure injury), US (United States)
      On March 11, 2020, coronavirus disease 2019 (COVID-19) was labeled a global pandemic by the World Health Organization.

      World Health Organization. WHO Director-General's opening remarks at the media briefing on COVID-19 - 11 March 2020. Available at: https://www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19---;11-march-2020. Accessed May 16, 2020.

      Since that date, the virus that causes the disease, severe acute respiratory syndrome coronavirus 2, has infected millions of people around the world, with more than 3 million people worldwide and over 500,000 in the United States (US) who have died as of March 28, 2021.

      Johns Hopkins Coronavirus Resource Center. COVID-19 dashboard by the Center for Systems Science and Engineering (CSSE) at Johns Hopkins University. Available at: https://coronavirus.jhu.edu/map.html. Accessed March 28, 2021.

      This pandemic has drastically affected all health care organizations and providers as they collectively treated the surge of new inpatient cases. New York City and northern New Jersey were particularly affected early by this pandemic.

      Centers for Disease Control and Prevention. Coronavirus disease 2019 (COVID-19) in the U.S. Centers for Disease Control and Prevention. Available at: https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/cases-in-us.html. Accessed May 16, 2020.

      Persons with COVID-19 who survive the initial hospitalization may experience debilities secondary to COVID-19 and its associated complications that require acute rehabilitation at an inpatient rehabilitation hospital (IRH).
      • Phillips M
      • Turner-Stokes L
      • Wade D
      • Walton K.
      Rehabilitation in the wake of COVID-19 - a phoenix from the ashes.
      • Mao L
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      • et al.
      Neurologic manifestations of hospitalized patients with coronavirus disease 2019 in Wuhan, China.
      • Li J.
      Rehabilitation management of patients with COVID-19: lessons learned from the first experiences in China.
      To date, there have been no data regarding the prevalence of pressure injuries (PIs) in patients being admitted to an IRH since the start of the COVID-19 pandemic.
      PIs are lesions caused by unrelieved pressure that results in damage to the underlying tissue.
      Pressure ulcers get new terminology and staging definitions.
      These lesions typically result when soft tissue is compressed between a bony prominence and an external surface for a prolonged period. Injuries can range from nonblanchable erythema of intact skin to deep ulcers extending to the bone. Over 100 risk factors for the development of PIs have been identified, including immobility, malnutrition, reduced perfusion, sensory loss, and the use of various medical devices
      • Lyder CH.
      Pressure ulcer prevention and management.
      —all of which are commonly seen in acute care hospitals.
      Accounting for approximately $10 billion in annual health care spending in the US,

      Leaf Healthcare. White paper: the impact of pressure ulcers on patient care. Available at: http://www.leafhealthcare.com/pdfs/LH_WP_ClinicalOverview_1562AA_PDF_081114.pdf. Accessed May 16, 2020.

