Changes and Challenges for Wound Clinics After a Year of COVID-19

The COVID-19 pandemic has forced everyone to adapt to new realities, with wound clinics finding new ways of maintaining a high standard of patient care. One year into the pandemic, these expert panelists discuss how their wound clinics are adjusting to challenges and how the adaptations they made can help their clinics in the long run.

Q:

One year after COVID-19 began its spread and disruption in America, how is your facility coping?

A:

Jayesh Shah, MD, MHA, notes his facility and patients are coping well and says they are adjusting to the “new normal.” He notes patients and staff are maintaining social distancing. Due to facility rules, Dr. Shah adds that patients usually come with fewer family members to facility visits.

“The patients are now coming with masks. We miss seeing their smiles and hugs,” says Dr. Shah.

A year after COVID-19, Caroline E. Fife, MD, FAAFP, CWS, FUHM, is seeing only about 60% of the patient volume they saw prior to COVID. Last March, she notes the hospital’s initial impulse was to close the wound center but after Dr. Fife explained that this would increase traffic in the emergency department, they agreed the wound center should stay open with significant changes to operations.

“Unfortunately, the various strategies implemented in hopes of reducing the risk of spreading COVID included allowing only one patient in the waiting room at a time and forbidding family members and caregivers to accompany the patient,” says Dr. Fife. “This meant after each visit, much staff and physician time is spent communicating separately with the family and caregivers, who are forced to wait in the hallway or their car in the parking lot.”

When the above restrictions are added to the additional time consumed by COVID screening and spacing out visits to reduce individuals in the waiting room, Dr. Fife’s facility cannot see the same volume of patients. Some patients are still reluctant to come to the clinic, which she says reduces the volume of new patients. The result, she notes, is fewer patients seen per day and more time needed to see each patient. Dr. Fife’s facility is coping by helping its nurses get work hours in other hospital departments in the hopes that patient volume will increase before they face the loss of staff members.

Harriet Jones, MD, FACP, says her facility has done “very well.” In addition to dealing with the pandemic, Dr. Jones says her hospital system completed part of its merger process with a different hospital system based in Louisiana, all the while continuing to take care of the patients who depend on their services. 

“Our outpatient clinical staff and providers adjusted to patients’ needs and we probably became a little more understanding of the hardships our patients deal with all the time,” says Dr. Jones. 

As a provider, Dr. Jones notes she strives to do things the "ideal" way, and expects her patients to do the same. However, she says 2020 has proven that life does go on and sometimes, “less than ideal” is fine.

Q:

What has been your biggest challenge over the past year due to COVID-19 and how have you and your facility adjusted to those challenges?

A:

For Dr. Fife, it is hard to decide on one “biggest challenge” because there have been challenges on so many levels. She notes patients have been hurt by reduced access to care, saying this “is always the most important consideration.”

COVID-19 did not decrease the number of patients who need hospitalization for IV antibiotics and/or pain management but Dr. Fife notes the patients didn’t want to be hospitalized at the height of the pandemic, so they didn’t seek the treatment they needed. She worked with an inpatient rehabilitation hospital to handle the hospitalizations that were focused on wound infections and pain. In some cases she notes that approach has worked better than having patients hospitalized in the acute care setting.

One challenge for Dr. Shah’s patients is the inability to come in person, which can frequently cause a delay in their care. His facility implemented a telemedicine program early on as soon as COVID-19 hit to help his patients. Dr. Shah has also seen increased overhead costs for seeing patients because of personal protective equipment (PPE).  

Dr. Fife notes it is not possible to provide optimal patient care wearing a mask all the time. “Nearly all our patients are elderly and many have trouble hearing,” she says. “They can’t understand what we are saying if they can’t see our faces and I can’t effectively evaluate the patient without being able to see their face either.”

For dietitians in long-term care, Nancy Collins, PhD, RDN, LD, NWCC, FAND, notes the biggest challenge after a year of COVID-19 is meeting each resident’s daily nutritional needs. As she says, many of the residents who suffered with COVID and recovered continue to have a diminished appetite. “It is a challenge to get them to consume enough calories and protein, particularly if they have a wound,” she says.

Therefore, Dr. Collins has gotten creative with oral nutritional supplements such as making super-high-calorie milkshakes with added protein or will use commercial products, saying these are nutrition-packed.

“Encouraging consumption of both meals and supplements has always been challenging in the long-term care arena but now it is even more so,” says Dr. Collins. “We are making sure to provide flavors and taste profiles that appeal to the individual and even sending encouraging notes on trays to provide a more personal touch. Since staff has frequently been limited (due to many staff members also having COVID) in many facilities, we are making menus simpler and offering more finger foods and comfort foods.”

Another challenge for Dr. Fife is the difficulty in getting supplies. Her facility can get most dressings eventually, but cannot get certain disposables at all and sometimes will run out of supplies before they can get the next shipment. “We never know which dressing will be the one we can’t get today,” she says.
 
