COVID-19 has changed the way wound clinics operate, with wound care becoming untethered from site-specific locations. This author provides guidance for adjusting wound clinic practices to prep for a potential second wave of infection this winter, as well as developing a post-pandemic wound care model that can include providing wound care without walls.
In mid-March, it became apparent that the novel coronavirus, COVID-19, would seriously impact the health care system in the United States. The U.S. surgeon general, the Centers for Medicare and Medicaid Services (CMS), and the American College of Surgeons all recommended delaying or canceling non-essential medical and surgical services to reduce the exposure risk of the virus and conserve resources for the expected large number of infected. Within 2 weeks, many state and local governments even prohibited non-essential services.
Wound centers were uniquely impacted by this recommendation. In many cases, wound centers are located in the physical space of the hospital. Hospitals closed wound centers to decrease the risk of transmission among hospital outpatients. We also saw a workforce shortage because even in the centers that remained open, some doctors on multidisciplinary panels like ER doctors and infectious disease specialists were repurposed in preparation for COVID-19 patients. And then, even in open, fully-staffed centers, we witnessed a drop in patient volume by about 40% as patients decided not to expose themselves to the risk of infection and stay at home.
In some cases, wrongly, wound care was considered a non-essential service and the Alliance of Wound Care Stakeholders quickly released a position statement declaring wound care “an essential—not elective—service that prevents hospital admissions and ED visits among a fragile cohort of patients at high-risk of COVID-19.”1 The fear was that if wound care patients missed needed visits for debridement, offloading, compression, and other necessary wound treatments, they would become infected and require hospitalization, creating the opposite of the desired effect to unburden the health system.
Preparing for a Second Wave of Infection
Before I describe how the model of wound care is changing during the pandemic, I want to provide a disclaimer that the information in this article is current to the best of my knowledge at the time of its writing on May 27, 2020. The response to the pandemic by healthcare institutions, payers, and governments is very fluid and I advise readers to double check any policy or regulatory information provided herein with an appropriate source to determine if it is still accurate. Secondly, we have to be realistic on how long the effect of the pandemic on the health care system will last. The initial response and closure of non-essential businesses and places of gathering may only last weeks or a few months, but the U.S. government is predicting the pandemic lasting at least 18 months with widespread shortages.2 The health care system will be operating under a pandemic mode of care for up to 2 years, until a vaccine is developed and mass distributed with between 40–70% of the population being immune.3 Some of the most drastic effects will be on long-term care facilities, which may be on lockdown for the duration of the pandemic, prohibiting visitors and even consultants.
There will of course be waxing and waning periods of the pandemic that policymakers will have to adapt to quickly. In the 1918–1919 influenza pandemic, the second wave in the United States over the winter had a much higher infection rate and mortality than the initial wave.4 Experts think there will be some seasonality to the COVID-19 infection rate as well.5 We can already see that in the southern hemisphere (now going into winter), like in Brazil, where there are increasing infection rates and hot spots.6 We should expect the same in the northern hemisphere approaching winter.
Also, given the size of the U.S., the pandemic will be in different phases in various parts of the country. We should see regional or local responses, but not necessarily a uniform national response. In some parts of the country, elective surgeries may continue while in other hospitals that have limited ICU bed capacity and no ventilator surplus, we will see restrictions.
The good news is that we have already had a “fire drill” to practice for what may come in the winter. But we should all be preparing now for the second wave’s effect on the health care system by stocking up on supplies and adapting to the new normal procedures of limiting exposure to patients. The Centers for Disease Control and Prevention (CDC) recently issued interim guidelines on how to reduce exposure in ambulatory care settings.7
CMS quickly granted policy waivers and issued new rules to provide care to patients in lower risk settings. Some of these policy changes will help providers take better care of wound patients during the pandemic.
One CMS initiative was to create the concept of a “Hospital Without Walls” to assist institutions in surging their bed capacity to respond to an influx of COVID-19 patients. Hospitals can temporarily expand sites of care off-campus by placing tents in the parking lot, using hotels, dormitories, or cruise ships to meet the demand of patients.
Wound Center Without Walls
The wound care community can learn from these CMS requests and flexibilities, and adapt our response to continue to provide wound care and do our part to keep our patients out of the hospital and from utilizing medical resources. A group of wound care leaders and innovators and I recently proposed the concept of a “Wound Center Without Walls” (WCWW).8 In the WCWW, we use the flexibilities given by CMS to create the best strategy to take care of wound patients during the pandemic. This will involve a shift in the utilization and site of care (Figure 1). We must conserve needed resources while reducing the COVID-19 transmission risk to the patient by providing as much care as possible in lower risk environments, such as the home, if possible.
The home is the safest place to care for patients, but home may not have all the tools necessary to effectively treat wounds. Therefore, it is imperative to establish a triage system to determine which patients require the most urgent care and in which site. In the WCWW manuscript, we proposed the Pandemic Wound Triage System (Figure 2) to aid in the stratification of patients.
