INTRODUCTION

In March 2020, COVID-19 was declared a pandemic by the World Health Organization and Massachusetts experienced a rapid surge of COVID-19 patients as 2020 progressed. The Beth Israel Deaconess Medical Center (BIDMC), a 719-bed Academic Medical Center in Boston, employs a 6-person WOC nursing team that observed distinct cutaneous lesions in our COVID-19 patients. Initially, these impairments resembled deep-tissue pressure injuries (DTPIs); however, upon further evaluation, we observed that these lesions had different characteristics and progressed differently than DTPIs. Specifically, we observed deep purple, nonblanching lesions with superficial epidermal sloughing and irregular edges. The epidermal sloughing revealed a pale pink wound bed that led us to hypothesize these wounds reflected "top-down" versus "bottom-up" skin damage.1

Our experience with these cutaneous lesions led us to reach out to our local network of WOC nurses, who indicated they were observing similar lesions among their COVID-19 patients. The lesions occurred over the gluteal muscles, in the intergluteal cleft, and on the trunk, face, and extremities. These observations led our WOC nursing team to debate how we should classify these lesions. Members of our team contacted the WOCN Society and the National Pressure Injury Advisory Panel (NPIAP), who reported receiving other inquiries from WOC nurses looking for guidance in classifying and managing these novel cutaneous lesions.

We also conducted a review of the literature but found a dearth of research related to cutaneous manifestations of this novel coronavirus. In May, approximately 2 months into the COVID-19 surge in Massachusetts, the NPIAP released a White Paper confirming the findings of the BIDMC WOC team and other WOC nurses' assessments. These injuries were not classified as DTPIs; rather, they were hypothesized to have a vascular etiology based on histological tissue analysis and were classified as COVID-19 skin manifestations.2

Deep-tissue pressure injuries may present as intact or broken skin that does not blanch and has a deep red, maroon, or purple discoloration.3 Alternatively, DTPIs may present as broken skin with a dark wound bed or blood-filled blister.3 We observed key differences between DTPIs and COVID-19 skin manifestations. Specifically, COVID-19 skin manifestations presented as a generalized macular or maculopapular rash, papulovesicular rash, urticaria, painful acral red purple papules, livedo reticularis, petechiae, and necrosis, with the majority of the lesions being found on the trunk, followed by the hands and feet.2 Over time, these lesions tend to undergo superficial necrosis. In addition, COVID-19 skin manifestations occur on areas of soft tissue with off-loaded pressure excluding the likelihood of damage due to pressure-shear forces.

Caring for COVID-19 patients required practice changes throughout the medical center. Limiting staff exposure to prevent the spread of the virus required a "bundled care" model. The WOC nursing team coordinated care with the nursing staff to work within the time constraints of the "bundled care" model. Patient repositioning was performed every 4 hours or sooner if necessary at the discretion of the bedside nurse. If there was evidence of skin breakdown, or a patient was at a particularly high risk (Braden Scale score <18), more frequent turning was considered.

Prolonged placement of patients with COVID-19 in a prone position is often necessary to improve their respiratory status. In conjunction with multiple disciplines, we developed a COVID-19-specific Proning Policy. This policy reflected that most patients should be placed in a prone position for a target 16 to 20 hours at a time and they may be placed in a prone position as long as 24 hours on a case-by-case basis.

This policy also emphasizes positioning of medical devices, off-loading pillows, and foam dressings, along with use of barrier wipes for patients with COVID-19. A pictorial guide, titled "Pad before you prone," was developed. It is included in our online medical center resource page and posted on the exterior door of patients in the intensive care unit (ICU). Variable times for prone positioning occurred from a few hours to more than 24 hours, depending on the patient's acuity, hemodynamic stability, and tolerance. We observed that patients with SARS-CoV-2 often required placement in a prone position immediately upon arrival to the emergency department (ED) with or without intubation due to hypoxic respiratory failure. Prolonged prone positioning was implemented by selected operating room (OR) nursing staff, along with select redeployed nursing staff trained by our Respiratory Department. This interdisciplinary team also included Physical and Occupational Therapy staff. Prone positioning of patients within the ICU and the ED required staff education on pressure injury prevention and management tailored to the patient placed in a prone position for prolonged periods of time. A collaborative approach with the ICU and OR staff was established to facilitate efficiency, safety, and prevention of pressure injuries. A mobile cart was created for the Proning Team and the ICU staff that included a checklist and readily available supplies needed for prone positioning and ICU-level care.