      PIs remain a significant burden for patients and the health care system; an estimated 2.5 million PIs are treated in acute care facilities each year in the US.
      • Reddy M
      • Gill SS
      • Rochon PA.
      Preventing pressure ulcers: a systematic review.
      In 2008, the Centers for Medicare and Medicaid Services notably discontinued reimbursement for the treatment of health care–acquired (HA) PIs, thus increasing the emphasis on identification and prevention of PIs across the country. PIs are now a required quality indicator for all IRHs as part of the IMPACT Act of 2014.
      • DiVita MA
      • Granger CV
      • Goldstein R
      • Niewczyk P
      • Freudenheim JL.
      Risk factors for development of new or worsened pressure ulcers among patients in inpatient rehabilitation facilities in the United States: data from the Uniform Data System for Medical Rehabilitation.
      PIs have been shown to have an effect on IRH outcomes, including longer length of IRH stay, lower motor function gains, lower odds of being discharged to the community and functional independence, higher rate of readmission, and higher overall hospitalization cost.
      • Wang H
      • Niewczyk P
      • Divita M
      • et al.
      Impact of pressure ulcers on outcomes in inpatient rehabilitation facilities.
      • DiVita MA
      • Granger CV
      • Goldstein R
      • Niewczyk PM
      • Freudenheim JL.
      Mandated quality of care metrics for Medicare patients: examining new or worsened pressure ulcers and rehabilitation outcomes in United States inpatient rehabilitation facilities.
      • Dreyfus J
      • Gayle J
      • Trueman P
      • Delhougne G
      • Siddiqui A.
      Assessment of risk factors associated with hospital-acquired pressure injuries and impact on health care utilization and cost outcomes in US hospitals.
      There are many factors to suggest that PI incidence may have changed since the start of the COVID-19 pandemic. Critically ill patients with COVID-19 have risk factors for PI such as immobility, reduced perfusion, and use of medical devices such as ventilators and face masks.
      • Tang J
      • Li B
      • Gong J
      • Li W
      • Yang J.
      Challenges in the management of critical ill COVID-19 patients with pressure ulcer.
      Medical device–related PIs are commonly seen from the use of masks, cannulas, tubes, adhesive tapes, and devices themselves.
      • Kayser SA
      • VanGilder CA
      • Ayello EA
      • Lachenbruch C.
      Prevalence and analysis of medical device-related pressure injuries: results from the International Pressure Ulcer Prevalence Survey.
      Patients on continuous positive airway pressure and bilevel positive airway pressure often require high head of bed elevation to facilitate breathing, thus shifting more body weight to the sacrum and potentially increasing their risk for pressure injuries.
      • Peterson M
      • Schwab W
      • McCutcheon K
      • van Oostrom JH
      • Gravenstein N
      • Caruso L.
      Effects of elevating the head of bed on interface pressure in volunteers.
      Patients on mechanical ventilation are notably difficult to turn, potentially impeding routine PI care and examination. When placed in a prone position for improved oxygenation and ventilation, patients are also at an increased risk for PI of the elbows, head, genitals, knees, and toes.
      • Girard R
      • Baboi L
      • Ayzac L
      • Richard JC
      • Guérin C
      Proseva trial group. The impact of patient positioning on pressure ulcers in patients with severe ARDS: results from a multicentre randomised controlled trial on prone positioning.
      In addition, diarrhea is a common symptom in patients with COVID-19, potentially contributing to the incidence of sacral PIs.
      • Keller BPJA
      • Wille J
      • van Ramshorst B
      • van der Werken C.
      Pressure ulcers in intensive care patients: a review of risks and prevention.
      The purpose of this study was to perform a systematic retrospective assessment to determine the prevalence of HA PIs on patients with and without COVID-19 during the COVID-19 pandemic at the time of IRH admission. We hypothesized that there would be an overall increase in prevalence of HA PIs compared with the pre-COVID-19 period. As a secondary objective, we hypothesized that there would be a higher prevalence of HA PIs in individuals who were COVID-19–positive compared with those who were negative on admission to IRH. This knowledge has important implications for acute care hospitals to emphasize skin assessments and for IRH to consider for appropriate treatment plans in patients admitted with PIs.

      Methods

      Research design

      A retrospective cohort chart review was performed at our multicenter IRH system in the Northeast.

      Sample

      There are 4 IRHs in our system of care, all of which began admitting patients with diagnosed COVID-19 in late March 2021. This investigation includes data from 2 cohorts of patients admitted to the IRH facilities. The pre-COVID-19 cohort includes all patients admitted from January 1-February 12, 2020 (n=687), designated as the pre-COVID period. The second cohort, the COVID-19 period, includes all admissions from the initial 6-week period of the following quarter (ie, April 1-May 9, 2020) (n=357). This time was selected to coincide with the onset of COVID-19–positive patient admissions to these IRHs. All patients in both cohorts were admitted on a referral basis from local acute care hospitals. If the patient required acute care rehospitalization during their rehabilitation course, only their first rehabilitation stay was used in the analysis. When creating the “PI stage” variable (severity) for each patient we categorized it by the wound stage of the patient's most severe PI. When analyzing PI by location, COVID-19 status, and all other biometrics, all PIs were taken into account. The study received Institutional Review Board approval prior to initiating data collection. Three trained medical professionals (J.K., C.H., and R.D.) performed chart reviews and abstractions from electronic medical records for all patients included in the sample.

      Measures

      Primary outcome

      HA PI is a binary measure of assessing whether the patient was diagnosed as having a PI at admission to the IRH from the acute care hospital.

