The Impact of COVID-19 on Chronic Wound Treatment

Disclaimer: The following text includes information pertaining to telemedicine. The inclusion of this information within the text below is only for educational purposes and does not reflect the products, goals, services, or opinions of StimLabs, LLC as a company.

This month we are talking about the dreaded, ever-present, ever-exasperating Coronavirus Disease 2019, or COVID-19, pandemic. We’re all sick of hearing about it at this point but hear me out. Whether we like it or not, it has triggered an evolution in our social, economic, and medicinal practices around the world. I’m a virologist by trade but we aren’t getting into the nitty-gritty of COVID-19, COVID-19 symptoms, or even its causative agent, the coronavirus SARS-CoV-2. Today, we are talking about a more insidious cause-and-effect phenomenon created by the COVID-19 pandemic – the impact on the treatment of chronic wounds. Now, if you’re furrowing your brow right now because last time you checked, COVID-19 didn’t directly cause open sores, you’d be right for the most part. But its global and multi-faceted disruption of our health care systems has substantially affected patients’ access to care for a variety of chronic conditions, including wound care. In this blog post, we’ll learn how the pandemic has affected current treatment paradigms for chronic wounds and how treatment strategies are evolving to address disruptions in face-to-face patient care.

Chronic Wounds 101

Briefly, wounds that do not progress through the normal process of wound resolution are classified as chronic wounds.^1-3 More often than not, patients with chronic wounds also suffer from other major health conditions, such as diabetes and cardiovascular disease, that impair their body’s ability to heal.^1,2 Within the spectrum of chronic wounds there exist different classifications based on their causation or etiology. These wounds include vascular insufficiency ulcers, pressure-induced skin and soft tissue injuries, radiation wounds, surgical site infections, trauma, complications of flap reconstructions, and other less common causes like pyoderma gangrenosum.² Most chronic wounds are driven by metabolic deficiencies, such as those seen with diabetes and vascular insufficiencies, or mechanical impacts due to persistent, localized pressure.¹ If not properly managed, chronic wounds may result in significant health issues including, but not limited to, amputation and even death. Importantly, a lack of regular follow-ups can lead to drastic increases in hospitalization rates.¹

Prior to the pandemic, most treatment of chronic wounds was performed in hospitals, wound care centers, or off-site healthcare facilities; and involved a thorough history of the patient’s health with both visual and tactile examinations of the wounds. In addition to these assessments, some at-home treatments were recommended based on the severity of the wound.^3,4 The COVID-19 pandemic significantly challenged and reshaped this treatment paradigm.

Pandemic Inception: A Pandemic Within a Pandemic

When COVID-19 made its official appearance in early 2020, it caused massive, widespread disruptions in health care systems across the globe. Treatment of chronic wounds was no exception. All over the country, wound care centers were shuttered or disbanded for several reasons.  Wound care centers were largely considered non-essential, and staff doctors and nurses were being reallocated to other departments to accommodate the influx of COVID-19 patients in hospitals.^1,2,4-6 In addition to lack of access to proper wound treatment, patients also faced variations in treatment patterns based on the treatment facility, state regulations, and geographic areas.^5,6 The third, and perhaps most debilitating cause of the disruption in the treatment of chronic wounds, was the fear of exposure to SARS-CoV-2. Concerned with potential infection and becoming ill, people canceled health care appointments and tried to treat themselves at home or let their conditions go unchecked altogether. These factors laid the groundwork for a pandemic within the COVID-19 pandemic – insufficient chronic wound management.^5,6

The number of visits to wound care centers in 2020 was down by 40% compared to 2019.¹ Not because there were fewer chronic wounds to treat, but because of the reasons cited above.^1,4 This is evidenced by the almost 60% increase in major amputations across the country in 2020.⁶ Furthermore, higher proportions of severe infection in patients with diabetic foot disease were reported compared with pre-pandemic times.⁶ Incidences of pressure injuries also rose in hospitals in 2020.⁶ Reports on pressure injury occurrences included patients with COVID-19 who were developing wounds due to restricted mobility, implementation of proning (i.e, positioning of the patient on their stomachs), and the use of medical devices to treat COVID-19.⁶ Many medical device related-incidences included pressure ulcers appearing in atypical sites on the body such as the face because of ventilator equipment.^1,2,6 In the wound care setting, it became clear that treatment strategies for chronic wounds needed to change so patients could receive appropriate wound management without unnecessary risk of exposure to SARS-CoV-2.

