As health care providers scramble to treat COVID-19 patients and try to prevent the spread of the novel coronavirus, concerns are arising such as the potential for more pressure injuries. Several expert panelists discuss their experiences and how they are using innovations like telemedicine to adapt.
As we traverse these uncertain and rapidly changing times both professionally and personally, some questions regarding our charge of caring for patients and residents at risk for and with chronic wounds come to the forefront of our minds. In conversations with health care colleagues who serve in different care settings and locations around the country, it seems there are mixed experiences related to wound prevention and management.
Jeanine Maguire, MPT, CWS, stated that at Genesis HealthCare, the interprofessional team of MDs, APPs, RNs, PTs, and RDs—known formally as the Genesis Skin Integrity Practice Council—worked together to recognize potential concerns with skin integrity. The council created “outbreak” specific wound guidelines, recognizing that goals need to shift during COVID-19, or any outbreak, to maintenance rather than healing. As she explains, this puts the focus on patient comfort, minimizes risk of wound infection, and preserves personal protective equipment (PPE) by decreasing the frequency of dressing changes. It also standardizes basic treatment regimens to improve the ease of application for any nurse, including a nurse who may now have more responsibilities given COVID-19, or an agency nurse unfamiliar with the formulary. The Skin Council also developed and implemented newsletters to raise awareness on prevention during isolation, proning-related pressure injuires, medical device-related pressure injuires, and the potential of COVID skin, notes Ms. Maguire.
“There are too many COVID related responses to list here, well beyond skin and wounds, but it is noteworthy to mention that across our nationwide portfolio, our experience and ability to respond has allowed us to develop COVID-dedicated units and centers to best support the needs within communities of need,” says Ms. Maguire.
Ms. Maguire, and many others in the field, expressed their concern for what could be happening to the skin of the residents isolated in their rooms. Would there be an increase in facility acquired pressure ulcer/injuries (PU/PI) due to staff being focused on providing care to the COVID-19 patients? Would residents who currently have chronic wounds, of any etiology, be able to get the dressings, supplies, and practitioner services needed to care for their wounds, and would staff be able to give the needed wound care attention in the face of the needs of the COVID-19 patients?
As Karen Lou Kennedy-Evans, RN, APRN-BC, FNP, notes, with her long-term care (LTC) residents isolated in their rooms and buildings staff being overwhelmed with the possibility of our first cases of COVID, there may be the potential for the following:
• A decrease in skin sweeps: Ms. Kennedy-Evans notes skin checks at her facilities have not changed. Upon admission, each resident has a total body skin check and then a repeat skin check by the wound nurse the next workday. Each resident gets a skin check twice weekly by the shower aide and followed up by the nurse. Ms. Kennedy-Evans says others fail to realize that each resident is taken care of by a nurse aide who each day gets patients up, dressed and prepared for the day. She says while dressing the resident daily, the skin is always checked. If the resident is wearing a hospital gown during check and change, every two hours the skin especially in the sacral/buttock area is looked at. Each resident who is being turned has the sacral/buttock area looked at by at least one or two nurse aides 12 times a day, notes Ms. Kennedy-Evans.
• Decreased repositioning for mobility impaired individuals: Ms. Kennedy-Evans says COVID-19 has not changed anything in the way of the timing of turning and repositioning.
• Decreased visits by practitioners for all issues, including wound management: Ms. Kennedy-Evans says practitioners are limited to once a week unless it is an emergency. All wound rounds, weekly wound measurements/assessments, skin checks and dressing changes have not been affected by this COVID-19 virus.
On the other hand, Carmen Hudson, MD, FACS, CWSP, has found a definite overall decline in wound status, particularly in those buildings that stopped all formal wound rounds for a period of time and are now slowly adopting telemedicine, allowing limited visits, or both.