      Additional pressure injury characteristics

      PI staging was performed in accordance with the National Pressure Injury Advisory Panel staging definitions.
      • Edsberg LE
      • Black JM
      • Goldberg M
      • McNichol L
      • Moore L
      • Sieggreen M.
      Revised National Pressure Ulcer Advisory Panel pressure injury staging system: revised pressure injury staging system.
      The anatomic location and stage of the PI was documented in the electronic medical record by the admission nurse team for consistency. Four analytical categories are included: stage 1, stage 2, stage 3, and stage 4/deep tissue injury (DTI)/unstageable. DTIs were combined with stage 4/unstageable wounds because of the unknown, but potentially severe, depth of the PI behind the intact skin. PI diagnoses were further subcategorized as medical device–related (wound location based on use of medical equipment that could appear on the genitals, trachea, ear, or back) or prone-related (location of forehead, chin, breast, shin, leg, or toes) PIs. Mucosal pressure injuries were not included. Lastly, for overall PI severity, we used the highest stage PI the patient presented with at IRH admission.

      Covariates

      Demographic characteristics include patient age at admission (in years), sex, and race. Medical risk factors for PIs included blood albumin (measured in g/dL at admission,), blood hemoglobin (measured in g/dL at admission), and designation of obesity based on body mass index (calculated as weight in kilograms divided by height in meters squared) ≥30. Case mix index (CMI) was used to compare patients in the pre–COVID-19 and COVID-19 periods by acuity level. Acute length of stay (LOS) was measured as the number of days in the acute care hospital before transfer to the IRH and includes 4 categories: 0-7, 8-14, 15-30, and >30 days. Primary diagnosis at the time admission to the IRH (brain injury–related, spinal cord–related, general debility, other) was documented. Discharge location from the IRH included home and/or discharge against medical advice, skilled nursing or subacute facility, acute care transfer, and deceased. Patients were considered COVID-19–positive if they had a positive test result during their acute care hospital stay or tested positive on admission to the IRH. The latter accounted for only 6 patients. COVID-19–negative patients had received a negative test result at both the acute care hospital and on admission to rehabilitation.

      Analysis

      Bivariate statistics were used to compare incidence of HA PIs and other key characteristics for pre–COVID-19 vs COVID-19 period patients and for COVID-19–positive vs negative patients in the COVID-19 period; t tests were used to compare groups on continuous variables. Chi-square tests were used to compare used groups on categorical variables. Logistic regression models were used to predict the odds of HA PI. A set of 3 nested models was estimated. Model 1 estimates differences in the odds of HA-PI by medical risk factors. Model 2 adjusts for the effect of demographic characteristics (age, sex, race). Finally, model 3 tests the effect of testing positive for COVID-19. All analyses were conducted using Stata/SE 16.1.a

      Results

      Pre–COVID-19 vs COVID-19 period patients

      Table 1 presents the demographic data of the sample by time period. A significantly greater percentage of patients during the COVID-19 period had an HA PI at admission to the IRH (35.6% vs 20.7%; P<.001), as well as more severe HA PIs. Of those patients with HA PIs at admission, a significantly greater percentage of COVID-19 period patients had stage 4/DTI/unstageable wounds as their most severe wounds (28.6% vs 10.6%; P<.001), whereas a smaller percentage had stage 1/dressing wounds as their most severe wounds (29.4% vs 62%; P<.001). Patients also differed significantly by time frame in mean age, LOS in acute care, and primary diagnosis at admission. COVID-19 period patients were younger, with a mean age of 65.8±16.6 years compared with 70+15.3 years in pre–COVID-19 (P<.001). Although no significant difference was noted in PI location, most of the PIs in both groups were found on the sacral area and heels. A significantly higher percentage of COVID-19 period patients had an LOS in acute care that exceeded 30 days (18.2% vs 0.4%; P<.001). Slightly more than one-third (34.7%) of COVID-19 period patients were admitted to an IRH with a debility diagnosis compared with only 4.7% of pre–COVID-19 patients.
      Table 1Sample characteristics by quarter
      CharacteristicsTotal (N=1044)Pre–COVID-19 (n=687)Post–COVID-19 (n=357)P Value
      t tests were used to compare patients by quarter on continuous variables; chi-square tests were used to compare patients by quarter on categorical variables.
      Pressure injury at IRF admission (%)25.820.735.6<.001
      Pressure injury stage (%)<.001
      Stage 131.74319.1
      Stage 226.122.530.2
      Stage 38.24.911.9
      Stage 4/DTI/unstageable3429.638.9
      Age at admission (range, 17-101y), mean ± SD68.5±15.970±15.365.8±16.6<.001
      LOS at acute center (%)<.001
      0-7 d5568.928.3
      8-14 d24.623.626.6
      14-30 d13.97.126.9
      >30 d6.50.418.2
      Diagnosis at IRF admission (%)<.001
      Brain injury–related41.841.940.9
      Spinal cord injury–related5.85.17.3
      Debility14.94.734.7
      Other37.648.317.1
      Discharge location (%)
      Home/AMA71.771.871.6.98
      SNF/subacute17.517.517.4
      Acute10.810.711
      Case mix index (range, 0.18-4.12), mean ± SD1.6±0.51.6±0.51.7±0.5<.001
      Total (%)10065.834.2
      Abbreviations: AMA, against medical advice; IRF, inpatient rehabilitation facility; SNF, skilled nursing facility.
      low asterisk t tests were used to compare patients by quarter on continuous variables; chi-square tests were used to compare patients by quarter on categorical variables.

