Managing Telemedicine for Wounds in the COVID-19 Era: A New Proposal
Article originally featured on Advances in Skin & Wound Care
Last spring, Italy faced significant difficulties because of the novel coronavirus 2019 (COVID-19) pandemic. Italy was the first European country to adopt quarantine measures; hospital admissions were limited to patients who were COVID-19 positive or those with urgent care needs (determined by a complete triage at hospital entry). Providers therefore had to develop solutions to meet the needs of people with chronic diseases.
In this letter, we describe the strategy implemented in our wound unit to solve this problem. From March 8 to August 31, 2020, 45 patients divided into three “settings” were scheduled for a telemedicine visit every 10 days. All relevant data and pictures were aggregated in a digitized clinical report during each visit.
The first setting comprised six individuals who were already patients of the clinic: unit nurses conducted telephone check-ins asking about general status; pain levels (visual analog scale score); status of ulcerative lesions (ulcer size) and perilesional skin; and presence of necrosis, abundant exudate, inflammation, and skin swab (conducted by the patient’s general practitioner). Blood count, protein electrophoresis, renal function, and concomitant therapies for other comorbidities were also collected and sent by the patient’s general practitioner. After the phone call, pictures of the lesion(s) were obtained from the patient and sent to a dedicated encrypted e-mail address for the wound unit or via encrypted mobile messaging application to our nurses. After an interprofessional briefing, the patients/caregivers were contacted with instructions about therapy and a simple medication regimen.
The second setting included seven new patients. Appointments by phone were conducted similar to the first group; however, nurses also called general practitioners to verify comorbidities and topical or systemic treatments. The third setting included 32 patients hospitalized in other departments of our hospital. Nurses and/or physicians asked for a consult with our wound care nurses, and visits were conducted as in the first setting.
Healing was defined as complete resolution of the ulcer. Lesion improvement had to satisfy the following parameters: (1) total or greater than 60% reduction in necrotic tissue, (2) reduction in ulcer size of at least 20%, (3) reduction in peripheral inflammation, and (4) reduction in visual analog scale score of at least 30%. Wounds were considered stable if the ulcer did not worsen.
During the aforementioned period, 38 of 45 patients scheduled for visits completed their follow-up, of whom 7 achieved complete healing, 21 improved healing, and 10 stabilization. Overall, healing/improvement of lesions was seen in 74% of cases. Our unit performed 91 internal consults (vs 137 in the same period in 2019) and 662 visits for outpatients (vs 846 in 2019). In other words, 34% of inpatients and 22% of outpatients achieved what in our opinion is a good result compared with the previous year.
Thus, telemedicine for chronic wounds during the COVID-19 pandemic facilitated the management of patients with complex ulceration. This system could also be used in nonemergency situations, although it is not applicable to all patients and requires improvements.1-4 For telemedicine to work, we suggest providers (1) teach older adult patients and their caregivers the digital skills to conduct video visits, (2) routinely offer video visits to every patient (in particular for follow-up), and (3) facilitate access to care for medically fragile patients or older adults.
Issues that need resolution include reaching an official consensus on the use of telemedicine, ensuring all payers cover fees for telephone and video visits, offering patients who do not have internet or requisite devices ways to access video visits, and implementing networks of assistance between caregivers and hospitals. We believe that a patient’s first visit to specialized clinics for wound care should still be conducted in person because physicians must assess the disease. However, follow-up visits could be conducted digitally, even in the absence of unanimous consensus in the literature on this issue.5
1. Omboni S. Telemedicine during the COVID-19 in Italy: a missed opportunity? Telemed J E Health 2020;26(8):973–5.
2. Thomas EE, Haydon HM, Mehrotra A, et al. Building on the momentum: sustaining telehealth beyond COVID-19 [published online September 26 2020]. J Telemed Telecare.
3. Smith AC, Thomas E, Snoswell CL, et al. Telehealth for global emergencies: implications for coronavirus disease 2019 (COVID-19). J Telemed Telecare 2020;26(5):309–13.
4. Krupinski EA, Bernard J. Standards and guidelines in telemedicine and telehealth. Healthcare 2014;2(1):74–93.
5. Nordheim LV, Haavind MT, Iversen MM. Effect of telemedicine follow-up care of leg and foot ulcers: a systematic review. BMC Health Serv Res 2014;14(6):565–76.