As Dr. Hudson states, from a provider perspective, the single biggest issue happening during this time of emergency is the move to remote/virtual care. She notes a collective scramble across LTC buildings to implement remote visits and the emphasis (rightly) was on primary care physician (PCP) type visits. Those visits often took place on a platform entirely different from a good remote wound care platform. Hence, Dr. Hudson says already challenged wound care staffing in facilities were now down staff, dealing with increased patient care needs (residents in isolation) and faced with trying to learn new technology.
Some buildings have completely shut down wound rounds during the pandemic, notes Dr. Hudson, who suspects PI/PU prevention is better in buildings that have pivoted to weekly virtual rounds. She adds that buildings that have the level of support from administration to make virtual rounds happen may also have more support for CNAs, shower aides, and nurses.
In addition to concerns regarding the potential for an increased number of pressure injuries, Ms. Maguire notes the phenomenon of “COVID toes.” She says they have found these skin changes on the toes of some of their residents with COVID-19. Although not fully understood at this time, these skin changes may be associated with micro-clots and/or other viral inflammatory symptoms in the vessels to the toes and fingers.
The Downside of Lockdowns and Confinement During the Pandemic
Many of Dr. Hudson’s buildings are seeing deteriorating wounds largely due to patient confinement to rooms and the simple lack of movement. Her company, United Wound Healing, inherited many wound clinic patients who were unable to go out to appointments. “Going out to an appointment, just by being moved, is therapeutic in many cases,” notes Dr. Hudson.
Dr. Hudson says the “total lockdown” of skilled nursing facilities is a simple infectious disease solution for stopping the virus. Unfortunately, she notes a lockdown doesn’t factor in the morbidity and mortality from the interruption of routine care for a vulnerable population. “There will not be general news headlines about the surge in pressure injuries and pressure injury related deaths in the coming months,” says Dr. Hudson.
For Misty Vaughn, PT, CWS, DAPWCA, Senior Vice President of Clinical Programs for American Medical Technologies (AMT), one of the biggest challenges that suppliers face during the time of pandemic is communicating with facility staff and receiving the necessary information that is required to place orders for wound care supplies. Although AMT is working diligently to adhere to established monthly re-order schedules, situations in the facilities are evolving rapidly. Staffing shortages and higher acuity patients are requiring facilities to change their practice patterns, and Ms. Vaughn notes that as a result she and her colleagues are increasing the number of touchpoints during the month to ensure new patients are identified and products can be supplied.
How Telemedicine Is Filling the Needs of Wound Clinics
Ms. Vaughn states that AMT has implemented a tele-engagement program that allows them to reach their partner facilities during the COVID-19 pandemic. She and her colleagues collaborate remotely with both the facility’s nurses and wound care providers to ensure that all residents needing supplies are able to receive them in a timely manner. She adds that AMT is working closely with its partners to adapt protocols to the current situation and continuously monitoring to ensure that they meet clinical best practices. Additionally, Ms. Vaughn says AMT is participating in the Tele Wound Coalition, which brings together a variety of resources to address facilities’ wound care needs in the LTC setting.
As Ms. Vaughn states, electronic medical record (EMR) access is crucial to identify all patients who need supplies. However, she notes not all the required information is readily available because of the variability in EMR programs, the modules selected by the facilities, and the amount of access given to the suppliers. In an ideal situation, facilities would have a wound care module integrated into their EMR. All wound and skin issues would be documented in that module and remote access would be given to suppliers, greatly simplifying things for both the facility as well as the suppliers.
Ms. Vaughn adds that she and her colleagues are continuously training their staff on the various EMR programs to best identify all residents who qualify for Medicare Part B supplies. Additionally, AMT is working with EMR and other technology vendors to create HIPAA-compliant, scalable integrations to optimize the qualification of patients for various programs and to educate continually on clinical best practices.
Ms. Vaughn says software companies have been working feverishly to add new features, such as telemedicine, to their programs to accommodate the emerging needs of their new customers. She says staff members everywhere are open to using new technologies to get the tools and supplies they need to care for their residents.