The idea of the WCWW is to triage patients and provide care in the lowest risk environment, while escalating the care when necessary. In the home, telemedicine can aid in the triage of patients and use imaging to help diagnose infection, while providing face-to-face education to patients on the care of their wounds. Having family members or other caregivers present can assist in the acquisition of video and utilization of technology. Also, CMS recently allowed “simultaneous visits” to be reimbursed by home health and the physician, so a home health nurse can operate the hardware on the patient’s end and the physician can provide orders and bill an office visit. Also, rules have been waived requiring a face-to-face visit to order durable medical equipment (DME) dressings for Medicare patients, so now dressings can be prescribed after only a virtual visit.
Obviously, telemedicine cannot accomplish all the goals of a wound care visit. Debridement is one of the best practices that cannot be performed by telemedicine. Therefore, home visits by the physician or an occasional office visit may be necessary. Other novel methods of debridement, such maggots or abrasive tools, may be used in lieu of surgical debridement. Perhaps ultrasonic debridement will find use in the home along with cellular and tissue-based products. Also, offloading with total contact casts, the best practice for plantar diabetic foot ulcers, will require an office or clinic visit. Home visits might make the screening for arterial disease more difficult and some patients may go without testing for months. It is still unclear what effect this will have on the ultimate outcome of the wound. Infection is the most common reason that a wound patient requires hospitalization. Frequent telemedicine check-ins, early prescription of antibiotics, and the use of some newer long-acting antibiotics may be helpful. There are some pilot projects utilizing at home care by physicians or wound centers on wheels, which may find a useful place during the pandemic and after.9
Some patients will still require surgical procedures for wide debridements, incision and drainage, or revascularization. If a patient does not require admission, performing these procedures in an ambulatory surgery center (ASC) or office-based lab (OBL) may help to reduce their risk. Figure 3 shows the escalation of a patient from low risk to higher risk settings based on their triage category.
One thing is for certain: wound care has changed significantly during the COVID-19 pandemic. The first wave has given us a taste of what to expect this coming winter. It is wise for all of use to refine our standard operating procedures so that we may be ready for a stronger wave of infections with a larger impact on the health care system. It is also worth noting that the post-pandemic model of wound care may look nothing like the pre-pandemic model and we should be prepared to adopt new systems of care that have worked well during the pandemic. The post-pandemic model may become untethered from the site-specific location of the wound center and instead, be a more effective case management model navigating wound patients through the whole system.
Lee C. Rogers, DPM, is CMO of Amputation Prevention Experts (APEx) Health Network and a member of the board of directors of the American Board of Podiatric Medicine. He was the lead author of the “Wound Center Without Walls” manuscript recently published in WOUNDS and is a consultant to the Alliance of Wound Care Stakeholders in Washington, DC.
1. Alliance of Wound Care Stakeholders. Wound care is an essential—not elective—service that prevents hospital admissions and ED visits among a fragile cohort of patients at high risk of COVID-19. https://www.woundcarestakeholders.org/images/Final2_Statement_-_Wound_Care_as_Essential.pdf . Accessed May 27, 2020.
2. Baker P, Sullivan E. U.S. Virus plan anticipates 18-month pandemic and widespread shortages. New York Times. https://www.nytimes.com/2020/03/17/us/politics/trump-coronavirus-plan.html . Published March 17, 2020. Accessed May 27, 2020.
3. Heaney K. Everything we know about herd immunity and the coronavirus. The Cut. https://www.thecut.com/2020/05/herd-immunity-coronavirus.html . Published May 7, 2020. Accessed May 27, 2020.
4. Centers for Disease Control and Prevention. 1918 Pandemic influenza: three waves. https://www.cdc.gov/flu/pandemic-resources/1918-commemoration/three-waves.htm . Published November 29, 2018. Accessed May 27, 2020.
5. Goodyer J. Coronavirus: Will COVID-19 become a seasonal virus? BBC Science Focus Magazine. https://www.sciencefocus.com/news/coronavirus-will-covid-19-become-a-seasonal-virus/ . Published April 12, 2020. Accessed May 27, 2020.
6. Sandy M, Milhorance F. ‘We are not even close to our peak yet.’ Brazil risks being overwhelmed by coronavirus outbreak. Time. https://time.com/5837434/brazil-coronavirus-covid-19-latin-america/ . Published May 15, 2020. Accessed May 27, 2020.
7. Centers for Disease Control and Prevention. Coronavirus Disease 2019 (COVID-19). https://www.cdc.gov/coronavirus/2019-ncov/hcp/ambulatory-care-settings.html . Published May 7, 2020. Accessed May 27, 2020.
8. Rogers LC, Armstrong DG, Capotorto J, et al. Wound center without walls: the new model of providing care during the COVID-19 Pandemic. Wounds. https://www.woundsresearch.com/article/wound-center-without-walls-new-model-providing-care-during-covid-19-pandemic . April 2020.
9. SANUWAVE Health, Inc. SANUWAVE Health Partners with The Mobile Health Company, a New Company Formed by Former President Shri Parikh. GlobeNewswire News Room. http://www.globenewswire.com/news-release/2020/05/18/2034999/0/en/SANUWAVE-Health-Partners-with-The-Mobile-Health-Company-a-New-Company-Formed-by-Former-President-Shri-Parikh.html. Published May 18, 2020. Accessed May 27, 2020.