A shift in the treatment paradigm for chronic wounds

Earlier I mentioned that wound care prior to the pandemic typically revolved around regular follow-up visits. Procedures and hospitalizations that were expected to increase the likelihood, or speed, of complete wound resolution were routinely performed.⁴ While these practices are very much still in use, the pandemic impacted several aspects of this traditional wound care paradigm including compliance with wound care visits. Two years into the pandemic, the focus of chronic wound treatment has started shifting from wound resolution at all costs to one of wound management. Treatment goals are starting to focus on proper at-home wound care; controlling pain, wound deterioration, and decreasing hospitalization, which reduces emergency room (ER) visits and minimizes exposure to SARS-CoV-2.^1,2,4,6 To further support sufficient at-home wound care, strategies such as video instructions are being implemented to improve patient understanding of self-care and compliance. Instructions on caring for wounds treated with skin substitutes or advanced wound dressings are particularly important for patients caring for their wounds at home; video formats may be more useful than physician-provided paper or verbal instructions that have been previously provided during regular office visits.⁴

This new treatment paradigm is largely supported by telemedicine. Telemedicine is the use of telecommunications technology to facilitate remote consultation and care for patients. It provides many advantages compared to in-person visits and limits exposure to SARS-CoV-2. It expands options for sites available for treating patients with chronic wounds by allowing virtual consults in a patient’s home rather than only in hospitals, ERs, and extended care facilities.^2,3 Several studies have shown that telemedicine options are cost-effective and promote patient compliance.^1,2,4 Patients have also reported high levels of satisfaction with telemedicine visits and perceive them to be a more affordable and safer improvement to traditional in-person visits.⁶

As with most new technologies, there are a few barriers to use that the industry should be aware of as telemedicine treatment continues to evolve. So far, key issues with the use of telemedicine include technical barriers (e.g., access to the internet and practical computer knowledge), proper documentation of services provided and the ability to collaborate with other providers, privacy and security concerns, variation among telemedicine wound care models, and expectations of unlimited access to a health care practitioner (HCP).^1,3 Despite these obstacles, HCPs, patients, and regulatory entities seem ready to take the virtual leap. The Centers for Medicare and Medicaid Services (CMS) have promoted the concept of ‘hospitals without walls’ which provides flexibility to temporarily expand sites of care to reduce the burden on hospitals. CMS has also listed various telemedicine services as reimbursable.^1,2,6

This new treatment paradigm is still evolving and its final form will likely include a mixture of in-person and telemedicine visits. To ensure patients continue receiving optimal care, patient education is paramount. Adequate education allows patients to communicate effectively with their providers, whether in-person or virtually, about their wounds and to advocate for themselves in this new digital health treatment landscape.⁶ As new treatment strategies are formed in the office and at home, we at StimLabs are continuously exploring options and adapting to ensure our patients have access to our products wherever they are needed.

For the latest updates on StimLabs, information on disease states that may create risk factors for chronic wounds, and non-medicinal educational patient tips, please follow StimLabs Unprocessed.

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1. Sen C. K. (2021). Human Wound and Its Burden: Updated 2020 Compendium of Estimates. Advances in wound care, 10(5), 281–292. https://doi.org/10.1089/wound.2021.0026 2. Oropallo, A. (2020). COVID-19: Issues related to wound care and telehealth management. UpToDate. https://www.uptodate.com/contents/covid-19-issues-related-to-wound-care-and-telehealth-management. Accessed 8 December 2021 3. Kim, P. J., Homsi, H. A., Sachdeva, M., Mufti, A., & Sibbald, R. G. (2022). Chronic Wound Telemedicine Models Before and During the COVID-19 Pandemic: A Scoping Review. Advances in skin & wound care, 35(2), 87–94. https://doi.org/10.1097/01.ASW.0000805140.58799.aa 4. Rogers, L. C., Armstrong, D. G., Capotorto, J., Fife, C. E., Garcia, J. R., Gelly, H., Gurtner, G. C., Lavery, L. A., Marston, W., Neville, R., Nusgart, M., Ravitz, K., & Woelfel, S. (2020). Wound Center Without Walls: The New Model of Providing Care During the COVID-19 Pandemic. Wounds : a compendium of clinical research and practice, 32(7), 178–185. 5. Armstrong, D. G. (2021, September 21). Managing the Surge: Delayed Chronic Wound Care During COVID-19. https://www.ajmc.com/view/managing-the-surge-delayed-chronic-wound-care-during-covid-19. Retrieved December 1, 2021, from https://www.ajmc.com/ 6. Driver, V. R., Couch, K. S., Eckert, K. A., Gibbons, G., Henderson, L., Lantis, J., Lullove, E., Michael, P., Neville, R. F., Ruotsi, L. C., Snyder, R. J., Saab, F., & Carter, M. J. (2021). The impact of the SARS-CoV-2 pandemic on the management of chronic limb-threatening ischemia and wound care. Wound repair and regeneration : official publication of the Wound Healing Society [and] the European Tissue Repair Society, 10.1111/wrr.12975. Advance online publication. https://doi.org/10.1111/wrr.12975