General Dermatology

Risk of Hospital-Acquired Sacral Pressure Injuries in COVID-19 Patients

Patients who are hospitalized with COVID-19 (COVID-19(+)) are at an increased risk of hospital-acquired sacral pressure injuries (HASPIs), compared with patients who are hospitalized without COVID-19. (COVID-19(-)).¹ Further, COVID-19(+) patients with HASPIs have higher stage ulcerations than COVID-19(-) patients. In a retrospective study of 58,766 hospitalized patients who spent ≥ 5 days at Cleveland Clinic from March 1, 2020─December 31, 2020, 293 developed HASPI. When controlling for Braden risk at admission, age, length of stay, medical comorbidities, intensive care unit admission, and need for ventilation, COVID-19(+) patients had 40% increased odds of developing a HASPI compared with COVID-19(-) patients (P = 0.03) and were more likely to develop a HASPI of severe stage (P = 0.001). Additionally, COVID-19(+) patients with HASPIs had 2.2x odds of a more severe hospitalization course compared with COVID-19(+) patients without HASPIs (P < 0.001). When comparing histologic features of biopsies/debridement tissue related to HASPIs, tissue from COVID-19(+) patients (N = 4) had 3x the number of thromboses in dermal vessels compared with tissue from COVID-19(-) patients (N = 2).

These findings support the observation that the skin may sustain significant damage secondary to COVID-19.²⁻⁴ These injuries may contribute to significant future morbidity, healthcare expenditure, and even mortality in patients who recover from COVID-19.⁵⁻⁶ Histopathologic analysis suggests thrombotic vasculopathy in areas of pressure may play a role in COVID-19-associated HASPI development.

HASPIs among COVID-19(+) Patients vs. COVID-19(-) Patients (N = 58,766)

March 1, 2020 ─ December 31, 2020

Total admissions5,48253,284
Total HASPIs49244
HASPI rate7.5 per 10,000 days4.6 per 10,000 days

HASPI = Hospital-acquired sacral pressure injury.

Assessing the Impact of COVID-19 Status on HASPI Development and Outcomes

March 1, 2020 ─ December 31, 2020


Regression Estimate (95% CI)


Developing a HASPIᵇ1.4 (1.01-1.9)0.03
Stage of HASPIᶜ2.1 (1.4-3.3)0.001
Need for debridementᵈ3.1 (1.02-9.4)0.045
Wound sizeᵉ8.1 (-0.4-16.5)0.06

HASPI = Hospital-acquired sacral pressure injury. Bolded values denote statistically significant P-values.

P-values are representative of 5 different multivariable regression analysis all controlling for Braden ulcer risk at admission, medical comorbidities (hypertension, congestive heart failure, chronic obstructive pulmonary disease, and diabetes mellitus), age at admission, length of hospital stay, requirement for ICU admission, and requirement for intubation with COVID-19 status (positive vs. negative) as the predictor variable.

P-value based on odds ratio from multivariable logistic regression results.

P-value based on hazard ratio from multivariable Cox proportional hazards model.

P-value based on odds ratio from multivariable ordinal regression.

P-value based on parameter estimate from multivariable linear regression.



  1. Carvalho T. Extrapulmonary SARS-CoV-2 manifestations. Nat Med. 2020;26(12):1806. doi:10.1038/s41591-020-01162-z

  2. Galván Casas C, Català A, Carretero Hernández G, Rodríguez-Jiménez P, Fernández-Nieto D, Rodríguez-Villa Lario A, et al. Classification of the cutaneous manifestations of COVID-19: a rapid prospective nationwide consensus study in Spain with 375 cases. Br J Dermatol. April 2020. doi:10.1111/bjd.19163

  3. Magro C, Mulvey JJ, Berlin D, Nuovo G, Salvatore S, Harp J, et al. Complement associated microvascular injury and thrombosis in the pathogenesis of severe COVID-19 infection: a report of five cases. Transl Res. 2020;220:1-13. doi:10.1016/j.trsl.2020.04.007

  4. Magro CM, Mulvey JJ, Laurence J, Sanders S, Crowson AN, Grossman J, et al. The differing pathophysiologies that underlie COVID-19-associated perniosis and thrombotic retiform purpura: a case series. Br J Dermatol. July 2020. doi:10.1111/bjd.19415

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  6. Sen CK, Gordillo GM, Roy S, Kirsner R, Lambert L, Hunt TK, et al. Human skin wounds: a major and snowballing threat to public health and the economy. Wound repair Regen Off Publ Wound Heal Soc [and] Eur Tissue Repair Soc. 2009;17(6):763-771. doi:10.1111/j.1524-475X.2009.00543.x