By Marcia Nusgart, RPh; Lee C. Rogers, DPM; Mark D. Iafrati, MD, FACS; Paul J. Kim, DPM, MS, FACFAS; Karen Ravitz, JD; Stephanie Woelfel, PT, DPT, CWS, FACCWS; and Emily Greenstein, APRN,CNP, CWON

Editor's Note: The information provided herein is based solely on the opinion the panelists, based on the information available to them at the time of their answering. This answer may not be inclusive of later findings or may in time be considered out of date, as research on COVID-19 continues and new findings are explored. Answers were provided before June 10th 2020.

On May 7, 2020, the Alliance of Wound Care Stakeholders presented a round table discussion with frontline experts to discuss the challenges and opportunities clinicians are facing during the COVID-19 pandemic. The discussion reviewed the significant changes wound care professionals are undergoing, a review of relevant regulatory flexibilities, and the Alliance's role in ensuring that wound care is identified as "essential" care, rather than "elective." A question and answer session followed the panels' discussion; the following represents some of the most frequently asked questions.

Frequently Asked Questions

Question: Can you elaborate on the 12-week program you mentioned during the webinar?
Answer: Go to the WOCN society web page. The WTA program is listed there.

Question: How have pressure injury protocols and assessments changed, if at all?
Answer: In my facility we have made a “smart set” of orders that triggers interventions specifically for prone patients, including photos, head positioners, foam dressings, and a different type of endotracheal tube holder.

Question: What do you see as the general state of affairs for the wound, ostomy, and continence nurse (WOCN) as coronavirus disease 2019 (COVID-19) winds down?
Answer: I think we are going to see an increased need. I do feel that because of the vascular component to this virus, we don't know the long-term effects that these people are going to have.

Question: Do you have any tips on how to take care of a peristomal wound for patients with COVID-19?
Answer: I would recommend trying to use photos and telehealth. If that is not acceptable, then the patient would need to be assessed using full personal protective equipment (PPE) for COVID-positive patients.

Question: I’m in southwest Florida, where a large majority of our patients are seniors. In terms of risk reduction, telemedicine seems a natural solution. However, realistically there are still barriers to telemedicine with this population, including potential technology challenges, cognitive issues, physical issues, hearing issues, etc. What are your thoughts on a hybrid model of care that combines telemedicine with an in-home visit by a certified wound care RN? (Home health nurses often cannot offer that expertise.)
Answer: I agree that using a hybrid model is the best option, having the patient call into the wound center while the home nurse is present.

Question: Is anyone doing teleconsults, such as having RN staff using phones to show the wounds to the WOCN, who then identifies the stage, classification, and treatment options?
Answer: Nursing cannot bill for televisits, so it would have to be done by a physician or midlevel provider.

Question: NPIAP recommends collaboration with nutrition for prevention and management of pressure injuries. Are there any strategies you have identified as most successful with this partnership during or prior to COVID-19?
Answer: Some things we have implemented are making sure our wound patients are receiving adequate nutritional supplementation, whether a multivitamin or a protein supplement. I do also make sure they are not vitamin D deficient and supplement when necessary. It is hard right now for some patients because of their lack of access to food. We recommend they try to use a supplement and get frozen fruits and vegetables versus fresh if they don't have access to fresh produce.

Question: With the practice of proning patients on ventilators for extended periods of time, what practices are being utilized or recommended to prevent pressure injuries?
Answer: This is the routine set we use:

• Initiate pressure relief interventions based on risk:
• Turn and reposition every two hours.
• Monitor under and around all medical devices.
• Heel offloading boots while in bed.
• Limit layers under patient to flat sheet and incontinence product only.
• Place moisture management textile in skin folds, change as needed.
• Check for incontinence every two hours.
• Apply protective ointment to perineal area daily and after each incontinence episode.
• Keep the head of bed 30 degrees or less as tolerated.
• Apply foam dressing to the sacrum, and change every five days and as needed.

For prone patients, we also added recommendations from the NPIAP. They have a great white paper with photos of interventions.

Question: What are you seeing as the biggest struggle (overall and with pressure injury prevention as well) now that we are weeks into the PPE shortage?
Answer: The biggest things we have seen in our facility are the staff being overwhelmed and a lack of education when it comes to pressure injury prevention in prone patients. A lot of the nurses in the specialty unit are volunteers from other units where they may have never proned a patient before.

Question: What are your thoughts regarding the future of your roles and work with vendors and access moving forward?
Answer: I think that work with vendors will gradually resume over time but that preference will likely be given to vendors who are able to provide “solutions” to patient problems—with a new focus on those issues that have been highlighted as a result of COVID-19—facial pressure injuries, decreasing device-related pressure injuries, extending dressing wear-time to avoid more frequent visits, having a broad range of offerings (having one vendor coming in who solves multiple problems is more advantageous than numerous niche vendors in the post-COVID environment).

