Wound care in OPDs or wound care clinics during COVID-19

Given the current COVID-19 pandemic and related issues, the Centers for Disease Control and Prevention (CDC) has issued guidelines for health care centers regarding preparedness and responsiveness around the community spread of corona virus. They include outlining the major actions to be taken, such as,

  • deployment of comprehensive staff training
  • postponement and rescheduling of non-urgent hospital appointments and elective surgeries
  • avoidance of unnecessary diagnostic testing
  • setting standard operating protocols for the rest alongside limiting hospital visitors.

Outpatient setups or smaller clinics are being advised to “reschedule non-urgent OPD appointments visits as and when required or necessary”.

The intended goal of these collective efforts is multiplicative: keeping vulnerable patients, or, in other terms, patients at risk, healthy while preserving resources, medical supplies, staff, and personal protective equipment (PPE).

As per the issued directions, healthcare communities are aligned towards creating specific plans best suited for their respective organizations. For several establishments, this has meant even temporary shutdowns of OPDs including wound care clinics.

Many wound care stakeholders and advocacy groups have recently shown their concerns around the decision to shut down wound care departments stating reasons for resulting unintended negative consequences like

  • an increase in patient visits to a hospital’s emergency department
  • potential for complications from poorly managed, chronic non-healing wounds like wound infection, sepsis, limb amputation or even death in a few cases.

 

Most such outpatient departments or wound care centers fall within the CDC’s “groups at higher risk for severe illness” of COVID-19.3 The patient group mostly falls into the elderly category and might have multiple co-morbidities including diabetes, obesity, chronic kidney disease, cardiac issues and/or respiratory issues. The primary and secondary caregivers, who accompany the patients during the clinic visits are also often elderly and have multiple co-morbidities.

The wound care procedure (cleaning, debridement, wound dressing changes, application of compression systems and the use of advanced treatments such as vacuum-assisted compression or negative pressure wound therapy systems) requires optimum knowledge, mental and physical strength as well as assessment expertise. All of that is not always easy to impart to patients and their caregivers during a 30-minute clinic visit, especially in developing countries where literacy rates are feeble.

So, what is the solution to this dire problem of catering to wound care essentials during COVID-19 at hand?

How can wound care centers or designated wound care outpatient departments walk the tight rope of balancing patient and staff safety and addressing patient care in an effective and time-bound manner to prevent worsening of the wound by either deterioration, recurrence, limb amputation or life-threatening complications?

Strategies that can be considered to salvage the wound -

1. Assigning the degree of urgency to the wounds

Establish a policy that determines patient’s condition and the optimal site of care. A recent article by Rogers et al. outlined this concept in detail.

It classifies –

  • A. Patients with severe and moderate infections, gas gangrene, and acute limb-threatening ischemia as critical and needing acute care intervention.
  • B. Patients with deteriorating foot ulcers, mild and moderate infections including osteomyelitis, active Charcot foot, chronic limb-threatening ischemia as serious with a suggested site of care being the outpatient departments of hospitals or wound care management centers.
  • C. Other less complicated and chronic conditions such as improving wounds or routine diabetic foot assessments to be selected to be managed remotely.

Health care centers are also creating their own unique models of care. For example, in-person clinic visits are prioritized for patients at high risk for infection, post-operative patients, patients without reliable wound care supplies and assistance at home, receiving compression with high drainage, being treated with cellular or tissue-based product, being managed with Negative Pressure Wound Therapy (NPWT), or those that require continuous debridement.

2. Partnership

Home care and nursing agencies have never been more crucial than they are in current times. Patient’s care, with the goal of discharging patients as quickly as possible, and outpatient clinics that are attempting extended intervals between patient assessment are both looking towards the home wound dressing services for help.

New policies related to the COVID-19 pandemic are being put in place, many of which impact the provision of wound care at home. One of the most relevant changes involves the definition of the term “homebound”.  As part of that policy change, the definition of “homebound” has been expanded to include patients that are determined by a provider to be vulnerable to coronavirus and therefore advised not to leave their home, increasing the coverage of home wound dressing services for many wound clinic patients.

This change was made due to anticipation of increased demand of physicians and will be especially useful for wound care management centers where many of the providers are non-physician practitioners.

3. Telehealth

In effect since March 2020 and for the duration of the COVID-19 Public Health Emergency, implementation of new policies with the goal of expanding the use of telehealth services has been put to proactive practice.7

Various telehealth agencies using audio, video or both forms of communication may be used to assess patients with the goal of triaging those needing in-person assessment or assessment of progress.

For wound care clinics, this creates an opportunity to monitor high-risk patients and assist with triaging new patients. Visual images (video or photography), although not a substitute for in-person assessment, provide context to the patient, caregiver, or referring provider descriptions.

4. Keep it Simple

When creating a treatment plan, the current times require prioritization of practicality and simplicity.

Consider treatments that can be applied safely and easily with minimal dressing changes and help to reduce the risk of complications. Many wound care providers are used to adjusting topical care based on subtle changes in wound characteristics documented during weekly or alternate week assessments.

What are the treatments that could be appropriate for the several week durations between assessments that reduce confusion and the need for additional supply procurement?

What would be uncomplicated for independent application patients/caregivers?

What requires fewer dressing changes but can still support the priorities 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, pain, bleeding biofilm, or infection?

Regardless of the treatment selected, be it negative pressure wound therapy system or an advanced wound dressing, it is critical to provide patients and their caregivers supportive material including detailed instructions written in a clear, easily understandable form.

Avoid all unnecessary steps.

The goal is simple. Keep patients safe, promote healing, and prevent complications.

[This article has been prepared and backed by extensive research done by Juwariah Khan, Senior Product Manager at Axio Biosolutions.

Juwariah has more than five years of experience working in the field of AWC related Medical devices and holds a Masters Degree in Sciences (Biotechnology).

You can reach her on LinkedIn for any questions related to the article.]

Sources:-

  1. Interim Guidance for Healthcare Facilities: Preparing for Community Transmission of COVID-19 in the United States
  2. Statement from Alliance of Wound Care Stakeholders (March 20, 2020)
  3. Centres for Disease Control and Prevention Coronavirus (COVID-19)
  4. Journal of the American Podiatric Medical Association In-Press 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
  5. Association for the Advancement of Wound Care Couch, K., & Song, E. (2020, March 31). Best Practice in Telemedicine – Wound Care [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)

#woundcare #nursing #makeitbetter #MedEd #pressureinjury #WoundCareAtHome #COVID19

Disclaimer: Issued in public interest by Axio Biosolutions Private Limited. Kindly check the official guidance on WHO for more information on infection prevention and control of covid-19.

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