Diabetic Wound Care in a Mid-Pandemic Healthcare Setting
The COVID-19 pandemic has created a true challenge for healthcare providers who need to keep constant contact for the management of their patients’ conditions that existed before the pandemic set in. Chronic wounds can be a problem for diabetics, especially when open ulcers from Diabetic Foot Disease are present.
Wound patients are at risk for the most extreme complications in their conditions if they contract COVID-19 due to their pre-existing comorbidities. It has been advised that clinicians should be prepped for the pandemic disruption in the provision of care for a minimum of another 18 months. If a telehealth program has not yet been established, it is time for the design and implementation of one.
Common Wounds and Risks of Treatment Disruption
The most common wounds are directly caused by diabetes, venous or arterial insufficiency, or pressure. These wound-causing conditions cause the patient to be labeled as comorbid and increases their risk of death tremendously. If treatment for these patients is disrupted (which it has been due to COVID-19) there is a risk for increased emergency room visits, frequent hospitalizations, amputations, and death is a devastating possible outcome.
The challenge therein is to maintain the continuum of care required by wound patients. Hospitals are already overwhelmed. Eliminating disruptions in DFD patient care will decrease the risk of these patients needing to be hospitalized, or filling an ICU bed if the patient has infection issues that lead to sepsis.
COVID-19 Shift in Medical Care Provision Setting
Keeping patients safe has been achieved through an adjustment to the care setting. The major goal of wound care during the pandemic is to achieve management of the wound. The prevention of serious complications and hospitalizations are a priority. Preventing infection is of utmost importance, but if one arises, the diagnosis and treatment remain to be paramount. Higher tolerance for ischemia in the limbs and longer wound healing time are both to be expected.
Diabetic patients frequently will not present a normal inflammatory response to infection, therefore the visual cues may not be present even when the infection is severe and deeply rooted in the soft tissue or the bone. Paying attention to other infection indicators is necessary when treating a patient remotely. Infection is a driver for resource utilization, readmission post-surgical, prolonged hospitalizations, multiple surgeries, and amputations. With COVID-19 forming mysterious micro clots in patients, the urgency to prevent wound care patients from contracting the virus is elevated.
Effective Case Management of DFD Patients
The remote treatment of Diabetic Foot Disease patients must be strongly coordinated to be successful. A multidisciplinary team is essential including the primary care provider, any specialists, home health providers, and a medical equipment and supply company. Optimal strategies to manage the patient’s conditions in the home should be decided on a team basis. Triage necessities can be done by phone or telemedicine.
The patient should be involved in self-care if remote patient monitoring through telemedicine is to be beneficial. This will require the patient’s use of provided equipment to take their own blood pressure, blood glucose reading, and more that can then be sent to the provider(s) in real-time. The Veterans Administration has begun using a temperature sensing mat that can detect 97% of diabetic foot ulcers in patients with as much as a five-week notice before the ulcer even offers a visual cue.
How to Motivate Patients to Take Part in their Care
Engaging your patient in the care and management of their condition is a mandatory step in making telehealth work. Consider making tutorial videos for your patients on various subjects. Advanced wound dressings provided by a durable medical supplier should be arranged to be delivered to the patient’s home. Keep in mind that single-dose packaging can reduce confusion and improper bandaging. Consider assigning one staff member of the team to coordinate all interactions with durable medical equipment providers. Due to pandemic closures, some durable medical equipment suppliers who operate on a mail-order basis may be necessary as an alternative until businesses begin opening up.
Telehealth in the Home, Hospital, and Skilled Nursing Facility: The New Normal
In response to the COVID-19 pandemic, CMS rapidly began encouraging the use of telehealth and telemedicine and enacted looser regulations and restrictions as well as waivers to make it easier for providers to continue to care for their patients while reducing the risk of COVID-19 spread.
There are three levels of virtual visits:
• Medicare telehealth visits
• Virtual check-ins
Wound consults can take place via telehealth for hospital inpatients, patients in the emergency room, and residents in skilled nursing facilities (in addition to visits with regular patients). The pandemic makes the performance of all the components of a consult infeasible for the proper coding of the visit, so providers should use time-based coding instead.
Two-way video communication such as FaceTime has become a considerably vital tool in wound evaluation in today’s health care setting. If a mild infection is present, empiric antibiotics can be prescribed electronically. Counseling the patient with regards to relieving pressure on the ulcer/wound, the importance of compression, basic wound care tutorial, and how to properly use AWD are all key components in keeping patients home and safe.
The New Normal
With professionals predicting that this “disruption” in life created by the COVID-19 pandemic will last at least 18 months, telehealth is very likely the new normal. The strategy of virtual health care may have been born from the current health crisis, but it will be beneficial when the new normal is firmly established. The most telling factor in how widespread telehealth will be is dependent on the most critical factor: the healthcare industry’s willingness to invest in the underlying infrastructure that is necessary for the operational capability to communicate adequately with their patients.
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