Implementing a Skin Assessment Instrument to Distinguish Between COVID-19 Skin and Deep Tissue Injury

Description: The novel COVID-19 virus is associated with many conditions beyond respiratory ailments. Unique skin findings related to coagulopathic processes is one such condition. These COVID-19 skin findings are similar in appearance to hospital-acquired pressure injuries (HAPI), predominantly deep tissue injuries (DTI).
Objective: The purpose of this evidenced-based practice project is to implement a skin assessment instrument to standardize the approach to identifying patients diagnosed with COVID-19 and presenting with a skin injury with the goal of distinguishing COVID-19 skin manifestations from HAPI, predominantly DTI.
Background: Although the literature points to the nuances of distinguishing COVID-19 skin manifestations and DTIs, most clinicians do not have the tools to help with identification. Using the available science and integrating tools into practice, clinicians can be confident to make the necessary decisions.
Methods of Implementation: The Iowa Model Revised was implemented as the framework for this project. Based upon scientific findings, a standardized instrument for skin assessment was introduced to the clinicians and integrated into existing workflows. Upon identification of a COVID-19 positive patient presenting with a skin injury, the instrument was applied. First, the intensive care unit (ICU) nurse referenced the instrument to differentiate between a COVID-19 skin manifestation and a DTI. Without discussing results with the ICU nurse, the consulting wound care nurse then referenced the same instrument to assess the patient to make an independent decision. The final clinical diagnosis is determined and documented by the wound care nurse, due to their expertise.
Findings: Outcome measures included monitoring the use of the flowsheet and congruence with assessment findings. Adherence to use of the flowsheet was 100% and congruence between the wound care nurses and ICU nurses was 50%. Within the cases of incongruence, one was due to difficulty assessing darker skin tone and the other was a clinical misunderstanding of HAPI versus moisture associated skin breakdown. Staff’s feedback was positive and consistently commented on the helpfulness of the form. Finally, the cost savings of implementing the instrument was calculated to a total of $124,606 with the identification of 2 COVID-19 skin manifestations.
Implications for practice: Utilizing tools to aid in assessments ensures standardization and proper documentation. A standardized process assists the clinical team with consistent use. Proper documentation is required for accurate coding and has financial and reputable impact on an institution. An evidence-based identification form will help to fill the gap in practice to distinguish between COVID-19 skin manifestations from DTI.