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Considerations and Recommendations Regarding the COVID-19 Virus for Wound Centers

As the coronavirus continues to infect more people with COVID-19, health care providers must be vigilant when patients present to wound centers. This author offers guidance on steps to take to minimize the spread of the infection while providing effective wound care. 

COVID-19 is the abbreviated name of a viral organism that was identified as the cause of an emerging respiratory infection first reported in Wuhan, China at the end of 2019. It is generally accepted that it came from an undomesticated animal species sometimes used for food. It has been further classified as Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2).  

COVID-19 is spread by close person-to-person transmission via coughing or sneezing infected particles/droplets into the air, which can land on any surface within a radius of 6 feet. These particles can then be picked up by an unsuspecting bystander who touches a contaminated surface onto which the infectious droplet was deposited. In closed areas, as opposed to out of doors, infected airborne droplets may remain airborne even after a person with the virus leaves the area. Symptoms of human infection can develop within 14 days of contracting the illness and symptoms of illness include those similar to the common cold or influenza: cough, fever, and shortness of breath. Many of those who have been infected with it become asymptomatic carriers of the virus or experience only mild “common cold”-like symptoms.

COVID-19 should be considered in any person who has a fever with a severe acute lower respiratory illness (e.g., pneumonia, acute respiratory distress syndrome) requiring hospitalization, and without an alternative explanatory diagnosis such as influenza. Groups at higher risk infection include: lower income, tight knit communities; the homeless; inmates; members of group home settings; and extremes of age. Influenza vaccination and standard respiratory hygiene remain essential for health. In addition, given the increased evidence of community spread within the U.S., a physician’s suspicion for COVID-19 is a sufficient indication for testing for milder presentations not requiring hospitalization. The availability of testing also continues to expand as new testing sites, procedures, and kits become available.

How the National Response Developed: A Historic Perspective

While it is outside of the scope of this article to fully explain the development of public health policy, it is important to understand the development of recommendations for our national healthcare.

In 1970, the Institute of Medicine (IOM) was established as a nonprofit organization that functions as a branch of the National Academy of Science. As such, it works outside the normal framework of government to provide evidence-based research and recommendations for public health and science policy. In 1988 the IOM delivered a groundbreaking report that first described 3 core pillars of public health functions: assessment, policy development, and the assurance of proper implementation of policy. Subsequently, in 1994, 10 essential public health services were identified by the Public Health Functions Steering Committee at the national level of our government. These further described the core functions and public health responsibilities. These include the following:

1.    Monitor health status to identify community health problems.
2.    Diagnose and investigate health problems and health hazards in the community.
3.    Inform, educate, and empower people about health issues.
4.    Mobilize community partnerships to identify and solve health problems.
5.    Develop policies and plans that support individual and community health efforts.
6.    Enforce laws and regulations that protect health and ensure safety.
7.    Link people to needed personal health services and assure the provision of health care when otherwise unavailable.
8.    Ensure the existence of a competent public health and personal health care workforce.
9.    Evaluate effectiveness, accessibility, and quality of personal and population-based health services.
10.    Research for new insights and innovative solutions to health problem

This is the framework from which all centers of public policy development operate. The information provided below has been derived from governmental and corporate resources including: The Centers for Disease Control and Prevention (CDC); Johns Hopkins University and Medicine Coronavirus Resource Center; Johns Hopkins Bloomberg School of Public Health; the American College of Physicians; and the Division of Infectious Diseases at the Mayo Clinic.

Epidemic or Pandemic?

It is important that every member of the wound care team not add to unnecessary panic caused by misinformation of whether it is an epidemic or pandemic we are dealing with. In epidemiologic terms, an epidemic refers to an outbreak in which the number of cases exceeds what would be expected. A pandemic is a situation in which there is an outbreak that affects most of the world. Interestingly, neither term implies anything about the morbidity or mortality of an infectious agent. COVID-19 is now recognized as a pandemic because it has spread to most of the countries of the world’s continents, affecting a large number of people.  

At this writing it presumed that influenza type A and B viruses are more prevalent and more pathogenic than COVID-19. Because so little is known about the natural pathogenicity of COVID-19, it is not definitively known if this outbreak should be handled as a large outbreak of influenza otherwise would be. Despite this, however, there is agreement from all public healthcare policy makers that until it is known otherwise, clinics should be implementing measures already proven to limit the spread of disease by pathogenic viruses.   

By the numbers:  
COVID-19: Approximately 693,282 cases worldwide; 163,539 cases in the U.S. as of Mar. 31, 2020. Approximately 33,106 deaths reported worldwide; 2,860 deaths in the U.S., as of Mar. 31, 2020
Flu: Estimated 1 billion cases worldwide; 9.3 million to 45 million cases in the U.S. per year. Approximately 291,000 to 646,000 deaths worldwide; 12,000 to 61,000 deaths in the U.S. per year.

Precautions to Take in the Clinic

Fear and panic can be barriers to taking concrete actions to getting/being prepared and can also be detrimental to the delivery of healthcare.

Triage begins on the phone:
• Be sure to ask patients if they have traveled outside the country in the last 14 days, particularly to countries affected by COVID-19.
• Be sure to ask patients if they have been within 6 feet with someone who has COVID-19 for an extended period of time. If the answer to either is yes, patients should be directed to your facility’s triage location.  

