During this unprecedented time of COVID-19-related crisis, the CDC has issued guidance for health care facilities on how to prepare and respond to community spread of the virus.1 This outlines actions such as deploying comprehensive staff training, rescheduling elective surgeries and diagnostic testing and limiting visitors. Outpatient clinics are being advised to “reschedule non-urgent outpatient visits as necessary”. The intended goal of these efforts is multifold: keeping vulnerable patients healthy while preserving staff resources, medical supplies and PPE.
Based on this information, healthcare networks are tasked with creating a specific plan for their organization. For many, this has included closing outpatient wound clinics.
The Alliance of Wound Care Stakeholders, a wound care advocacy group, recently released a statement emphasizing that the decision to shut down wound care departments “will result in unintended negative consequences” including increased patient visits to emergency departments and the potential for complications from unmanaged, non-healing wounds including wound infection, sepsis, limb amputation and even death.2
Most wound clinic patients fall within the CDC’s “groups at higher risk for severe illness” of COVID-19.3 They are typically elderly and have multiple co-morbidities including diabetes, obesity, chronic kidney disease, cardiac issues and respiratory issues. Their caregivers who attend clinic visits are also often elderly and have multiple co-morbidities. The treatment of wounds (debridement, dressing and compression application and the use of advanced treatment modalities such as negative pressure wound therapy), involves knowledge, physical strength and assessment skills that are not always easy to impart on patients and their caregivers during the course of a 30-minute clinic visit.
So, what is the solution? How can wound care clinics walk the tight rope of balancing the need for patient and staff safety while providing (or coordinating) patient care in an effective way in order to prevent wound deterioration, recurrence or limb or life-threatening complications?
Strategies to consider:
1. Triage
Establish a policy that determines patient condition and the optimal site of care. A recent article by Rogers et al. outlined this concept in detail.4 It classifies patients with severe and moderate infections, gas gangrene and acute limb-threatening ischemia as critical and needing acute care intervention. Patients with worsening foot ulcers, mild and possibly moderate infections including osteomyelitis, active Charcot foot, chronic limb-threatening ischemia are classified as serious with suggested site of care being the outpatient clinic or office setting. Other situations of less acuity such as improving wounds or routine diabetic foot assessments may be deferred or managed remotely.
Facilities are creating their own unique triage models. A recent Association for the Advancement of Wound Care (AAWC) webinar reviewed the plans in place at George Washington University Hospital Wound Healing and Limb Preservation Center. At this facility, in-person clinic visits were prioritized for patients at high risk for infection, post-op patients, patients without reliable wound care assistance at home, receiving compression with high drainage, being treated with a cellular or tissue-based product, being managed with negative pressure wound therapy (NPWT), or those that require serial debridement.
2. Partnership
Home care agencies have never been more essential than they are right now. Acute care, with the goal of discharging patients as quickly as possible, and outpatient clinics who are attempting extended intervals between patient assessment are both looking to home care services for help. Home care services are not only being asked to deliver care, but also provide advanced assessments for referring providers and reinforce education of patients and family to promote independence. Recently, CMS released new policies related to the COVID-19 crisis, many of which impact the provision of home care. One of the most relevant changes involves the definition of the term “homebound”. As part of that policy change, the definition of “homebound” has expanded to include patients that are determined by a provider to be susceptible to COVID-19 and therefore advised not to leave their home, increasing the coverage of home care services for many wound clinic patients.
Additionally, home services and supplies can now be ordered by non-physician providers (NPPs) including nurse practitioners and physician assistants in order to streamline the referral and ordering processes. This change was made due to anticipation of increased demand of physicians and will be especially useful for wound clinics where many of the providers are NPPs.6
3. Telehealth
Effective March 6, 2020 and for the duration of the COVID-19 Public Health Emergency, CMS implemented new policies with a goal of expanding the use of telehealth services.7 Various telehealth platforms (including those with audio and video capabilities) may be used to assess patients with the goal of triaging those needing in-person assessment or assessing progress. During the COVID-19 emergency, the Office for Health and Human Services will exercise its enforcement discretion and will not penalize health care providers covered by HIPAA that provide telehealth services to patients in good faith.8 Verified Telehealth services are paid by CMS under the Medicare Fee-For-Service Physician Fee Schedule at the same amount as in-person services. Check with the specific payer for coverage and payment.
