Article originally featured on Provider Magazine
Of the many and varied changes to care strategies for residents of long term care facilities resulting from the COVID-19 pandemic is a notable shift that has occurred in the area of wound care, with new approaches like telemedicine playing a leading role at a time when preventing the spread of the coronavirus is a top priority, experts in the field tell Provider.
Isolated From Experts
Rochelle Rindels, vice president of nursing and clinical services, The Evangelical Lutheran Good Samaritan Society, says even amongst the tidal wave of COVID-19 precautions in place and the herculean effort providers are making to keep pace with federal regulatory changes related to the pandemic, her organization has been very careful not to lose sight of other clinical priorities, with wound care among them.
“I think one of the biggest challenges is that we have had restrictions put on our locations, not just on family and visitors but other clinical expertise not being able to fulfill their roles in the facilities,” she says.
This means doctors who normally could visit residents in person, instead are not doing so in many cases. In wound care, Rindels says Good Samaritan Society clinical staff continue to perform daily assessments as before the pandemic, with a twist.
“Wound care has been one of the many things we have opened our services up to virtually, like we have also done for behavioral health,” she says.
For examining skin conditions, Rindels says the majority of the nursing staff use iPads to show doctors connected to the screen what they are seeing in any given resident. This was made easier when in early April as the COVID-19 crisis hit hard across the country, Good Samaritan Society purchased 1,000 iPads to send to skilled nursing facilities to use for virtual visits.
Technology Bridges the Gaps
The technology has worked very well, she says, but of course cannot totally replace the personal care required for the residents. “The population we care for has extremely fragile skin and can experience skin tears. We are there for them ensuring that we are repositioning and rehabbing residents to avoid pressure injuries and pressure skin wounds,” Rindels says.
Beyond being able to use the telehealth options during the pandemic, she says advances have come in recent years to help prevent or ease skin conditions. These include better cushioning in wheelchairs, improved mattress technology, and turning mechanisms to shift residents while they lie in bed.
An operational assist for wound care strategies has also come from the coordinated care programs Good Samaritan Society has undertaken with Sanford Health, which it became affiliated with in 2019 following the two nonprofit, privately held organizations merging.
Rindels says one of the larger clinical initiatives between the long term care specialists at Good Samaritan Society and the acute-care-focused Sanford is the program to limit hospital-acquired pressure injuries. Several clinical members from both groups share best practices on skin injury prevention, which has led to better communication between nursing staffs and more attention to skin injuries as patients transition from long term care to hospital and back.
“We are making sure that skin intervention stays a priority along with that patient,” she says. “This has been a big success on how we integrate and educate to keep residents safe.”
Offering Guidance for Nurses
Another leading expert, Jeanine Maguire, vice president, skin integrity and wound management, Genesis HealthCare, says the onset of the pandemic forced the organization to make changes to deal with a new reality in caring for residents. She oversees Genesis’ skin integrity and wound management programs and chairs the company’s skin integrity council, which includes nurses, therapists, dietitians, and other specialists.
“What we crafted for COVID included some wound guidelines. For example, we know when anyone has an active infection, particularly one like COVID that impacts the respiratory system, this means the impaired oxygen perfusion impacts heal-ability of any skin integrity condition or wound,” Maguire says.
And, to reflect this, the Genesis guidelines for patients with active COVID are basic instructions made to maintain the patient’s wound to minimize additional dressing changes in hopes of keeping the patient as comfortable as possible, “but also minimizing excessive personal protective equipment [PPE] use, which clearly globally we want to always preserve during the pandemic,” she explains.
Making Checks More Often
While Maguire says there are a lot of unknowns when it comes to COVID, there is some evidence that those with the virus tend to develop unusual skin conditions.
“We did put out education and communication to all of our centers to be aware of that so we do weekly skin checks, but we also do skin checks upon admission and we also train CNAs [certified nurse assistants] to look at skin every day with routine care,” she says.
The goal is to raise awareness that there’s a potential that something that a clinical staff member might see on the skin could be an early predictor of COVID-19.
“Again, there is a lot we don’t know with COVID, but we know that for all of us when we’re sick and don’t feel good we move less, and when you move less you are at higher risk for pressure injuries, as well as other ones,” Maguire says.