The first person to come into contact within the clinic should initiate the screening process:
• Screen all patients for cough, shortness of breath, fever, travel history, and history of close contact with ill people.
o Travel screening to include any within last 14 days
o Cruise ships
o Those returning from spring break from higher incidence areas
o Respiratory symptoms similar to those of common cold and influenza

• For any patient presenting to a healthcare setting who has respiratory symptoms, have the patient wear a mask over the mouth and nose, and isolate the patient in an airborne infection isolation room if available.
• Immediately notify local infection control and the local or state health department of possible patients under investigation for SARS-CoV-2.
• While maintaining standard contact, and airborne infection control precautions including use of personal protective equipment and respirators, follow your institutions protocol to collect both standard respiratory pathogen test samples and SARS-CoV-2 samples, using CDC sample collection guidance.
• Provide supportive care for respiratory disease.
• Masks are not routinely advised except for symptomatic people to reduce transmission of virus through coughing or sneezing or other aerosolized viral spread.
• If seeing a patient in a primary care setting or in the emergency department, do not discharge the patient under investigation without consulting public health staff and determining there is a safe home isolation and treatment plan.
• Mitigate the risk to healthcare workers by implementing engineering, administrative, and personal protective equipment guidance.
• Health care professionals should regularly self-assess for absence of fever and symptoms prior to starting work each day and should not report to work when ill.
• Ask symptomatic patients to take appropriate infection control actions. Consider hanging posters or other visual reminders.
• Healthcare personnel with potential exposure to 2019-nCoV in a healthcare setting should follow health department guidance for assessment of risk, monitoring, and work restriction decisions.

What Conditions Leave Patients More Vulnerable to COVID-19?

Listed below are comorbid conditions that can increase patients’ risk of contracting and/or having a poor outcome to COVID-19 infection. These include but are not limited to:
• Diabetes (uncontrolled or controlled)
• Hypertension
• Chronic renal insufficiency and end stage renal disease receiving peritoneal dialysis or hemodialysis     
• Chronic heart failure with and without preserved ejection fraction
• Pulmonary hypertension
• Sickle cell anemia
• Idiopathic thrombocytosis
• Autoimmune hemolytic anemia
• Rheumatoid arthritis
• Scleroderma
• Lupus
• Dermatomyositis
• Multiple sclerosis; myasthenia gravis
• Recurrent staphylococcal infections
• Chronic lymphocytic leukemia; acute lymphoblastic leukemia; myelodysplastic syndrome
• Patients on chronic prednisone; methotrexate and/or Plaquenil
• Psoriasis; eczema; bullous pemphigoid
• Chronic obstructive pulmonary disease; emphysema; asthmatics
• Smoker (cigarettes)
• Alcoholism
• Recreational drug users (crack/cocaine; cannabis; methamphetamines; vaping)
• Malignancies treated with immunologics
• Past solid organ transplant
• HIV infection regardless of AIDS status
• History of mitral valve replacement

Other Considerations to Reduce Infection

If possible, consider implementing additional strategies.
• Consider allowing patients to wait in a personal vehicle or outside the healthcare facility until they are contacted by mobile phone when it is their turn to be evaluated.
• Cohort patients; maintain 6 feet of distance between patients.
• Flex scheduling of staff and patients.   
• Schedule only one patient per appointment time. Minimize overlapping of patients in the clinic.
• Advise patients to minimize early arrival for their appointment.
• Implement social distancing of patients if clinic space allows. Physically separate available seating.
• Disinfect waiting room furniture, doorknobs, and partitions frequently.
• Provide educational material for your patients of how to reduce risk of viral respiratory illnesses.
• Depending on the patient’s health insurance, availability of services, and/or the local coverage determinant provisions in your area consider initiating home-health services for wound care. Having patients cared for in the home will further enhance social isolation efforts.

For Patients: How to Wash Hands Correctly  

A quick splash of soap and water isn't enough.   

• Lather all parts of your hands by rubbing them together with the soap. Be sure to lather the backs of your hands, between your fingers, and particularly under your nails.
• Scrub your hands for at least 20 seconds. This is the time it takes to hum the "Happy Birthday" song from beginning to end twice.
• Rinse your hands well under clean, running water. If the water does not automatically shut off, there is no clear data supporting use of a paper towel to shut off the tap, and using the rinsed hands to turn off the tap reduces paper waste.
• Dry your hands using a clean towel or air dry them. Germs can be transferred more easily to and from wet hands, so drying hands after washing is advisable for further protection.

Or use alcohol-based hand sanitizers. Soap and water are the preferred method to clean hands, because washing removes many pathogens and toxic substances. When washing with soap and running water isn't feasible, alcohol-based hand sanitizers may be helpful with the following caveats:
• Select a product with at least 60% alcohol.
• Apply the product to the palm of one hand. Use the amount recommended on the product label.
• Continue to rub the product into hand surfaces until hands are dry. Wiping sanitizer off before it dries will reduce effectiveness
• Rub the product all over the surfaces of your hands. Just as with soap and water, all surfaces including under the nails need decontamination.

Final Thoughts

By the time this article is read by its intended audience, there will have been additions and/or changes to the recommendations of how we, healthcare providers and officials at all levels of government, are to respond to COVID-19. Please check the following websites for updates:

Education/resource websites:
- https://www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public/myth-busters    
- https://www.idsociety.org/public-health/COVID-19-Resource-Center/

Preparedness checklist:
- https://www.cdc.gov/coronavirus/2019-ncov/downloads/hcp-preparedness-checklist.pdf
Up to date case numbers:
- https://www.cdc.gov/coronavirus/2019-ncov/cases-in-us.html

Harriet Jones, MD, FACP, practices at the Internal Medicine Group of St. Dominic's Hospital in Jackson, MS.

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Harriet Jones, MD, FACP
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