For wound clinics, this creates an opportunity to monitor high risk established patients and assist with triaging new patients. Visual images (video or photography), although not a substitute for in-person assessment, provide context to patient, caregiver or referring provider descriptions.
4. Keep it Simple
When creating a treatment plan, now is the time to prioritize practicality and simplicity. Consider treatments that can be applied safely and easily while decreasing dressing change frequency and helping to reduce the risk of complications. Many wound care providers are used to adjusting topical care based on sometimes subtle changes in wound characteristics documented during weekly or every-other-week assessments. What treatments could be appropriate for several weeks between assessments – reducing confusion and the need for additional supply procurement? What would be easiest for independent application for patients/caregivers? What requires fewer dressing changes but can still support the priority goals of maintaining a moist wound environment and promoting granulation tissue development? Which products would be best to support autolytic debridement, exudate management or management of inflammation, biofilm or infection?
Regardless of the treatment selected, whether it is a negative pressure wound therapy system or an advanced wound dressing, it is critical to provide patients and their caregivers supportive material including detailed, written instructions in lay-person language during this time. Avoid unnecessary steps.
Refer patients to supplemental resources including product websites with illustrated instructions and/or video tutorials. Outline instructions on when to call the clinic with concerns – including how to recognize signs of infection or other complications such as periwound skin irritation (e.g. maceration, dermatitis, medical adhesive-related skin damage) and when to call the clinic about their dressing or device (e.g. leakage, displacement, unresolved alerts).
The goal is simple. Keep patients safe, promote healing and prevent complications. Achieving this goal for wound clinics during a time of a public health emergency is not an easy task. But, then again, nothing about wound care is easy.
References:
1 Interim Guidance for Healthcare Facilities: Preparing for Community Transmission of COVID-19 in the United States. https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-hcf.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fhealthcare-facilities%2Fguidance-hcf.html
2 Statement from Alliance of Wound Care Stakeholders (March 20, 2020) https://www.woundcarestakeholders.org/news/studies-and-publications/alliance-covid-19-response-and-guidance
3 Centers for Disease Control and Prevention Coronavirus (COVID-19) website. Groups at Higher Risk for Severe Illness https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/groups-at-higher-risk.html
4 Rogers, LC., Lavery, LA., Joseph, WS., & Armstrong, DG. (2020) All Feet On Deck—The Role of Podiatry During the COVID-19 Pandemic: Preventing hospitalizations in an overburdened healthcare system, reducing amputation and death in people with diabetes. Journal of the American Podiatric Medical Association In-Press. https://doi.org/10.7547/20-051
5 Couch, K., & Song, E. (2020, March 31). Best Practice in Telemedicine – Wound Care [Webinar]. Association for the Advancement of Wound Care. Retrieved from https://aawconline.memberclicks.net/2020-telemedicine-webinar
6 Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency, 66 Fed. Reg. 19230, [page 17, 46] (April 6, 2020) https://www.federalregister.gov/documents/2020/04/06/2020-06990/medicare-and-medicaid-programs-policy-and-regulatory-revisions-in-response-to-the-covid-19-public
7 Medicare Telemedicine Health Care Provider Fact Sheet (March 17, 2020). https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet
8 Notification of Enforcement Discretion for Telehealth Remote Communications During the COVID-19 Nationwide Public Health Emergency (March 30, 2020) https://www.hhs.gov/hipaa/for-professionals/special-topics/emergency-preparedness/notification-enforcement-discretion-telehealth/index.html
