key: cord-0718078-atyo7c1x
authors: Kendall, Jamila A.; Haberl, Jack K.; Hartsgrove, Caitlin; Murphy, Lauren F.; DeLuca, Robert; Diaz-Segarra, Nicole; Kirshblum, Steven C.
title: Surveillance for Pressure Injuries upon admission to Inpatient Rehabilitation HOSPITALS during the COVID-19 Pandemic
date: 2021-07-10
journal: Arch Phys Med Rehabil
DOI: 10.1016/j.apmr.2021.06.011
sha: fcaec05e63e1a40639504cd624a3b647a783e1f9
doc_id: 718078
cord_uid: atyo7c1x

OBJECTIVE: : To determine if the incidence of pressure injuries (PIs) upon admission to an inpatient rehabilitation hospital (IRH) system of care was increased during the early COVID-19 pandemic period. DESIGN: : Retrospective survey chart review of consecutive cohorts. Admissions to four acute IRHs within one system of care over the first consecutive 6-week period of admitting COVID-19 positive patients during the initial peak of the COVID-19 pandemic, April 1 to May 9, 2020. A comparison was made with the pre-COVID-19 period of 2020, January 1 to February 19, 2020. SETTING: : Four acute IRHs with admissions on a referral basis from acute care hospitals. PARTICIPANTS: : A consecutive sample of pre-COVID-19 admissions (n = 768) and COVID-19 period admissions (n = 357); including persons who were COVID positive (n = 161) and COVID negative (n = 196). MAIN OUTCOME MEASURE(S): : Incidence of PIs on admission to IRH. RESULTS: : Prevalence of PIs on admission during the COVID-19 pandemic was increased when compared to the pre-COVID-19 period by 14.9% (p < 0.001). 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% to 35.7%). The severity of PIs, measured by the wound stage of the most severe PI the patient present with, worsened during the COVID-19 period in comparison to pre-COVID-19 (chi-squared 32.04%, p < 0.001). The length of stay in the acute care hospital prior to transfer to the IRH during COVID-19 was greater than in pre-COVID-19 by 10.9 % (p < 0.001). CONCLUSIONS: : During the early part of the COVID-19 pandemic timeframe, 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.

On March 11, 2020, Coronavirus Disease 2019 (COVID- 19) was labeled a global pandemic by the World Health Organization. 1 Since that date, the virus that causes the disease, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-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 passed away as of March 28, 2021. 2 This pandemic has drastically impacted all health care organizations and providers as they collectively treated the surge of new inpatient cases.

New York City and Northern New Jersey (NJ) were particularly impacted early by this pandemic. 3 Persons with COVID-19 who survive the initial hospitalization may suffer debilities secondary to COVID-19 and its associated complications that require acute rehabilitation at an inpatient rehabilitation hospital (IRH). [4] [5] [6] 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.

Pressure injuries are lesions caused by unrelieved pressure that results in damage to the underlying tissue. 7 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 8 -all of which are commonly seen in acute care hospitals.

Accounting for approximately $10 billion in annual healthcare spending in the US, 9 PIs remain a significant burden for patients and the healthcare system; an estimated 2.5 million PIs are treated in acute care facilities each year in the US. 10 In 2008, the Centers for Medicare and Medicaid Services notably discontinued reimbursement for the treatment of Healthcare-Acquired pressure injuries (HA-PI), 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. 11 PIs have been shown to have an impact 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. [12] [13] [14] There are many factors to suggest that PI incidence may have changed since the start of the COVID-19 pandemic. Critically ill COVID-19 patients have risk factors for PI such as immobility, reduced perfusion, and use of medical devices such as ventilators and face masks. 15 Medical device related PIs are commonly seen from the use of masks, cannulas, tubes, adhesive tapes, and devices themselves. 16 Patients on continuous positive airway pressure (CPAP) and bilevel positive airway pressure (BiPAP) 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. 17 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. 18 In addition, diarrhea is a common symptom in COVID-19 patients, potentially contributing to the incidence of sacral PIs. 19 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 when compared to 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 as compared to 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.

