“Our goal is to reduce the burden on the healthcare system by keeping patients safe, functional, and at home during the COVID-19 pandemic,” state the authors of a new viewpoint published in the Journal of the American Podiatric Medical Association. Outlining the role of podiatry in these challenging times, Lee C Rogers (Los Angeles, USA), Lawrence A Lavery (Dallas, USA), Warren S Joseph (Bethesda, USA) and David G Armstrong (Los Angeles, USA) emphasise the importance of preventing hospitalisations, and reducing both amputation and death, in people with diabetes.
“The COVID-19 pandemic is driving significant change in the healthcare system and disrupting best practices for diabetic limb preservation,” Rogers et al emphasise, noting that patients with diabetes and foot ulcers now find themselves at an “increased risk” of infection, hospitalisation, amputation, and death.
Although podiatric care, as the authors acknowledge, is associated with fewer amputations as a result of diabetes, it has been recognised that podiatrists “must mobilise and adopt the new paradigm of shifts away from hospital care to community-based care”. Rogers et al continue, stating: “Implementing the proposed Pandemic Diabetic Foot Triage System, in-home visits, higher acuity office visits, telemedicine, and remote patient monitoring, can help podiatrists manage patients while reducing the COVID-19 risk.”
In the face of “drastic containment and mitigation measures”, the authors posit that fragile patients could be left without necessary services, with wound care centres closing or significantly reducing their opening hours. Equally, Rogers et al highlight that procedures and surgeries for the treatment of diabetic foot ulcers may be “misclassified as non-essential”, also depriving patients of the podiatric care they require.
Underlining “the importance of podiatry’s role in unburdening the system”, as well as meeting patients’ needs, the authors strongly recommend the use of a new triage system for lower-extremity wounds and diabetic foot problems:
- For 94% of patients with diabetes—including those with uncomplicated venous leg ulcers, recently healed foot ulcers and healed amputation—treatment at home and via telemedicine is advised. (Stable; Priority 4)
- In a further 3% of diabetic patients, visits to the podiatrist’s office are recommended in addition to treatment at home and through telemedicine, which accounts for those with improving, but not healed, foot ulcers, and those with inactive Charcot foot who are not yet in stable footwear. (Guarded; Priority 3)
- In 0.75% of patients with diabetes, which includes those affected by chronic limb-threatening ischaemia (CLTI), osteomyelitis, active Charcot foot, and worsening foot ulcers, it is recommended that they are given care at an outpatient clinic, office-based lab, surgery centre or podiatrist office. (Serious; Priority 2)
- For 0.25% of patients, with severe (and some moderate) infections, sepsis or gas gangrene, and acute limb-threatening ischaemia, admission to hospital remains the recommendation. (Urgent; Priority 1)
On this system, the authors write: “We have identified the following changes in the healthcare system impacting podiatrists and their patients and recommend strategies to perform best practices in the new pandemic standard of care for the at-risk diabetic foot.”
Moving into the community
Although the American Podiatric Medical Association (APMA) strongly discourages hospitals and regulators from “declaring all ‘podiatric procedures’ as non-essential”, Rogers et al agree that “in some cases that are not critical, podiatrists can shift the site of hospital-based wound care and surgical procedures to ambulatory surgery centres and podiatry offices”.
“A large percentage of outpatient wound centres are located in the physical space of the hospital, which is unique among all outpatient service lines, for both billing reasons (hospitals charge facility fees) and safety considerations (ability to respond to hyperbaric oxygen treatment emergencies).
“However, in the coming months, we anticipate that many wound centres will close because of guidance from the US Surgeon General, CMS, and state/local governments to reduce outpatient traffic in the hospital and non-essential services,” write the authors, who also state that for some patients, who require revascularisation, referral to office-based labs—that are extensions of vascular surgery, cardiology, or radiology outpatient offices—is possible.
Another key aspect of the move away from hospital-based care is the increased employment of telemedicine and remote patient monitoring as modes of treatment. “The CDC is recommending that providers leverage telemedicine whenever possible to protect patients and staff from COVID-19,” Rogers et al reveal, adding that “in our experience using FaceTime and Google Glass in wound-based assessment, combinations of ‘store and forward’ photos, short message service (SMS) text, or text video chat are useful to screen for infection and evaluate wound progress.”
Remote patient monitoring is said to show “great promise” too in identifying areas of impending injury/tissue loss, as well as the presence of potential infection, while monitoring through temperature sensing devices is supported by “robust data” as an “early warning system for diabetic foot ulcers in high-risk patients”.
“These patients were typically seen in podiatry offices every two to six months for preventative visits to reassess changes and risk for ulceration,” explain the authors, “but with remote patient monitoring could be pushed out longer and the podiatrist notified when a problem is imminent.”
Visiting the home
It is expected by the APMA that use of home health will rapidly expand as a result of the COVID-19 pandemic. According to the authors, as well as regular telemedicine check-ins from a provider, podiatrists can order home health visits, dressing changes, and/or prescribe dressings and antibiotics to be used at home by the patient.
Regarding the expansion of home health, the authors state: “All indications are that podiatrists will be seeing a reduced regular workload over the next 12 to 18 months, with cancellation of clinics and elective surgeries, increased patient no-show rate, and reduced demand for some foot and ankle care. There are opportunities for podiatrists to play a larger role in in-home care. House calls can be conducted with lower-extremity exams for infection and peripheral artery disease and podiatrists can perform simple wound procedures in the home.”
They also cite a review of care from the COVID-19 epicentre of Italy, which calls for the increased consideration of community-based care “where doctors may be performing more house calls” in order to ease pressure on hospitals, though the risks that this can pose to both patient and provider would have to be managed with the use of personal protective equipment (PPE).
In closing, Rogers, Lavery, Joseph and Armstrong deliver a clear message to podiatrists in the USA, asserting the need to adapt in the wake of the coronavirus pandemic. “All hands are on deck preparing to treat the expected wave of COVID-19 patients. Podiatrists must mobilize to provide organised care of the diabetic at-risk foot in a shifting environment and system.”
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