Unavoidable Pressure Injury During COVID-19 Pandemic

Mary Madison, RN, RAC-CT, CDP 
Clinical Consultant – Briggs Healthcare

Unavoidable Pressure Injury During COVID-19 Pandemic: A Position Paper from the National Pressure Injury Advisory Panel was posted this week by NPIAP (National Pressure Injury Advisory Panel; previously known as NPUAP – U for ulcer).

The purposes of this National Pressure Injury Advisory Panel (NPIAP) Position Paper (8 pages) are to:

1. Summarize the current NPIAP position regarding unavoidable pressure injuries.

2. Examine the effects of the COVID-19 crisis on the scope of what is considered an unavoidable pressure injury.

3. State the position of the NPIAP regarding determinations of unavoidable pressure injuries during the COVID-19 crisis.

4. Renew the NPIAP call to collaborate on the development of criteria for the determination of unavoidable pressure injuries in acute care. 

The NPIAP remains fully committed to its mission to improve patient outcomes in pressure injury prevention and management through education, public policy, and research. Every reasonable effort should be taken to prevent pressure injuries. The mere diagnosis of COVID-19 does not make a pressure injury inevitable or unavoidable. However, some pressure injuries are unavoidable. Intrinsic factors with the COVID-19 virus pathophysiology and extrinsic factors during the COVID-19 pandemic associated with its propensity to overwhelm health care systems should be taken into consideration when determining whether a pressure injury was unavoidable. It is imperative that we prepare for future pandemics with adequate supplies of functioning equipment, supply chain management to ensure timely and appropriate distribution of supplies and pressure injury prevention protocols designed to be effective in crisis situations. Criteria for unavoidable pressure injury determinations require clarification for all patients with pressure injuries, whether or not they are affected by the COVID-19 crisis.

The NPIAP takes the following positions on the development of pressure injury during COVID-19 crisis situations:

1. Before any decision is made about the avoidability or unavoidability of a pressure injury that developed during the COVID-19 crisis, all factors should be considered on a case-by-case basis, including both the intrinsic issues in the critically ill patient and the extrinsic issues in the health care facility at the time of the injury.

2. Before labeling purpuric skin manifestations in COVID-19 patients, consider that the skin manifestations of COVID-19 may mimic the appearance of pressure injuries and should be considered in the differential diagnosis.

3. Areas of skin discoloration or tissue injury on non-loaded anatomic locations (i.e., no history of pressure and/or shear stress, no use of a medical device) are most likely not pressure injuries.

4. When pressure injuries occur on anatomical locations likely subjected to pressure and/or shear stress in patients with COVID-19, the pressure injury may be unavoidable IF:

  • Microvascular occlusions from COVID-19 increased the magnitude and severity of nonmodifiable risk to a level that preventive interventions were not able to be overcome despite reasonable efforts at prevention;
  • Multiorgan dysfunction issues from critical illness ultimately affected the skin’s normal abilities to protect the body and remain resilient to injuries and trauma including pressure injuries; and,
  • All reasonable efforts to provide evidence-based preventive care were attempted within the context of a health care system determined to be at crisis capacity.

Please review and share this position paper with your team and colleagues.  There’s great information within the paper that you can utilize to further improve your skin care/pressure injury prevention protocols.