The WOC nursing team also alerted the staff that the use of low air loss mattresses are contraindicated in patients maintained in a prone position. In addition, we taught staff that when prolonged prone positioning was no longer indicated, patients at risk for pressure injury development should be placed on a low air loss mattress to continue pressure injury prevention. We also revised the process for obtaining specialty beds/support because outside vendors were not permitted into the medical center during the surge. The medical center worked with vendors to keep our specialty mattresses within the in-house distribution center for staff access. The Proning Team also assisted with head repositioning to prevent and decrease the incidence of facial skin injuries. Specifically, we educated staff to protect the patient's skin using a skin protectant on areas at risk for moisture-associated skin damage due to increased oral secretions and recommended absorbent dressings for moisture management. We collaborated with our central distribution service to ensure enough supplies of dressings were available within the medical center to meet the demands of the COVID-19 patients during the surge.

During the surge of patients with COVID-19, we also found it necessary to modify follow-up wound evaluations due to high census, bundled care, personal protective equipment (PPE) limitations, and the need to limit staff contact. As a result, photographic documentation became critical for sharing the most current information among the WOC nursing team and other members of the healthcare team. Similar to the procedures described by Engels and colleagues,4 photographs were taken and uploaded to the electronic medical record, enabling WOC nurses and other healthcare team members to monitor and adjust treatments while minimizing staff exposure to patients with COVID-19. In contrast to Engels and colleagues,4 we did not use telehealth to assess our patients. We collaborated with nursing in real time at the bedside during bundled care sessions; we used these interactions to obtain photographs on a weekly basis. Our facility also instituted government-mandated disaster documentation to reflect critical patient assessments. Our nursing team documented the COVID-19 cutaneous lesions as full- or partial-thickness versus pressure injury staging in accordance with the NPIAP White Position Paper statement.2

We believe due to coagulopathies caused by the COVID-19 virus, these wounds should be managed using a conservative approach. We advocate avoidance of surgical sharp debridement due to high risk of bleeding. Instead, we advocate for topical therapy using existing standards of care. We also found that many of our patients were incontinent of stool and urine, creating a need for moisture management. Indwelling urinary catheters, external fecal containment pouches, or indwelling fecal management systems were placed when indicated. Cleansing of skin with a pH-balanced no-rinse foam cleanser was used with a dimethicone-based skin protectant.

CONCLUSIONS

At the beginning of the COVID-19 pandemic, we encountered skin impairments presumed to be DTPIs. As our experience caring for these patients grew, it soon became evident that these lesions had a different cause and progression than DTPIs. While DTPIs are attributable to pressure-shearing forces, COVID-19 skin manifestations are attributable to a systemic inflammatory response resulting in coagulopathies. We also observed that patients with COVID-19 often had multiple comorbid conditions and many developed multisystem organ failure and hemodynamic instability. Despite this new threat to healthy skin, our WOC nursing team remained focused on pressure injury prevention, optimizing nutrition, topical therapy principles, and staff education focusing on differential assessment and management of DTPIs versus COVID-19 skin manifestations. We believe further consideration is needed to determine whether the coagulopathies and skin manifestations of many patients with COVID-19 should be classified as acute skin failure and sometimes observed in other critically ill patients with acute systemic exacerbations. We recommend additional research into the etiology, epidemiology, assessment, and management of COVID-19 skin manifestations.

ACKNOWLEDGMENT

We would like to acknowledge Susan DeSanto-Madeya, PhD, RN, CNS, FAAN, for her dedication and contribution to helping us along this journey. We could have never completed this short paper without her support.

REFERENCES