1. Padula, William V.
  2. Reid, Natalie M.

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The 2019 coronavirus pandemic (COVID-19) presents the most encompassing public health issue of the 21st century in the United States and globally. Hospitals are hitting a proverbial panic button as they face surges of patients with COVID-19 that have overwhelmed emergency departments (EDs) as well as intermediate and intensive care units (ICUs). We have also observed that the pandemic is leading to widespread unemployment or reduction in work hours among laborers in multiple areas of our economy, including many health care workers. In order to cope with this economic crisis, many groups and industries are looking for new and creative solutions to this problem; or for that matter, generate options to cope with the sustained impact that the pandemic may prolong throughout multiple surges to come. With these thoughts in mind, we assert that we must not forget the fundamental practices of health care and public health throughout this pandemic. We also warn that these fundamentals could easily be ignored as health care workers become overwhelmed. Despite the current trends that health systems are taking to cut costs by reducing excess labor (ie, health care workers), nurses, and especially WOC nurses, are critical to the success of our health care system.


Nurses are not only frontline health care workers in the fight against COVID-19; they are critical in ensuring all patients who interact with different parts of health systems return home as safely and healthy as possible. Current evidence clearly shows the benefits of professional nurses. For example, the addition of 1.0 nurse per 1000 persons is associated with a -2.0 cases per 1,000,000 reduction in COVID-19 mortality worldwide.1 Similarly, an increase in the nurse-to-patient ratio is associated with an increase in recovery from COVID-19. Therefore, we assert that investing in professional nursing staff, rather than reducing it, is justified because the care nurses provide is associated with recovery and reduced mortality, thereby increasing the value of care that health systems provide. This could be one of the most important steps we can take for recovering from this pandemic.


The WOC nurse sits at the center of the challenges of patients with COVID-19. Patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in particular are hospitalized for long periods of time, as much as 1 to 2 weeks, and are frequently immobilized due to extreme fatigue and being on respiratory support. While COVID-19 patients are immobilized and ventilated, and likely catheterized, they become susceptible to pressures injuries on their body from prolonged time in the prone position as well as catheter-associated urinary tract infection (CAUTI). Additionally, we can anticipate that these ventilated patients may become malnourished over time. Mobility and nutrition, 2 key risk factors for pressure injury, are likely to affect critically ill patients with COVID-19. In addition, the acute respiratory syndrome associated with the coronavirus (SARS-CoV-2) contributes to oxygen deprivation throughout the body. Combining low oxygen levels with poor tissue perfusion in areas under pressure while bedridden is a recipe for disaster when considering the risk of tissue damage and pressure injury, exemplified by the cutaneous and vascular sequelae of COVID-19, such as "COVID toes," rashes, and cardiovascular manifestations. We conclude that all of these phenomena and connections affirm the essential role of the WOC nurse in the fight against COVID-19.


There are important steps nurses can take to improve the likelihood that a COVID-19 patient will be discharged from hospital free from complications such as a pressure injury and CAUTI. In addition to immobility, nutritional management is an element that the WOC nurse is well equipped to manage in conjunction with staff nurses at the bedside. We have observed that WOC nurses know how to build interdisciplinary teams inclusive of physical therapists, nutritionists, and other specialty practice nurses to build awareness about pressure injuries and CAUTI to ensure that these and other complications such as the cutaneous and cardiovascular manifestations of coronavirus are not developed while battling COVID-19.2


While data collection is not yet complete, we should anticipate higher rates of pressure injuries and CAUTI due to COVID-19 if actions emphasizing nursing best practices are not taken. We assert these data will be a wakeup call for the health care system to invest in WOC nurses. We assert that if health care leaders had made this investment sooner in the past decade, that society would not have suffered as many pressure injuries, CAUTIs, and other hospital-acquired conditions with associated higher mortality rates and billions of dollars in wasted costs as reported by the US Agency for Healthcare Research and Quality (AHRQ).3 The value of WOC nurses is important for health plan directors and hospital administrators to realize now more than ever in order to substantiate the use of best practices, nursing education and team building to manage COVID-19 volume surges.


The ability of WOC nurses to prevent pressure injuries and CAUTIs (among other hospital-acquired conditions) is invaluable in the care of COVID-19 patients. Many COVID-19 patients go straight from the ED to ICU. Hospitals cannot afford to treat additional complications during surges of COVID-19 hospitalizations if their ICUs and EDs are already full.