      COVID-19 period patients by COVID-19 status

      Table 2 presents the descriptive statistics (ie, means, percentages) by COVID-19 status for all COVID-19 period patients. There were no statistically significant differences in rates of HA PIs, PI staging, medical device–related PIs, or PIs attributed to proning by COVID-19 status. During this time, COVID-19–positive patients had significantly longer stays in acute care than COVID-19–negative patients. Approximately half (49.4%) of all COVID-19–positive patients had an acute hospital stay between 14-30 days compared with 15.8% of COVID-19–negative patients. Most of the COVID-19–negative patients (37.2%) had an acute care stay of 7 or fewer days compared with 17.4% of COVID-19–positive patients. A significantly greater percentage of COVID-19–positive patients were admitted to IRH with a debility diagnosis compared with COVID-19–negative patients (60.3% vs 13.3%). Albumin status was not clinically significant between the groups. A significantly greater proportion of COVID-19–positive patients met the criteria for obesity (38.5% vs 27%). COVID-19–positive patients had a significantly lower mean CMI than COVID-19–negative patients (1.6 vs 1.8).
      Table 2Sample Characteristics by COVID-19 status for quarter 2 patients
      CharacteristicsTotal (n=357)COVID– (n=196)COVID+ (n=161)P Value
      t tests were used to compare patients by quarter on continuous variables; chi-square tests were used to compare patients by quarter on categorical variables.
      Pressure injury at IRF admission (%)35.635.735.4.95
      Pressure injury stage (%).33
      Stage 119.120.317.5
      Stage 230.230.429.8
      Stage 311.915.97.0
      Stage 4/DTI/unstageable38.933.345.6
      Medical device related PI (%)3.42.64.4.35
      Prone positioning related PI (%)2.84.11.2.11
      Medical device– OR prone-related PI (%)5.96.15.6.83
      Age at admission (range, 17-101y), mean ± SD65.8±16.666±17.265.6±15.9.86
      Male (%)56.956.157.8.76
      Race (%)>.99
      White69.272.565.2
      Black19.918.921.2
      Other10.98.713.7
      LOS at acute center (%)<.001
      0-7 d28.337.217.4
      8-14 d26.631.121.1
      14-30 d26.915.840.4
      >30 d18.215.821.1
      Diagnosis at IRF admission (%)<.001
      Brain injury–related40.951.528
      Spinal cord injury–related7.310.73.1
      Debility34.713.860.3
      Other17.1248.7
      Discharge location (%).56
      Home/AMA71.671.471.9
      SNF/subacute17.418.915.6
      Acute119.712.5
      Case mix index (range, 0.2-3.7), mean ± SD1.7±0.51.8±0.51.6±0.4<.001
      Blood albumin (range, 1.9-4.7g/dL), mean ± SD3.3±0.53.3±0.53.2±0.5.02
      Blood hemoglobin (range, 6.6-18.4g/dL), mean ± SD11.2±2.211.3±2.211.1±2.2.47
      BMI≥30 (%)32.22738.5.02
      Total (%)10054.945.1
      Abbreviations: AMA, against medical advice; BMI, body mass index (calculated as weight in kilograms divided by height in meters squared; SNF, skilled nursing facility.
      low asterisk t tests were used to compare patients by quarter on continuous variables; chi-square tests were used to compare patients by quarter on categorical variables.

