SEARCHCOHORTcritical care, intensive care

cohort·critical care, intensive care, dermatology, infectious disease, nursing·PMC10158435

Incidence of hospital acquired pressure injury in critically ill patients with COVID-19 in prone position admitted to the intensive care unit

Medicine · 8 authors, 3 centres

AI SUMMARY

FIDELITY 100%

POPULATIONCritically ill patients with COVID-19 admitted to the ICU who were placed in the prone position (n=84)

INTERVENTIONProne positioning (duration mean 48.3 hours in HAPI group, 46.3 hours in non-HAPI group)

COMPARISONPatients who developed HAPI vs. those who did not develop HAPI

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AGENT 01 · STRUCTURED SUMMARY

TRACE TO SOURCE

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TL;DR

This retrospective cohort study found that 62% of critically ill COVID-19 patients placed in the prone position developed hospital-acquired pressure injuries (HAPI). Longer ICU stay and lower Braden Scale scores were independently associated with HAPI occurrence. These findings highlight the need for targeted prevention protocols in prone-positioned COVID-19 patients.

Full summary

3,817 CHARS

**Background:** Hospital-acquired pressure injuries (HAPI) are a significant quality-of-care concern in intensive care units, particularly among critically ill patients with reduced mobility. During the COVID-19 pandemic, the prone position was widely used to improve oxygenation in patients with severe ARDS. However, prone positioning places pressure on anterior body regions, potentially increasing HAPI risk. This study aimed to identify the incidence and factors associated with HAPI in COVID-19 patients placed in the prone position in the ICU.

**Methods:** This retrospective cohort study was conducted in an ICU of a tertiary university hospital. All patients admitted from May to September 2020 with confirmed COVID-19 (positive real-time PCR) who were placed in the prone position during ICU admission were included. Patients with pre-existing HAPI at admission were excluded. Data were collected from electronic medical records across three domains: (1) demographics and baseline characteristics (sex, age, skin color, comorbidities, Braden Risk Scale score, SAPS III score, ICU length of stay); (2) risk factors (sedation, vasoactive drugs, prone position duration, laboratory values, BMI, mechanical ventilation/tracheostomy, P/F ratio, enteral nutrition, central venous catheter, urinary catheter); and (3) HAPI occurrence, location, and stage according to the International Classification System. Statistical analysis used Student's t-test for quantitative variables and Fisher's exact test for qualitative variables. Variables with P<0.20 in univariate analysis were entered into a logistic regression model. Significance was set at α=0.05.

**Key Results:** Of 204 COVID-19 patients evaluated, 84 were included (required prone positioning). None had HAPI prior to ICU admission. Fifty-two patients (62%) developed HAPI during hospitalization. In univariate analysis, factors significantly associated with HAPI were: tracheostomy (81.8% vs. 54.8%, P=0.021), immunosuppression (90.9% vs. 57.5%, P=0.045), longer ICU length of stay (27.3 vs. 16.8 days, P=0.001), lower Braden Scale score (10.8 vs. 12.6, P=0.029), and lactate dehydrogenase levels (791.4 vs. 1076.7, P=0.051). In multivariate logistic regression, only Braden Scale (OR 0.84, P=0.031, 95% CI 0.714–0.984) and ICU length of stay (OR 1.12, P=0.008, 95% CI 1.028–1.209) remained independently associated with HAPI. Each additional day of hospitalization increased HAPI odds by 1.12 times. Among the 52 patients with HAPI, 27 (51.9%) had one lesion, 13 (25.0%) had two, and the remainder had three or more. A total of 105 HAPI lesions were documented. The most common sites were sacral region (25, 23.9%), gluteus (13, 12.4%), thorax (10, 9.5%), and calcaneus (9, 8.6%). Twenty-six patients (50%) had HAPI in sites potentially associated with prone positioning. Only one lesion was classified as stage IV (sacral region); the remainder were stage I, II, III, or unclassifiable.

**Clinical Implications:** This study demonstrates a high incidence (62%) of HAPI in critically ill COVID-19 patients requiring prone positioning, substantially higher than pre-pandemic rates reported in the literature (46.3–57.1%). The Braden Scale proved to be a useful predictor of HAPI risk even in this specific population, and longer ICU stays independently increased risk. Notably, time spent in the prone position was not significantly associated with HAPI, possibly due to the use of specialized cushions. These findings underscore the importance of implementing structured prevention protocols that address both dorsal and anterior pressure points, particularly given the challenges of frequent repositioning during periods of staff overload. The study is limited by its single-center, retrospective design and reliance on medical record documentation.

PICO

PPOPULATION

Critically ill patients with COVID-19 admitted to the ICU who were placed in the prone position (n=84)

IINTERVENTION

Prone positioning (duration mean 48.3 hours in HAPI group, 46.3 hours in non-HAPI group)

OOUTCOME

Incidence of hospital-acquired pressure injury and associated risk factors

STUDY TYPE

cohort

SPECIALTY

critical care

SUMMARISED BY

AI pipeline

FIDELITY CHECK

100% · A

ORIGINAL PAPER

PMC10158435

Incidence of hospital acquired pressure injury in critically ill patients with COVID-19 in prone position admitted to the intensive care unit

Medicine

READ THE FULL PAPER

ABSTRACT

Abstract Critical patients have conditions that may favor the occurrence of hospital-acquired pressure injury (HAPI). The objective of this study was to identify the incidence and factors associated with the occurrence of HAPI in patients with coronavirus disease 2019 admitted to the intensive care unit (ICU) who used the prone position. Retrospective cohort study carried out in an ICU of a tertiary university hospital. Two hundred four patients with positive real-time polymerase chain reactions were evaluated, of which 84 were placed in the prone position. All patients were sedated and submitted to invasive mechanical ventilation. Of the prone patients, 52 (62%) developed some type of HAPI during hospitalization. The main place of occurrence of HAPI was the sacral region, followed by the gluteus and thorax. Of the patients who developed HAPI, 26 (50%) had this event in places possibly associated with the prone position. The factors associated with the occurrence of HAPI in patients prone to coronavirus disease 2019 were the Braden Scale and the length of stay in the ICU. The incidence of HAPI in prone patients was extremely high (62%), which denotes the need to implement protocols in order to prevent the occurrence of these events. Keywords: COVID-19, critical care, hospital-acquired pressure injury, prone position

CITATION EXPORT

Lucas Sato, Letícia Olandin Heck, Karina de Fátima Bimbatti et al.. Incidence of hospital acquired pressure injury in critically ill patients with COVID-19 in prone position admitted to the intensive care unit. Medicine. (2023). https://doi.org/10.1097/MD.0000000000033615

AUTHORS

8 · 3 CENTRES

Lucas Sato, Letícia Olandin Heck, Karina de Fátima Bimbatti, Bruno Cesar Petroski-Moraes, Christiane Becari, Anibal Basile-Filho, Maria Auxiliadora-Martins, Mayra Gonçalves Menegueti

a Division of Intensive Care Medicine, Department of Surgery and Anatomy, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
b Ribeirão Preto Nurse School, University of São Paulo, Ribeirão Preto, Brazil
c Division of Vascular and Endovascular Surgery, Department of Surgery and Anatomy, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil.