When a Telehealth Wound Care Consult Is Not Enough

The COVID-19 pandemic has placed an immense strain on health care resources and the amount of care patients have been able to receive. Due to these limitations, the transition to telemedicine as a heavily utilized form of care has accelerated among health care workers, including wound care specialists. Wound care provision has been deemed as elective and non-essential care, but without regular monitoring and support, patients can quickly succumb to dangerous wound infections that increase the risk of amputations and life-threatening sepsis.^1,2 

Being able to recognize that a telehealth wound care consult is not enough first requires the infrastructure for a prognostic case examination. In our recent article (“Tips for a Successful Wound Care Telemedicine Consultation”), we mentioned several tips that could contribute to a successful wound care telemedicine consultation, including how and what sort of information is needed to characterize wound severity and having a triaging system to designate following steps. With these suggestions in mind, providers should know how to collect and process medical information to make further suggestions.

A typical, telemedicine wound consultation generally involves a face-to-face encounter over a publicly available platform, such as Skype (Microsoft Inc., US) and Zoom (Zoom Video Communications, US), or hospital-based platforms, such as Amwell (American Well, US) and EPIC telemedicine (EPIC, US).² Providers can instantly interact with the patient, where medical history and concerns can be addressed.

Wound assessment can be performed through digital images or videos taken by the patient or their caregivers, who have been provided guidance ahead of time. Checklists provided to the patient of additional characteristics, such as wound diameters, skin texture, and odor, should be noted as well to provide as much diagnostic information as possible. A workflow governing the diagnosis and longitudinal monitoring of the patient case can then be evaluated for how to proceed with homecare services and necessary wound supplies or whether the case severity requires in-person visitation.²

Scenarios Where Continued Teleconsultations and At-Home Wound Care Are Insufficient

1. High severity wounds that require professional intervention. One wound care scenario in which teleconsultations are insufficient is high-risk, life-threatening or limb-threatening patients who require urgent care. Based on the Infectious Diseases Society of America (IDSA) practice guidelines for soft-tissue infections, Rogers et al.¹ developed a telemedicine triage system for lower extremity and diabetic foot wounds by associating locations of care to the case urgency. IDSA-classified mild and some moderate infections such as dry gangrene, active Charcot foot, and chronic limb-threatening ischemia call for professional intervention due to the immediate threat of worsening conditions if not treated. These conditions require the professional expertise and medical resources found in an outpatient clinic, and patients should be directed as such. More serious cases such as gas gangrene, SIRS/sepsis, acute limb-threatening ischemia are categorized as severe wound infections, which also coincide with systemic signs of infections (eg, high temperatures >38°C, tachycardia, tachypnea).³ These patients would be designated as priority 1 and should be immediately directed to the hospital due to the critical care facilities and resources needed.

Providers should be able to recognize the severity of cases similar to priority groups 1 and 2 based on prior knowledge of such conditions and the rapid escalation of risk, if no professional intervention has taken place, and redirect these patients to hospital or outpatient clinics. Physiological symptoms should always be taken into account alongside digital and verbal characterizations of the wound(s), as an indication of a systemic reaction.

Therefore, prior to implementing telemedicine as a form of care, all sites of care should establish a workflow guideline that highlights urgent symptoms calling for professional intervention.

2. Wound deterioration from prior telemedicine consult. Keeping careful measurements and conditions to track wound development over time is essential, particularly if telemedicine is the predominant form of monitoring for a patient. Oropallo et al.² noted in a telemedicine-initiated patient flow that deterioration of wound progress should be directed back to the outpatient clinic for further evaluation. Criteria indicating deteriorating conditions of lower extremity wounds included increased necrotic tissue, presence of infection, prolonged duration of healing progress, and appearance of excessive fibrotic tissue that would require sharp debridement.²

Moreover, providers may miss out on systemic symptoms from localized wound images and from low-quality face-to-face video that could signify urgent and dangerous complications. Worsening wound status indicates that the current course of at-home or hybrid treatment with teleconsultations is not sustainable, and intervention is needed to change the course of wound progress.

3. Patient is not suitable for telehealth. Physical wound assessment can provide invaluable information that video or digital images find difficult to supply, particularly if the patient or their caregivers do not feel comfortable in using the technology.⁴ If the technological infrastructure to provide streamlined virtual consults or sufficient quality images or videos is found to be lacking after an initial teleconsultation, patients should also be brought back to the office. Low-quality static images can be difficult to provide useful diagnostic quality.

For patients who lack the technological literacy or infrastructure, the physician must decide if they receive sufficient diagnostic value from telemedicine.² If conditions are urgent, patients should return to traditional care via in-person consultation. If conditions are non-urgent, patients should be brought back to the office for further telemedicine guidance.

Alisha Oropallo, MD FACS, FSVS, FAPWCA, FABWMS, is an Associate Professor, Zucker School of Medicine, Hofstra/Northwell Health; Associate Professor, Feinstein Institutes of Medical Research, Northwell Health; Director, Department of Vascular and Endovascular Surgery; Medical Director, Vascular lab, Department of Vascular Surgery; and Co-Chair, Northwell Wound Symposium, Department of Surgery.
 
Adrian Chen, BS, is a medical school student at the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health.

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References

1. Rogers LC, Lavery LA, Joseph WS, Armstrong DG. All feet on deck-the role of podiatry during the COVID-19 pandemic: Preventing hospitalizations in an overburdened healthcare system, reducing amputation and death in people with diabetes [published online ahead of print, 2020 Mar 25]. J Am Podiatr Med Assoc. 2020;10.7547/20-051. doi:10.7547/20-051
 
2. Oropallo A, Lantis J, Martin A, Al Rubaiay A, Wang N. Wound care during the COVID-19 pandemic: improving outcomes through the integration of telemedicine. J Wound Care. 2021;30(Sup2):S12–S17. doi:10.12968/jowc.2021.30.Sup2.S12

3. Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America [published correction appears in Clin Infect Dis. 2015 May 1;60(9):1448. Dosage error in article text]. Clin Infect Dis. 2014;59(2):e10–e52. doi:10.1093/cid/ciu444.
 
4. Bondini CM, Sage S, Wilson BP, Hall MR, Wallis EAR. Modified telehealth for care of chronic wounds during the Coronavirus disease 2019 pandemic: A rapid literature review of alternative care modalities. Int Wound J. 2020;17(6):1960–1967. doi:10.1111/iwj.134883.             

5. Carter MJ, Fife CE. Clinic visit frequency in wound care matters: data from the US wound registry. J Wound Care. 2017;26(Sup1):S4–S10. doi:10.12968/jowc.2017.26.Sup1.S4
 
6. Warriner RA 3rd, Wilcox JR, Carter MJ, Stewart DG. More frequent visits to wound care clinics result in faster times to close diabetic foot and venous leg ulcers. Adv Skin Wound Care. 2012;25(11):494–501. doi:10.1097/01.ASW.0000422629.03053.06
 
7. Huang Z, Wu S, Yu T, Hu A. Efficacy of telemedicine for patients with chronic wounds: a meta-analysis of randomized controlled trials. Adv Wound Care (New Rochelle). 2021;10(2):103–112. doi:10.1089/wound.2020.1169