PRONING-RELATED PRESSURE ULCERS IN COVID ICU PATIENTS: AN UNNOTICED EPIDEMIC IN THE MIDDLE OF THE PANDEMIC

Abstract

TOPIC: Education, Research, and Quality Improvement TYPE: Original Investigations PURPOSE: Intensive care units have been strained across the globe due to the impact of the coronavirus disease (COVID) pandemic responsible for over 147 million confirmed cases and 3 million deaths. (Source: Johns Hopkins COVID resource center) Nearly 26-32% of the hospitalized COVID patients require admission to the intensive care unit (ICU) and aggressive management of ventilation for Acute Respiratory Distress Syndrome (ARDS). Proning has emerged as a supportive therapy in mechanically ventilated patients with ARDS. (Source: CDC) Such patients may remain proned for 12-16hours which increases the risk of pressure-injury. Furthermore, We wanted to see how proning has impacted the incidence of pressure ulcers in COVID ICUs when compared to the Non-COVID ICUs at a tertiary care hospital. METHODS: This study was conducted in the ICUs at a tertiary care academic medical center. Permission was obtained from the 'System Quality & Patient Safety' and 'Quality Operations' departments for the use of data. The data for the rate of unit acquired Pressure injury (UAPI) was obtained from all ICUs across the hospital. UAPI rate in COVID ICU compared to non-COVID ICUs. To minimize any other variable, it was noted that the COVID ICU was equipped with a special proning team from day one of the inception of the COVID unit in our institution. RESULTS: We observed a steep increase in the rate of UAPI 2+/1000 patient days from 4 to 22 in our COVID ICU unit. While the rates of UAPI 2+ in the cardiovascular, cardiac, surgical ICU remained consistent throughout the year at 7.16, 2.50, and 7.16. The neuro-ICU had the lowest pressure ulcer rate of 1.00. The pressure ulcers in COVID ICU were noted to affect the forehead, cheeks, jaw-line, anterior shoulder, chest, abdomen, and anterior lower extremities. The only variable in COVID ICU was proning. The target UAPI rate for our institution was 5.10 /1000 patient days using the definition of 2016's National Pressure Ulcer Advisory Panel (NPUAP) and the European Pressure Ulcer Advisory Panel (EPUAP), and as per the National Database of Nursing Quality Indicators (NDNQI). There is a 450% increase in pressure ulcers due to proning in COVID ICU. Despite the presence of staff members trained to perform proning, the spike in pressure ulcers was noticed in the COVD-ICU. In addition, there was no shortage of personal protective equipment (PPE) during this time. CONCLUSIONS: Our results show that the incidence of pressure ulcers has increased several-fold (450%) throughout the year 2020 (pandemic) in the COVID unit. The rates of UAPI remained consistent and comparable to the years prior to 2020 in the non-COVID ICUs. This unintended life-threatening consequence of the pandemic went relatively unnoticed due to other major co-existent high morbidities. CLINICAL IMPLICATIONS: Pressure ulcers can prolong the course of illness in ICU patients thereby increasing patient morbidity and mortality. Furthermore, it can lead to a prolonged hospital stay and increased healthcare costs, As pressure ulcers are preventable more effective strategies are needed especially in the COVID ICU setups. There is a need to address this life-threatening complication during disaster preparedness with special beds or the application of pads at the body area prone to UAPI. DISCLOSURES: No relevant relationships by Sahar Fatima, source=Web Response No relevant relationships by FAISAL MASUD, source=Web Response No relevant relationships by Iqbal Ratnani, source=Web Response No relevant relationships by AYESHA SAFDAR, source=Web Response No relevant relationships by Salim Surani, source=Web Response