Positives Outcomes and the Challenges of Providing Care
During the pandemic, Ms. Vaughn says everyone has been working as a team, putting patients ahead of profits. Ms. Vaughn is encouraged that health care (in general) is expanding its way of thinking about patient care, being more willing to accept telemedicine. CMS has paved the way for telemedicine to be utilized in both urban and rural settings, as well as allowing physicians and providers to practice “across state lines.” These are positive changes that many would like to see remain in place long after the situation with COVID-19 has been resolved.
It is no secret that the entire nation has been experiencing PPE shortages. However, as part of a large national organization, Ms. Maguire says Genesis fortunately has been able to leverage all possible avenues to obtain PPE, as the company has been able to shift supply around from location to location as needed.
In addition, Ms. Maguire, both a physical therapist and certified wound specialist, recognized early on that the isolation practices required to keep residents, staff, and families safe would be a major issue from mobility and activity perspectives. This gave her the idea to partner with recreational therapy to find creative ways to encourage patients and residents to be as mobile as possible while in their rooms from the beginning of the cohorting process and isolation interventions. She and the recreational therapy team considered this to be the same as any outbreak intervention when isolation is put in place.
Many states allow registered nurses, nurse practitioners and physical therapists to do sharp debridement, which is considered a standard of practice intervention when necrotic tissue is present to support wound closure. In a Genesis building, where the wound management practitioners could not come into the facility to provide their usual care, including sharp and surgical debridement, the nurses and PTs skilled and competent in sharp debridement stepped in to fill that gap in care.
The current challenge posed by COVID-19, Dr. Hudson stresses, is trying to get back to helping patients without becoming a vector of viral spread. Her providers in “lockdown” buildings are looking at ways to schedule appointments to see those patients who might otherwise need to be sent to the hospital if they were unable to see an advanced practitioner.
Dr. Hudson emphasized that getting enough testing, performing contact tracing and obtaining the resources required to isolate and protect staff is crucial in preventing a resurgence and recurrence of infections.
“If we could do our jobs with adequate protection for ourselves and our patients, there would be a lot less suffering and long-term consequences,” says Dr. Hudson. “I carry and re-use a basic surgical mask because some of the buildings I end up in are using washed and re-washed home-sewn masks that are lovely and heartfelt—and have gaps to drive a spitball through.”
Recently the National Pressure Injury Advisory Panel released a white paper related to skin manifestations in patients with COVID-19. This paper describes some of the skin changes seen as complications of this virus, including skin lesions that mimic, in color and presentation, pressure injuries. It is important that clinicians recognize this issue and have the skills necessary to make the correct differential diagnosis, ensuring that we don’t call a purple skin lesion a deep tissue injury, when in reality it is a skin complication related to COVID-19. More information should be forthcoming in the future related to these unusual skin changes that are currently being identified in patients with this virus.
Looking to the Future
As the country looks to reopen, how do we continue to protect our most vulnerable population? Long-term care facilities will need to adopt new practices until such a time that either a vaccine or bedside testing becomes far more readily affordable and available. As facilities begin to allow additional workers, family members, and other visitors to return, there will need to be a balance between reducing social isolation and protecting our residents and preventing infection.
Carmen Hudson, MD, FACS, CWSP, is the Medical Director of United Wound Healing in Puyallup, WA.
Karen Lou Kennedy-Evans, RN, APRN-BC, FNP, is the President of KL Kennedy, LLC, in Tucson. She is a Wound Consultant for Foothills Rehabilitation Center in Tucson, AZ. She is an adjunct faculty member at the University of Arizona School of Nursing in Tucson.
Jeanine Maguire, PT, MS, CWS, is the Vice President for Skin Integrity & Wound Management at Genesis HealthCare in Quakertown, PA.
Pamela Scarborough, PT, DPT, MS, CWS, CEEAA, is the Director of Public Policy and Education for American Medical Technologies in Irvine, CA.
Misty Vaughn, PT, CWS, DAPWCA, is the Senior Vice President of Clinical Programs for American Medical Technologies in Irvine, CA.