question: Background: We aimed to compare risk of hospital-acquired sacral pressure injuries (HASPI) in COVID-19+ and COVID-19- patients Method: Single-institution, multi-hospital, retrospective cohort review of all hospitalizations from March 1st, 2020 to September 1st, 2020 Patients with new-onset HASPI (stage II or greater) were included in our study Patients with chronic history of sacral ulcerations or patients with ulceration present on admission were excluded Patient demographics, baseline ulceration risk (based on Braden risk assessment), HASPI characteristics, laboratory parameters, and ulcer-associated morbidity were collected Results: During our study period, 36 of 59,208 COVID-19- and 13 of 3,488 COVID-19+ hospitalized patients developed a HASPI COVID-19+ patients had a 5 5x higher relative risk of developing a HASPI compared to COVID-19- patients (46 5 per 100,000 hospitalization days versus 8 4 per 100,000 hospitalization days, 95% CI 3 3-11 5, p&lt;0 0001) Of patients that developed a HASPI: median age, gender distribution, baseline ulceration risk, nursing skin checks per day, and time from admission to HASPI were similar between COVID-19+ and COVID-19- patients COVID-19+ patients had larger (median ulcer size 85 cm2 vs 7 5 cm2, p=0 04) and more severe (46 2% Stage 4/Unstageable vs 19 4%, p=0 03) HASPIs compared to COVID-19- patients All COVID-19+ patients with HASPI had elevated D-dimer concentrations, with a median peak D-dimer of 6,755 ng/mL that occurred on average 3 5 days before ulcer formation HASPI led to severe morbidity in 6 of 11 COVID-19+ patients who survived initial hospitalization, including need for debridement or surgery (n=5) and ulcer infection/sepsis (n=5) Conclusions: Hospitalized COVID-19+ patients are at increased risk for developing large and severe HASPI The etiology of increased HASPI risk is unclear, but may due to poor tissue perfusion secondary to microvasculature occlusion, decreased staffing, and inability to appropriately position hemodynamically unstable patients