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

There are four 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 two cohorts of patients admitted to the IRH facilities. The pre-COVID-19 cohort includes all patients admitted from January 1 st to 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 (i.e., 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 utilized 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 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 performed chart reviews and abstractions from electronic medical records for all patients included in the sample.

Primary Outcome: HA-PI is a binary measure of assessing whether the patient was diagnosed with 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 (NPIAP) staging definitions. 20 The anatomic location and stage of the PI was documented in the electronic medical record by the admission nurse team for consistency. Four analytic categories are included: Stage 1, Stage 2, Stage 3, and Stage 4/DTI/ unstageable. DTIs were combined with Stage 4/unstageable wounds due to the unknown, but potentially severe, depth of the PI behind the intact skin. PI diagnoses were further subcategorized as Medical Device Related PIs (MDRPI) (wound location based upon 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). Mucosal pressure injuries were not included. Lastly, for overall PI severity, we used the highest stage PI the patient presented with at IRH admission. Table 2 age, race and gender). After accounting for demographic differences, an increase in CMI is associated with 89% higher odds of having a HA-PI. Male patients had 81% greater odds of having a HA-PI compared to female patients. Finally, the effect of COVID-19 status reveals that a positive diagnosis was not associated with presenting with a HA-PI. After incorporating COVID-19 status, a LOS of >30 days is significantly associated with more than double the odds of having a HA-PI. Table 4 summarizes all PIs during the COVID-19 period subcategorized by location COVID status, and severity.

This is the first study to report on incidence of PIs upon 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, higher average CMI, had longer LOS in acute care hospitals, 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 & Medicare Services (CMS) due to 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-positive and COVID-negative patients was not statistically significant. COVID-positive patients had significantly longer LOS in acute care hospitals, a lower CMI and higher rates of obesity. Regression analyses also confirmed that male gender was significantly associated with higher odds of PI. 26 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 upon admission to IRH during the COVID-19 pandemic. The US healthcare system, particularly in New York and New Jersey, was overwhelmed with the wave of COVID patients 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. 21, 22 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) 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. 23 While 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. 24, 25 This study found that male gender was a risk factor for development of a PI during the acute hospital stay. 26 This variable has limited evidence in the literature to support their classification as risk factors for PIs. [29] [30] [31] [32] [33] [34] 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, and in the case of malnutrition (low blood albumin levels), and PI severity. [35] [36] [37] There are many relevant future directions for research of PIs upon 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 U.S. More research is needed into prevention strategies to help overwhelmed healthcare 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, expanded use of telehealth consultations in these settings to expand access to PI care during the pandemic. [40] [41] [42] 

Persons used in this study reflected a population accepted at four IRHs within one 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 upon the highest Stage of an individual's presentation at IRH admission. This might dilute the true degree of severity of PIs at admission, since a person presenting with one Stage 4 PI would be would considered more severe than two Stage 3 PIs.

Lastly, the COVID-19 period sample size was smaller when compared to pre -COVID-19 time period. 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 due the lack of available data on covariates for pre-COVID-19 patients.

There was an increased prevalence and severity of PIs upon admission to an IRH at the beginning of the COVID-19 pandemic as compared with the pre-pandemic period. Key risk factors included a higher CMI and longer length of acute hospital stay prior to transfer to the IRH. No differences were found in the incidence of PIs between COVID-positive and COVIDnegative 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.

Despite 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 impact in 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.

Jamila A. Kendall has nothing to disclose. Jack K. Haberl has nothing to disclose. Caitlin

Hartsgrove has nothing to disclose. Robert DeLuca has nothing to disclose. Lauren F. Murphy has nothing to disclose. Nicole Diaz-Segarra has nothing to disclose. Steven Kirshblum has nothing to disclose. There were no funding, grants or equipment were used for this work. There are no financial gains from this work to any of its authors. This manuscript is an original piece and has never been presented or considered for publication in another journal. All images here in are original and are not subject to copyright laws. All authors have contributed to writing this manuscript.

Dr. Kendall has nothing to disclose. Dr. Diaz-Segarra has nothing to disclose. Dr. Kirshblum has nothing to disclose.

Dr. Murphy has nothing to disclose. 

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