How COVID-19 is changing wound care: New triage models, metabolic inflammation in diabetes, and the need for international consensus

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COVID-19Speaking from four separate rooms in four different corners of the world, William Ennis, Desmond Bell, Michael Edmonds, and William Li expounded over zoom on the myriad ways in which COVID-19 had impacted multidisciplinary wound care, both in terms of the disruption the pandemic had caused to their daily practices, and how the echoes of this disruption would ripple into the future. They also touched on the interrelationship between diabetes and COVID-19, questioning what the downstream effects will be in the vulnerable diabetic population. Watch the full video here.

William Ennis (University of Illinois, Chicago, USA), president of the American College of wound healing and tissue repair and chief medical officer of Healogics, moderated the panel discussion. Desmond Bell is the founder and president of the non-profit organisation Save A Leg, Save A Life Foundation, and chief medical officer at Omeza. Michael Edmonds is a diabetologist at King’s College Hospital, London, UK. William Li is an internal medicine physician at Harvard Medical School, Cambridge, USA, the CEO, president, and medical director of the Angiogenesis Foundation, and a board member of the American College of wound healing and tissue repair.

How has your practice been impacted by COVID-19?

Ennis first detailed how in the USA, practitioners were asked to shut down their outpatient services, and were told that there was a difference between essential and non-essential services, but, in his opinion, “there was not a great deal of clarity of granularity as to what defines that and who makes those decisions. […] We personally felt like we were left to figure out our own triage system”.

Bell reported the same experience in Jacksonville, USA. “Nobody really saw this coming, obviously. We have been left on our own to figure it out.

“Initially, we kept patients out of clinic. […] I think the full impact is still yet to be felt as to some of the long-term implications. We may see a spike in hospitalisations for infections and that type of thing from that two to three-week period where patients were not coming in to clinic.”

Detailing the response of the National Health Service (NHS) in the UK, Edmonds explained that there was a more centralised approach than in the USA, but the directives were similar: “We had a mandate to differentiate between life- and limb-threatening conditions and other diabetic foot conditions, which we could treat in the community, out of the clinic. We had to preserve resources for the hospital itself. From the beginning of March, there was an avalanche of COVID patients coming into the hospital, filling up the ICU [intensive care unit], taking over the wards. By 17 April, King’s College Hospital  in South-East London had treated 2,339 COVID-19 cases. Some of the staff from the foot clinic were redeployed.

“But, the NHS acted as a whole, and the mandate coming from the NHS actually said that multidisciplinary foot clinics should continue, so we did not have to close down completely.” Patients deemed “non-essential” to visit the clinic (those with simple ulcers and mild infections) were treated in the community, rather than in the hospital, leading the multidisciplinary foot clinic team to conduct a reorganisation. Edmonds described how this created “a safety net of care” by linking up with the community podiatrists and community nurses.

“We feel that we have kept the standard of care to our patients, but on the other hand been able to reduce the number of patients coming into clinic by 30 to 40%”, he summarised.

Both Bell and Edmonds highlighted the importance of communication and coordination when treating a greater number of patients in the community as opposed to in outpatient clinics. Bell raised the concern that these disparate specialists, the nurses and podiatrists and diabeticians, may work in silos, but added that it sounded as though Edmonds’ experience in London was well-organised due to the presence of a dedicated co-ordinating role of the diabetic foot clinic to structure the new triage system.

Musing on the potential fallout from this stripped back outpatient service, Bell said: “I just think for the long-term, this is going to be something note-worthy. How is it going to have a direct impact—will wound care centres ever be the same? It sounds like, in a sense, there is a recognition of the services we provide. However, there might be a de-emphasis on the outpatient wound centre.”

Summarising the lessons learned through comparing Jacksonville and London, Ennis opined: “That infrastructure [the NHS] was not created simply for COVID, it was in place, then augmented and used to a greater degree. I think it emphasises the frailty of the US healthcare system. I think this has exposed a lot of our lack of communication, lack of using community.”

“Among the weaknesses that have been revealed, I think across the board in every country, is the lack of a centralised plan to deal with a sudden need to react acutely, while still managing those chronic situations,” Li commented, weighing in on the discussion.

“So I think one thing other specialities are going to teach us in wound care is the need to actually have a protocol for normal management, acute response management, and then how to triage those patients according to need, but also where do you send them, and what is the chain of communication that is required.”

A “telemedicine explosion has been fuelled by this pandemic”—What does this mean for the future of wound care?

“I have been a proponent of telemedicine for years,” Bell disclosed, “because I saw the value as smart phones and the technology emerged. Why would you not use a phone to communicate with your patients and vice versa?” Before the COVID-19 pandemic racked healthcare systems worldwide, Bell would ask his patients to send him a photo of their wound to keep him apprised of their symptoms between clinic visits and so he can guide them through any at-home behaviours or treatments.

Bell explained how he saw the rapid adoption of telemedicine as “one of the silver linings” of the current pandemic, calling telehealth “something we have needed for a really long time.

However, Li expounded on some of the challenges presented by telehealth. “First of all,” he said, “there is a lot of heterogeneity in the comfort level of physicians and patients alike with technology, and some of our neediest patient populations do not necessarily have access to the kind of technologies that might be required to do reliable telemedicine.