Care for Non-COVID Patients
For Genesis, the advent of the coronavirus also meant the start almost overnight of the need to lean on telemedicine in a way never imagined before, she says. “Yes, it seemed to happen overnight where we had this major shift because of COVID-19 to telehealth. And, that’s something many of us wanted for a very long time,” Maguire says.
“I cannot speak for non-wound treatments, but when it comes to wound therapy, telehealth is a real winner.”
The use of such technology has been sped by special federal regulatory waivers granted by the Centers for Medicare & Medicaid Services, something she hopes will continue even after the pandemic ends.
Another major help in caring for residents is the way in which colleagues at Genesis and peers across the country via Maguire’s work with the American Health Care Association talk about best practices, with many of these providers using telehealth as well.
“I would say I hear mixed messages from these conversations,” she says. “I hear from some groups that they’re seeing an uptick in pressure injuries with COVID-19, but for some groups not so much. It’s hard to say, it’s kind of like a mixed bag at this point. In some instances, however, COVID-19 might have raised awareness for skin and mobility.”
This heightened awareness of the need to keep residents mobile and avoid pressure ulcers is part and parcel of the virus’ impact on the body, which works to make people less mobile and unable to move even when lying down.
“COVID can really devastate a lot of the systems within a human being, and what I have seen is people who have breakdowns much quicker than I’ve ever seen before,” Maguire says.
Challenges to Shifting Quickly
She notes that shifting so quickly to telehealth has not come without its challenges. Nursing staff had a bit of a struggle, Maguire says, in that there is normally not a device holder in place to support telehealth, so the clinician has to maneuver the patient to obtain the correct iPad picture during an exam.
“We are struggling trying to get a device holder from vendors, but of course they are sold out globally. We are working now with Direct Supply to have one designed for us, but that means that [now] a staff member has to be the holder, which means we use more PPE,” she says.
PPE is definitely one of the areas that has also drawn the attention of Good Samaritan Society’s Rindels, who notes that doing wound care exams with full protection on is not always easy. “This is certainly not a barrier to care as much as it is another layer being added. Staff have masks on, making it harder to hear a resident as wound care assessments are taken,” she says.
But, the very fact more attention to each resident’s vital signs is taking place as part of the heightened precautions in place for COVID-19 is perhaps paying off, although it is too early to determine if this is statistically helping to identify skin issues earlier.
“These increased screenings for temperature and pulse and other measures are making it easier to catch skin conditions. We have a higher awareness with these increased assessments and screenings, and we can now find and prevent wounds sooner,” Rindels says.
Deb Bielek, speech-language pathologist, serves as the therapy education and programs resource with Ensign Services, part of the The Ensign Group. She tells Provider that her group has used telehealth for physician visits and been impressed with the results.
“I feel like we’ve seen the physicians become a little bit more comfortable with coming into facilities over time, but in the beginning of the pandemic, it was especially important to be able to have our wound physician do a telehealth visit with us,” she says.
“And, I will tell you I think that those visits have been really effective because we get this one-on-one time with a nurse and the therapist. If the therapist is involved with the physician on Zoom or whatever platform they happened to be using, we can have a very effective and focused exchange of information during that visit.”
The telehealth experience really lifts the burden of having to contemplate a visit given there is no need to be seen in an office or have a specialty clinician come to the nursing home or assisted living community.
“This is really significant in states we operate in like Arizona where you have heavy heat or California,” Bielek says.
“So, you’re dealing with that and in the winter, you have cold and you’re dealing with all those temperature issues, but then you’re also dealing with transportation wait time and having to allocate staff time for all of this. Having this telehealth capability post-pandemic would be a great option when you have a more compromised patient.”
It is all a matter of working through the COVID-19 challenge, even when doing the routine assessments of residents that mark a normal day at a nursing facility, she says.
“I was just talking by Facetime to a few of our nursing staff, and they expressed how hot the PPE equipment is and how hard it is to drink water when they have it on. These are little things, but if you can imagine that’s become your day where you were wearing a mask and face shield and one gown underneath and another gown that’s washable,” Bielek says.
“It’s pretty extensive.”