      Predictors of HA PIs at admission to IRH

      Table 3 summarizes the results of the logistic regression predicting HA PIs at admission for COVID-19 period patients. Obese patients had 47% lower odds of having an HA PI than nonobese patients. Regression model 2 adjusts for the effect of demographic characteristics (eg, age, race, sex). After accounting for demographic differences, an increase in CMI is associated with 89% higher odds of having an HA PI. Male patients had 81% greater odds of having an HA PI than female patients. Finally, the effect of COVID-19 status reveals that a positive diagnosis was not associated with presenting with an HA PI. After incorporating COVID-19 status, an LOS of >30 days is significantly associated with more than double the odds of having an HA PI. Table 4 summarizes all PIs during the COVID-19 period subcategorized by location, COVID-19 status, and severity.
      Table 3Logistic regression of pressure injury at admission with medical risk factors, demographic characteristics, and COVID-19 status for post–COVID-19 patients (n=357)
      VariablesOdds RatioP Value95% CI
      Blood albumin (g/dL)0.50.040.26-0.98
      Hemoglobin (g/dL)0.93.270.81-1.06
      Acute length of stay (ref: 0-7 d)
       8-14 d1.08.830.55-2.13
       14-30 d1.93.080.93-4.01
       >30 d2.24.050.98-5.09
      Primary diagnosis at admission (ref: Brain injury–related)
       Spinal cord–related1.66.300.64-4.28
       Debility1.43.330.70-2.90
       Other1.75.140.83-3.73
      Case mix index1.88.041.03-3.41
      Obese (vs nonobese)0.58.040.34-0.98
      Male (vs female)1.80.021.08-2.99
      Race (ref: White)
       Black1.07.840.57-1.99
       Other0.49.110.21-1.18
      Age at admission (y)1.02.060.99-1.04
      COVID-19–positive (vs negative)0.83.530.47-1.48
      Log likelihood−202.00
      LR χ2df, P value48.0815, <.001
      Pseudo R2.11
      Abbreviations: CI, confidence interval; LR, likelihood ratio; ref, reference.
      Table 4PI location by COVID-19 status and severity (n=127)
      COVID-19–PositiveCOVID-19–Negative
      PI LocationTotal1 or DTI n (%)2 n (%)3 n (%)4 n (%)Total1 or DTI n (%)2 n (%)3 n (%)4 n (%)
      Occiput/post parietal50 (0)0 (0)0 (0)5 (100)30 (0)1 (33.3)0 (0)2 (66.7)
      Ear70 (0)1 (14.3)0 (0)6 (85.7)33 (100)0 (0)0 (0)0 (0)
      Chin10 (0)1 (100)0 (0)0 (0)00 (0)0 (0)0 (0)0 (0)
      Trach site00 (0)0 (0)0 (0)0 (0)10 (0)0 (0)0 (0)1 (100)
      Shoulder10 (0)0 (0)0 (0)1 (100)20 (0)0 (0)1 (50)1 (50)
      upper ext/elbow00 (0)0 (0)0 (0)0 (0)135 (38.5)4 (30.8)3 (23.1)1 (7.7)
      Breast00 (0)0 (0)0 (0)0 (0)10 (0)1 (100)0 (0)0 (0)
      Spine/back31 (33.3)0 (0)1 (33.3)1 (33.3)21 (50)0 (0)1 (50)0 (0)
      Labia/vulva10 (0)0 (0)0 (0)1 (100)10 (0)1 (100)0 (0)0 (0)
      Penis00 (0)0 (0)0 (0)0 (0)10 (0)1 (100)0 (0)0 (0)
      Groin00 (0)0 (0)0 (0)0 (0)74 (57.1)1 (14.3)2 (28.6)0 (0)
      Sacral3015 (50)7 (23.3)1 (3.3)7 (23.3)3111 (35.5)9 (29)2 (6.5)9 (29)
      Coccyx51 (20)2 (40)0 (0)2 (40)52 (40)2 (40)0 (0)1 (20)
      Perineum11 (100)0 (0)0 (0)0 (0)10 (0)1 (100)0 (0)0 (0)
      Gluteal112 (18.2)5 (45.5)2 (18.2)2 (18.2)197 (36.8)9 (47.4)0 (0)3 (15.8)
      Ischium43 (75)1 (25)0 (0)0 (0)41 (25)1 (25)0 (0)2 (50)
      IGF31 (33.3)2 (66.7)0 (0)0 (0)30 (0)1 (33.3)0 (0)2 (66.7)
      Shin/leg10 (0)0 (0)1 (100)0 (0)100 (0)4 (40)2 (20)4 (40)
      Heels2017 (85)2 (10)0 (0)1 (5)3325 (75.8)4 (12.1)1 (3)3 (9.1)
      Ankle/foot41 (25)2 (50)0 (0)1 (25)1410 (71.4)1 (7.1)0 (0)3 (21.4)
      Toes00 (0)0 (0)0 (0)0 (0)32 (66.7)0 (0)0 (0)1 (33.3)
      Totals97422352715771411233
      Abbreviations: ext, upper extremity; IGF, intergluteal fold; Trach, tracheotomy.