Regardless of the pandemic, many hospitals that are not in an epicenter of COVID-19 have already experienced dire financial situations. The cancellation of elective procedures has resulted in the loss of profitable admissions. Hospitals cannot afford the additional costs of nonreimbursable outcomes if their COVID-19 patients experience facility-acquired pressure injuries and infections. While providing high-value care to patients is one of the most important things a health care system can do, it is imperative that we ensure patients are getting care for the condition they are presenting with, while preventing the need to treat them for hospital-acquired conditions.


We have known from previous economic studies that WOC nurses possess skills and practices that are extremely cost-effective, if not cost-saving. A team of well-paid WOC nurses, averaging a ratio of about 6 to 7 per 1000 hospital beds, generates value in terms of quality and patient safety that more than offset their costs.4 Given our understanding of the value that WOC nurses provide to patients, it is important to invest in resources and labor for pressuring injury and CAUTI prevention. Following international guidelines published by the National Pressure Injury Advisory Panel, European Pressure Ulcer Advisory Panel, and Pan Pacific Pressure Injury Alliance can prevent unnecessary and costly pressure injuries and other hospital-acquired infections.5 We know that skin checks and assessments, repositioning, reducing friction shear and pressure, new support surfaces, and managing moisture and incontinence issues are key in preventing a variety of adverse events and associated costs. Now is not the time to "throw out the baby with the bathwater," rather, it is time to practice the preventive skills and adhere to best practice guidelines, that we know work. Empowering WOC nurses to practice with evidence-based protocols will help patients and show their value for hospitals' financials in the future.


While there are mixed data suggesting a general downward trend in rates of hospital-acquired conditions across the country, rates of pressure injuries and CAUTI have either not changed much over the past decade or may have increased.3 Furthermore, new findings published by the AHRQ Patient Safety Network show that Magnet hospitals (hospitals that have achieved the highest grade of medical quality and nursing excellence in the country) are now seeing increases in CAUTI and surgical site infections.6 These statistics emphasize that WOC nurses are important in all health care settings and not just in acute care facilities with high concentrations of patients with COVID-19.


While the world struggles to develop effective interventions to prevent and treat COVID-19, the WOC nurse represents an important safety net for patients in need of acute and critical care. WOC nurses require ongoing support and recognition for their contribution, because they could be the lynchpin to ensure that patients who come to the hospital with COVID-19 do not incur avoidable harm by implementing standardized best practices that could easily be overlooked in the midst of these stressful times. Patients need every ounce of energy to fight COVID-19, and nurses need every ounce of energy to help them with this fight. Pressure injuries and CAUTI represent a fatal and costly distraction worth the time to employ evidence-based guidelines rather than overlook them in these emergent times.




1. Padula WV, Davidson PM. Using COVID-19 stimulus funds to invest in a skilled nursing workforce. American Nurse, May 18, 2020. Accessed July 2, 2020. [Context Link]


2. Padula WV, Makic MBF. View from here: informal leadership translating evidence-based practices for pressure ulcer prevention in the hospital setting. J Wound Ostomy Continence Nurs. 2017;44(2):153-154. [Context Link]


3. AHRQ National Scorecard on Hospital-Acquired Conditions. Updated Baseline Rates and Preliminary Results 2014-2017. Rockville, MD: US Agency for Healthcare Research and Quality; 2019. Accessed July 2, 2020. [Context Link]


4. Padula WV, Davidson PM, Nagarajan M, Pronovost PJ. Investing in skilled specialists to grow hospital infrastructure for quality improvement [published online ahead of print July 23, 2019]. J Patient Saf. doi:10.1097/PTS.0000000000000623. [Context Link]


5. National Pressure Injury Advisory Panel (NPIAP), European Pressure Ulcer Advisory Panel, Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline. Accessed July 2, 2020. [Context Link]


6. Hamadi H, Borkar SR, Dha LM, et al Hospital-Acquired Conditions Reduction Program, patient safety, and Magnet designation in the United States [published online ahead of print March 25, 2020]. J Patient Saf. doi:10.1097/PTS.0000000000000628. [Context Link]