“The second issue I think has to do with privacy. Many of these telemedicine consults occur in whatever space we are in. […] And then the other issue is actually control of time. If you schedule a tele-visit, I think that is appropriate, but it becomes really easy, without any control, to reach out to your provider at any time, which I think my patients might quite like, but clinicians might not be able to handle that as well. Finally, it is documentation—being able to do appropriate care on the fly using telemedicine. We need a structured approach to this—how do you appropriately document it [the care given], and then how do you actually share that documentation with other providers?”

The interrelationship between COVID-19 and diabetes

“The interrelationship between COVID and diabetes has really been a very dramatic one,” Edmonds explained. Diabetes is a risk factor for increased mortality, and leads to metabolic inflammation, leading to a greater susceptibility to increased release of cytokines.

The American College of wound healing and tissue repair released a position statement in April saying that the people most vulnerable to COVID-19 are the same demographic as those visiting wound care clinics. Referring to this, Ennis said: “So we knew right away that there was going to be a vulnerability piece. Are we going to be seeing wounds in a different way, or presenting in a different way?” he asked the discussants.

Li thought so, answering: “As somebody who specialises in the microcirculation, one of the things that I did was pull together my research team, and we began actually looking at tissues of people who had succumbed to COVID-19 and tried to understand what had happened at the pathophysiological level.”

COVID-19 is a respiratory disease caused by a virus that is more closely related to the virus that causes the common cold than influenza, he explained. The novel coronavirus travels straight to the vascular endothelial cells lining the pulmonary vessels, targeting the gas-exchange network.

While inside the endothelium, the virus particles upregulate the ACE-2 (angiotensin-converting enzyme 2) receptor, which enables viral entry into the host cell. “So this is really an angio-centric disease as much as it is a respiratory disease,” Li clarified. The microvascular thrombosis triggered by the presence of the virus in the endothelial cells leads to the attempted immunological clearance of the virus in those areas, further damaging the vessel lining and causing additional clotting. “That then brings us straight over to the wound,” Li said. If this is happening in a lower extremity in an elderly patient or a diabetic patient with an ischaemic ulcer, it will potentially make it harder for the tissue to granulate and heal.

“I think we have not even begun seeing some of the potential downstream problems from COVID-19 infection in our diabetic population,” Li surmised. “Since we know this might occur, we as a wound healing community, as clinicians, should unite and start to gather that data, so we can quickly get our arms around it the same way infectious disease doctors have tried to gather data from the respiratory side. Secondly, we should mobilise the research teams to take some of this tissue and look at it. So for example, if there is an amputation, whether it is a BK [below-the-knee] or AK [above-the-knee], we should take a look at that tissue and see if we can find any COVID correlates that may actually help us.”

Citing a research letter published 6 May in the Journal of the American College of Cardiology reporting that systemic anticoagulation may be associated with improved outcomes among patients hospitalised with COVID-19, Li asked: “Should we, as a wound care community, start to think in our patients who have chronic wounds, or might have chronic wounds, about some form of adaptive anticoagulant treatment to be able to mitigate either the formation of wounds, improved healing of wounds, or prevent recidivism? These are all outstanding questions that I think we can start to think about now.”

Thinking about these downstream effects of SARS-CoV-2 infection, Bell wondered if wound care clinicians are going to start seeing previously healthy patients coming into the clinic with chronic ulceration or a certain type of wound following infection with COVID-19.

What is the new normal for wound care? Life after COVID-19

“As providers, we are the rate-limiting step,” Bell said, talking about the wound care treatment algorithm. “To me, I think one of the weak links in the wound care model is that we have so many top-notch providers, or people who look at wound care as a full time specialty. […] The old model that we have seen is not going to completely go away, but there are going to be some major adjustments to it.” He proposed that coordinating with home health or other formats of outpatient care will “become more the norm”.

He also raised the issue of payers, noting that in the future they may flag that wound care specialists had been able to treat their patients during the height of the COVID-19 pandemic despite a reduced number of visits to the wound centre, and that this limited model might be attractive to them. “I think there is going to be this de-emphasis on the services provided or the frequency that you will be able to go to an outpatient wound centre.”

Offering the UK perspective, Edmond chimed in: “There already was a trend to increase resources in the community, […] and I think this pandemic will accelerate that.

“Treating the diabetic foot ulcer is very much a holistic pursuit,” he added. “You might say that the patient with the less severe ulcer has actually had improved care during this pandemic. They are being treated in the community, at home, and they can get in touch with us very quickly. […] I think that equilibrium and that dynamism will go on into the future, so I am optimistic, actually.”

Also concluding on an upbeat tone, Li said he thought that following this pandemic, wound care specialists would have an opportunity to develop a set of best practices on the international level for how to help prevent, treat, and manage people who are vulnerable in the wound care setting without a lot of “fancy equipment and exhibition halls”.

“I think if we could get some sort of international consensus on what that could be in the setting of what we are learning with COVID,” he continued, “then we would actually have an opportunity to reboot all the competitiveness and all the pettiness that surrounds wound care, and have a new starting point. […] There is a new opportunity for leadership to harmonise the practices that would allow wound care to become more recognised in its own right as a specialty.”

Watch the full video discussion here.

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