      Discussion

      This is the first study to report on incidence of PIs on admission to an IRH during the COVID-19 pandemic. When comparing pre-COVID-19 vs COVID-19 period patients, COVID-19 period patients were significantly younger, had higher average CMI, had longer LOS in acute care hospitals, were more likely to have a debility diagnosis, and had an increased incidence rate of PIs and more severe PIs present at IRH admission. An important reason for an increase in the debility diagnosis may be from waivers granted by Center for Medicaid and Medicare Services because of the Public Health Emergency, allowing IRHs to accept patients that would otherwise not fit the criteria for admission. When focusing on the COVID-19 period, the difference in incidence rates of PI and PI severity among COVID-19–positive and COVID-19–negative patients was not statistically significant. COVID-19–positive patients had significantly longer LOS in acute care hospitals, lower CMI, and higher rates of obesity. Regression analyses also confirmed that male sex was significantly associated with higher odds of PI.
      • Seibert J
      • Barch D
      • Bernacet A
      • et al.
      Examining social risk factors in a pressure ulcer quality measure for three post-acute care settings.
      Obesity seemed to offer some protection for PIs, which is consistent with previous reports.
      There are a number of potential reasons for the increase in HA PIs on admission to an IRH during the COVID-19 pandemic. The US health care system, particularly in New York and New Jersey, was overwhelmed with the wave of patients with COVID-19 during the early period of the pandemic. Providers were often relocated and tasked with monitoring patients outside of their scope of practice and preventing decompensation with respiratory distress. Frequent skin checks for PIs likely became difficult under these circumstances. Patients’ family members who often play a role in monitoring for PIs were restricted from visitation.
      • Bergstrom N
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      ,
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      • Ousey K.
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      In addition, increased LOS in the acute care hospitals during the pandemic also may have played a role in the increased PIs. A previous study found that the occurrence of pneumonia (pre-2020 and pre–COVID-19) was significantly associated with longer acute care time and increased occurrence of PIs in persons who sustained a traumatic spinal cord injury, further highlighting the increased need for PI prevention strategies in patients with pneumonia.
      • Martel T
      • Orgill DP.
      Medical device-related pressure injuries during the COVID-19 pandemic.
      Although these extrinsic factors may have contributed to the increased incidence of PIs, there are also many intrinsic factors to COVID-19 that may cause an increased risk of PIs, such as hypoxemia, microvascular injury, and thrombosis.
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      Facial pressure ulcers in COVID-19 patients undergoing prone positioning: how to prevent an underestimated epidemic?.
      This study found that male sex was a risk factor for development of a PI during the acute hospital stay.
      • Seibert J
      • Barch D
      • Bernacet A
      • et al.
      Examining social risk factors in a pressure ulcer quality measure for three post-acute care settings.
      This variable has limited evidence in the literature to support their classification as risk factors for PIs.
      • DiVita MA
      • Granger CV
      • Goldstein R
      • Niewczyk P
      • Freudenheim JL.
      Risk factors for development of new or worsened pressure ulcers among patients in inpatient rehabilitation facilities in the United States: data from the Uniform Data System for Medical Rehabilitation.
      ,
      • Dreyfus J
      • Gayle J
      • Trueman P
      • Delhougne G
      • Siddiqui A.
      Assessment of risk factors associated with hospital-acquired pressure injuries and impact on health care utilization and cost outcomes in US hospitals.
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      • Ishida S
      • Abe Y
      • Nakanishi H.
      Relation between the serum albumin level and nutrition supply in patients with pressure ulcers: retrospective study in an acute care setting.
      • Serra R
      • Caroleo S
      • Buffone G
      • et al.
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      • Liu Y
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      • et al.
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      However, these factors have been shown to play a role in the severity of COVID-19 morbidity, which may play a role in the development of PIs, in the case of malnutrition (low blood albumin levels), and in PI severity.
      • Peckham H
      • de Gruijter NM
      • Raine C
      • et al.
      Male sex identified by global COVID-19 meta-analysis as a risk factor for death and ITU admission.
      • Tartof SY
      • Qian L
      • Hong V
      • et al.
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      • Huang J
      • Cheng A
      • Kumar R
      • et al.
      Hypoalbuminemia predicts the outcome of COVID-19 independent of age and co-morbidity.
      There are many relevant future directions for research of PIs on admission to IRHs during the COVID-19 pandemic. PI incidence should be further evaluated in a prospective study during the upcoming months of 2021 as COVID-19 cases continue across the US. More research is needed in prevention strategies to help overwhelmed health care systems combat the rise of PI incidence during the pandemic. Further investigation is necessary to determine how physiatrists can help with interdisciplinary rehabilitation early on in the care for these patients at the acute stages, including monitoring and caring for PIs in the acute care and intensive care unit settings, increased patient and family education on PIs, and expanded use of telehealth consultations in these settings to expand access to PI care during the pandemic.
      • Turcu RP
      • Polich GR
      • Steere HK
      • Schneider JC
      • Borg-Stein J
      • Silver JK.
      Letter to the editor on “rehabilitation following critical illness in people with COVID-19 infection.
      • Sheehy LM.
      Considerations for postacute rehabilitation for survivors of COVID-19.
      • Barker-Davies RM
      • O'Sullivan O
      • Senaratne KPP
      • et al.
      The Stanford Hall consensus statement for post-COVID-19 rehabilitation.

