In many parts of the world, patients are being discharged with urgency to free up acute care beds. In the United States, The University of Washington Hospital, in one of the earliest-hit states in the COVID-19 battle, developed a discharge philosophy of “home-first” whenever possible, to reduce the risk of spreading the infection to other health care facilities or patients.1
Although data is sparse, estimates suggest that 30% of COVID-19 positive patients discharged from hospitals will require care in a post-acute facility; 20% will discharge home with the support of home healthcare. 2 Not only has the volume of referrals for home care services increased, but patient acuity has as well. Home care nurses are admitting patients that are deconditioned, nutritionally depleted and oxygen dependent. And, many will have skin breakdown.
Several unique events occur during hospitalization for COVID-19 that place patients at high risk for developing skin injury. These include:
COVID-19 patient may require oxygen delivery devices, which can pose a risk for the development of medical device related pressure injuries (MDRPIs).3 A recent study found that 30% to 70% of MDRPIs were caused specifically by respiratory-related medical devices, especially in critical care units.4
In cases of acute respiratory distress syndrome (ARDS), patients may be placed in the prone position while intubated to improve oxygenation. Attempting to position tubes like endotracheal tubes and urinary catheters while in the prone position is especially challenging and can contribute to MDRPIs.
Fever and Diaphoresis
One of the symptoms associated with COVID-19 infections is fever with diaphoresis (particularly night sweats). Moisture is a well-known risk factor for pressure injury (PI) development, and while commonly considered in relation to incontinence, diaphoresis is also a source of moisture. “Microclimate,” or the temperature and relative humidity at the surface of the skin, is an emerging concept in pressure injury development. Increased moisture decreases the resilience and barrier function of the skin and increases friction. Increased temperature can increase the rate of perspiration and the metabolic demand of the skin, further increasing risk for PI development.3
Research assessing the impact of isolation discovered that patients who are on contact precautions are more likely to experience an adverse event in the hospital, including falls and PIs.5
What does this mean for the home care nurse?
First things first:
Assess the skin. The classic “head to toe skin assessment” may have new meaning for COVID-19 patients.
In addition to the normal locations (sacrum, heels), assess anterior bony prominences for signs of pressure-related skin damage if proning was required during hospitalization. Look at the nose, clavicle/shoulders, elbows, chest, anterior hips, knees and toes for breakdown, non-blanchable erythema (Stage 1 PI) or areas of deep red, maroon or purplish discoloration (deep tissue injury). MDRPIs due to oxygen delivery devices can be found on the ears, cheeks, bridge of the nose, neck and nostrils. If intubation was necessary, lip and oral mucosa are vulnerable. Remember, mucous membrane pressure injuries are not staged due to the structural differences of mucosal tissue. An example of documentation would be: “Mucosal membrane pressure injury of (location) caused by (identify device, if known).3”
Assess skin folds, including the anterior groin and buttocks folds, for breakdown or inflammation. These are common locations for intertriginous dermatitis, one type of moisture-associated skin damage caused by heat, moisture and friction. If incontinence is (or was) a concern, assess perineum and perianal area for signs of incontinence-associated dermatitis (IAD).Document all findings per agency policy.
Create a plan. Keep it Simple.
If PIs are identified, determine a treatment plan. Consider the location, amount of drainage, depth (stage) and size. Select a dressing that will maintain placement in challenging locations (such as sacrum or heel), manage drainage volumes and maintain a moist wound base without macerating surrounding tissue. Choose dressings that can remain intact for several days to extend the interval between required wound care visits. As many recovering patients will have limited support due to quarantine, consider whether a simple dressing routine may be transitioned to a caregiver or even the patient themselves.
Assess ongoing PI risk and implement pressure reduction strategies. Determine the need for a support surface for the bed or chair. Due to respiratory concerns, patients may be spending more time in recliners or propped up in bed. This position can result in an increase of shear forces on the sacral area. Consider the use of a moisture barrier film or prophylactic dressing to protect the skin from shear.
If oxygen support is ongoing, make sure that the device is correctly sized, placed with the correct amount of tension and that skin is assessed at regular intervals. Consider a prophylactic dressing such as a silicone foam dressing beneath the device to help reduce risk of MDRPIs.6 Reassess the care plan regularly and adjust based on skin/wound assessment findings and patient condition.
Go Beyond Skin Deep.
Of course, COVID-19 patients will have many unique needs beyond their skin. These can include diabetic management, improving nutritional status, increasing strength, endurance and mobility and improving oxygen saturation. Addressing these other issues may have a positive effect on skin condition.
We have a lot to learn about the management of patients following an acute illness and hospitalization due to COVID-19. Home care nursing is leading the way in creating a strategy to meet the patient’s physical and emotional needs and restore health. Addressing skin health is a critical part of that strategy.
1 Buys C. 7 lessons on Discharge Planning During Covid-19 From UW Medicine. April 3, 2020. Advisory Board. https://www.advisory.com/daily-briefing/2020/04/03/uw-medicine
2 Walker M. Post-Acute Care: Brace for Influx of COVID-19 Patients — Facilities lack capacity, capability to deal with potential surge, experts argue. MedPage Today March 25, 2020 https://www.medpagetoday.com/infectiousdisease/covid19/85609
3 European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline. The International Guideline. Emily Haesler (Ed.). EPUAP/NPIAP/PPPIA; 2019.
4 Padula CA, Paradis H, Goodwin R, Lynch J, Hegerich-Bartula D. Prevention of medical device-related pressure injuries associated with respiratory equipment use in a critical care unit. A quality improvement project. J Wound Ostomy Continence Nurs.2017;44(2):138-141.
5 Labus D, Weinhold L, Heller J. The effect of isolation precautions on care processes and medical outcomes in patients colonized with MRSA. GMS Hyg Infect Control. 2019;14:Doc18.