Dr. Fife says the biggest challenge operationally has been protecting staff jobs when she and her colleagues see fewer patients and revenue is lower. As she notes, nurses are working fewer hours, so they have had a cut in pay, or they find work hours in other areas of the hospital.

Dr. Jones’s biggest challenge has been using telehealth. Although not a fan of telehealth, she bets it is here to stay. As she is a hands-on person, Dr. Jones finds it hard to really get a “feel” for how a patient is doing through a monitor. As she notes, many of her patients live in rural Mississippi and do not have a high-speed internet computer system or a smartphone and don't know how to operate Zoom or Doximity. 

Q:

Are there any innovations made during the past year due to COVID-19 that you would continue?

A:

Telemedicine is one innovation that Dr. Shah will continue. (To watch Dr. Shah’s Today’s Wound Clinic video, “Telemedicine in Wound Care,” click here.)  

Telemedicine visits have been valuable, but Dr. Fife advises approaching such visits carefully. Several of her patients received suboptimal care because they were not seen in person and the right treatment was not implemented. However, she has become comfortable with having patients’ family members and caregivers “present” via the FaceTime app.

“In the past they had to take time off work to come with their family member, so the fact that I am happy for them to be present via technology has been very well received,” says Dr. Fife.

Dr. Fife also has some patients who live far away but must still make the trip into the clinic monthly for their home health or durable medical equipment orders to be renewed. Generally, she says patients need to be seen at least that often anyway, but notes the increased flexibility in those follow-up visits (thanks to COVID) “has been a good thing.”
 
“Even before COVID, I gave a lot of patients my cell phone number and now with very few exceptions I give nearly all of them my personal cell phone,” says Dr. Fife. “I can often handle problems easily by phone and obviate the need for an in-person visit.”

To Dr. Jones, it makes sense that the use of masks should be encouraged during flu season. She would also personally like to see some level of continued restrictions on visitors to hospitals and on those who accompany patients to their clinic appointments.

“Before COVID, who would have ever thought that we would really ever be concerned about not having PPE? I hope I don't forget how to be a better steward of the resources we have available for patient care,” says Dr. Jones.

Q: 

Has COVID-19 provided any insights into greater challenges in the health care system?

A:

COVID-19 has proven there are still “old” challenges yet to be overcome and new issues to be addressed, says Dr. Jones.

As Dr. Jones notes, patients sometimes still have no idea what insurance plans they have and no idea as to what services the plan does or does not cover. She adds that insurance companies have also created more layers of paperwork for providers and patients in order to get needed services.

In addition, Dr. Jones ponders another challenge for health care: On a more national level, what is the best way to distribute a new immunization to the general public? 

Usually, Dr. Shah says wound care patients already have issues with social determinants of health and have historically caused problems with their healing, adding that usually social determinants of health cause issues with amputation.

“Longstanding systemic health and social inequities have put many people from racial and ethnic minority groups with wounds at increased risk of getting sick and dying from COVID-19,” says Dr. Shah.

Given that the average patient she sees has 5 doctors involved in their care, Dr. Fife cites challenges with care coordination, exacerbated by COVID. She notes the frustration of getting through the “horrible” automated answering system of many doctor’s offices, saying “I sent one primary care doctor a fax to say that I was unable to get through to leave a message.” Staff may be working from home but Dr. Fife says the problem getting through to their doctors is not unique to COVID.
 
Dr. Fife also notes problems with the supply chain, calling it “more vulnerable than we thought. We found that out after the hurricane in Puerto Rico—who knew that most of our IV bags were made there?” Today, Dr. Fife says she never knows whether they will have small gloves or what kind of gloves we will get—we are grateful just to get gloves.
 
“So many services function on a razor’s edge in terms of staffing,” says Dr. Fife. “COVID has hastened the retirement of many doctors and nurses and has dramatically and negatively impacted the training of medical personnel at all levels. I think we will feel the impact of that for at least half a decade.”

Nancy Collins, PhD, RDN, LD, NWCC, FAND, is a wound care-certified dietitian specializing in the relationship between nutrition and wound healing. She is also a medico-legal expert dedicated to improving provider-patient communication and bettering the patient experience. To contact her, visit her website, www.drnancycollins.com.

Caroline E. Fife is Chief Medical Officer at Intellicure Inc., The Woodlands, TX; executive director of the U.S. Wound Registry; medical director of St. Luke’s Wound Clinic, The Woodlands; and co-chair of the Alliance of Wound Care Stakeholders.

Harriet Jones, MD, FACP, practices at the Internal Medicine Group of St. Dominic’s Hospital in Jackson, MS.    

Jayesh B. Shah, MD, MHA, is past president of the American College of Hyperbaric Medicine and serves as medical director for two wound centers based in San Antonio, TX. In addition, he is president of South Texas Wound Associates, San Antonio. He is also past president of both the American Association of Physicians of Indian Origin and the Bexar County Medical Society.