      Study limitations

      Persons used in this study reflected a population accepted at 4 IRHs within 1 system of care and may not be fully representative of all IRHs. Although our focus was during the early part of the pandemic and may not reflect occurrences after hospitals became accustomed to care of persons with COVID-19, this represents a valuable opportunity to learn from this experience. We defined overall severity of PI based on the highest stage of an individual's presentation at IRH admission. This might dilute the true degree of severity of PIs at admission because a person presenting with 1 stage 4 PI would be would considered more severe than 2 stage 3 PIs. Lastly, the COVID-19 period sample size was smaller than the pre–COVID-19 time period group. At the beginning of the pandemic, our center admitted at 50% of full capacity to assure private rooms for all patients. The center's reduced capacity is a potentially confounding variable in the logistic regression model predicting odds of PIs in the COVID-19 sample that could not be accounted for because of the lack of available data on covariates for pre–COVID-19 patients.

      Conclusions

      There was an increased prevalence and severity of PIs on admission to an IRH at the beginning of the COVID-19 pandemic compared with the prepandemic period. Key risk factors included a higher CMI and longer length of acute hospital stay before transfer to the IRH. No differences were found in the incidence of PIs between COVID-19–positive and COVID-19–negative patients, potentially highlighting a downstream effect of the pandemic on PI management for all patients treated in acute care hospitals before being transferred to an IRH. Although having a positive diagnosis of COVID-19 did not increase the PI risk, hospitalization during this time period did possibly because of an overwhelmed acute care system and widespread ventilator use. This information is extremely important and instructive in future mass health events, particularly those that have an effect on pulmonary health. Key PI prevention strategies should be implemented where possible to prevent injuries in critically ill patients. On a larger scale the results of our study show the intimate relationship between acute care resources and PIs. The study also brought to our attention the relationship between PIs and widespread pulmonary problems requiring ventilator assistance.

      Supplier

      • a.
        Stata/SE 16.1; StataCorp.

      Acknowledgments

      We thank Daniel Pierce, MD, for presenting this fascinating topic to be researched during the COVID-19 pandemic. We thank Gabrielle Delauter, MPH, for helping us gather missing information and Quarter 1 data for this study. We thank Amanda Botticello, PhD, for overseeing the statistical analysis.

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