Wound Care is an essential service in this very difficult time of the Covid-19 pandemic.

There are reports that hospitals and clinics in the United States are severely curtailing clinicians' ability to see patients, including closure of outpatient wound clinics. This prompted the Alliance for Wound Care Stakeholders to draft a letter that wound care clinicians may use to justify ongoing care (click here). Patients with wounds represent an extremely vulnerable population. The case reports and clinical series coming out of Europe and China suggest that the factors associated with poor prognosis from Covid-19 are: older age, hypertension, chronic lung disease, diabetes and obesity. These are some of the factors that increase the risk for chronic wounds. If patients with wounds are not treated it is likely that they will get worse and need hospitalization. Ignoring wounds will not make them better!

Providing patients and their care givers with support as we go through this challenge to the status quo of health care deliver is critical. Envision the positive outcomes and possibilities that this challenge with allow us to develop. From this experience we will develop stronger processes and adopt technology to optimize care that would otherwise take years. This outline may provide with a framework to engage with your wound patients and provide care givers key support as the struggle to maintain the care and protection that they need to avoid ER and Hospital visits.

Given the limited supply of PPE and the fear that many of our patients and providers are experiencing, we are providing some guidelines that may be useful. This may differ from the usual aggressive approach that we are accustomed to but we recommend moderation for now and assuring patients that we will resume normal clinic operations when it is safe to do so.

  1. Review your clinic list for the week and cancel all non-essential appointments. Prioritize how often patients should be seen:
    1. Patients who must be seen
      1. Patients who are at high risk for infection
      2. Patients who have necrotic tissue and are actively undergoing serial debridement
      3. Patients who do not have reliable wound care at home
      4. Patients being treated with CTP
      5. Patients in compression with high drainage
        1. Patients in compression with low drainage and stable wraps may consider extending visits to every 2 weeks
    2. Patients who can be rescheduled in 2-3 weeks
      1. Wound care is provided by VNA
      2. Change to wound care strategy is likely to be needed in several weeks as the wound improves
      3. Patient and/or family is reliable and will call if there is a problem
    3. Patients who can be rescheduled in 4-6 weeks
      1. Stable wound with stable wound care
      2. Residents of skilled nursing facilities
    4. Patients who do not need to be seen - consider telemedicine options
      1. https://www.ama-assn.org/practice-management/digital/ama-quick-guide-telemedicine-practice
      2. No open wounds
      3. Extended follow up in very stable patients
    5. Consider telehealth visits
      1. Coordinate with caregiver or VNA
      2. Ask the following:
        1. Is there undermining or tunneling?
        2. What does the drainage look like?
        3. Has drainage increased?
        4. Is drainage blue-green with musty or fruity smell?
        5. Malodor after the dressing was removed?
        6. Is it firm around the wound?
        7. Does the patient have fevers, chills, new pain or increased pain or change in blood sugars?
      3. Photograph or live video with supplemental lighting if needed.
  2. For daily clinic operations
    1. Greet patients before entering clinic with temperature check and screening questions
      1. Provide mask if appropriate
      2. Defer clinic visit if appropriate based on upper respiratory symptoms
    2. While seeing patients in clinic, develop a strategy for follow up
      1. Need to be seen weekly
      2. Could be seen in 2-3 weeks
      3. 4-6 week follow up is acceptable
    3. With reduced volume in clinic
      1. Utilize clinic nurses for phone contact with patients
      2. Increase education in the clinic
        1. Teach family members to do the wound care (consider use of American College of Surgeons Wound Management Home Skills program, https://www.facs.org/education/patient-education/skills-programs/wound-care)
        2. Emphasize preventive measures and hand hygiene
        3. Follow your hospital guidance regarding use of PPE
          1. Clean all surfaces, especially stainless steel with antiviral wipes
          2. Clean waiting room surfaces on a regular schedule
          3. Utilize alternative waiting rooms and clinic rooms for symptomatic patients or PUIs who must be seen
  3. Utilize dressings that will allow decreased intensity of wound care
    1. No daily dressings
    2. Twice weekly or weekly wound care by VNA will allow them to see more patients. Engage the patient, family or other caregivers to do interim dressings if needed.
  4. Inpatients
    1. Review the consult list as a team, utilize photos as a form of telehealth
    2. Identify patients for whom debridement will facilitate earlier discharge
    3. Communicate with the primary team regarding follow up as outlined above
  5. For potential surgical patients
    1. Cancel all elective procedures in patients with a vital or functional prognosis that will not be significantly poorer after a two-month delay in treatment.
      1. Patients with chronic wounds considering flap reconstruction
      2. Ulcerated but stable, ie, slow growing skin cancers
    2. Perform day surgeries at an ambulatory facility and limit the number of people scrubbed to the absolute minimum
  6. Encourage basics of hygiene with hand washing, wiping down surfaces with antiviral wipes, wearing masks especially if patient has a cough or cold and maintaining physical distancing. These actions are critical to prevent the spread of Covid19 and other flu like illnesses. Take this time to educate your patients about the basics of wound care prevention: edema control, pressure relief, good nutrition and hydration.

Finally, remember that although we may not be on the 'front-line' at this time, we are in front of the front-line as we work to reduce resource utilization and keep our wound care patients from needing the hospital.