Question: Please speak to the injuries occurring as a result of proning.
Answer: We are predominantly seeing injuries to the face from proning. We did change out the type of endotracheal tube holders, and that has helped a little.

Question: Similarly, I am a certified wound/ostomy RN in large hospital in Boston (and also an intensive care unit RN). We have seen huge numbers of pressure injuries related to proning,- especially on face related to a lack of sufficient offloading and medical devices that are challenging to offload adequately (endotracheal tubes and holders; lines for continuous venovenous hemodialysis; arterial lines ,etc). My question is what are your thoughts are regarding “reportable” serious reportable events during the pandemic?
Answer: This is a helpful link for those who participate in the NDNQI reporting.

Question: How are you managing patients who need compression wrap on a virtual visit?
Answer: We have been having patients come in with a caregiver who is able to be trained for a single in-person visit. We do the needed training with the caregiver, take a video of them appropriately applying the compression with their own cell phone so they have it for reference, and then make sure they have direct dressing supply delivery to their home coordinated. In situations where this is not possible, we have one home health care agency as an option in our area, or we are looking at the use of Velcro compression garments during this time— not ideal, but better than nothing until in-person visits are more appropriate or possible.

Question: How has COVID-19 changed outpatient wound care therapy? Is telemedicine an option? Are there CMS codes?
Answer: We decreased our outpatient wound care volumes by ~75% for approximately two months and have now been ramping back up in coordination with our organization's business resumption plan. Medicare e-visits became an option for private outpatient physical therapy (PT) about 30 days into that process (telehealth coverage for private payers varied), and virtual visits for PTs functioning in HOPD's AND private outpatient PT were approved by Medicare just prior to this webinar. The Current Procedural Terminology (CPT) codes for virtual PT visits are the same as in person—there are just modifiers required on the back end to designate them as virtual visits. And you also need to designate the patient's home as a remote site of care. The Centers for Medicare & Medicaid Services (CMS) website would be the best resource for the specifics on how to do this. From a physician’s perspective, there are telehealth codes available as well.

Question: I practice in several different sites and patient populations. Can you comment on whether or not there are widespread reports suggesting generalized skin failure in hospitalized intensive care unit patients with COVID-19? Despite heightened preventive measures, we are seeing an increased incidence in hospital-acquired pressure injuries, skin excoriation without the typical moisture or incontinence-associated exposure. Are there other reports of critical care skin issues? Also, please elaborate on the “COVID toe” reports.
Answer: Based on the current evidence, there is no linkage of COVID-19 to increased incidence of “skin failure,” but there are several skin manifestations —rashes, purpura, even some areas of eschar that have been reported. (Casas CG, Català A,, Hernández GC, et al. Classification of the cutaneous manifestations of COVID‐19: a rapid prospective nationwide consensus study in Spain with 375 cases. Br J Dermatol. 2020 [published online ahead of print]. doi: 10.1111/bjd.19163; Bouaziz J, Duong T, Jachiet M, et al. Vascular skin symptoms in COVID‐19: a French observational study. J Eur Acad Dermatol Venereol. 2020 [published online ahead of print]. doi: 10.1111/jdv.16544). The "COVID toes" are likely a vascular manifestation of COVID-19, but there is not any definitive word on that as of yet.

Question: How can you highlight the importance of wound management? This is an area that appears to get very little attention.
Answer: I think in the context of COVID-19, the way to highlight wound management is as a means of preventing secondary complications in vulnerable populations. If we can prevent infection, buy time before a needed surgery, avoid hospitalization through solid wound management, we are doing a service to our patients and the health care system as a whole during the time of this pandemic.

Question: Kindly cover relevant legislation protecting practitioners when providing virtual consults. Thanks!
Answer: The Health Insurance Portability and Accountability Act—HIPAA—is the law that impacts practitioners when providing telehealth consults, along with the 1135 waivers that the CMS issued related to the public health emergency and virtual consults. The Office of Civil Rights (OCR) issued three notifications of enforcement discretion, the first of which was the notification of enforcement discretion for telehealth. Under this notification the OCR waived all provisions of the HIPAA privacy, security, and breach notification rules if a covered health care provider providing telehealth services acted in good faith compliance with the guidance. The notifications can be found at: https://www.hhs.gov/hipaa/for-professionals/special-topics/hipaa-covid1….

Question: Is there a chance wound care will be deemed “non-essential,” thus closing clinics? Do you consider ostomy care essential?
Answer: A couple of states at the beginning of the pandemic had deemed wound care to be non-essential, as did some hospital systems. However, the Alliance of Wound Care Stakeholders issued a letter and statement describing wound care and deeming it to be an essential service. As a result, clinicians were able to show their hospitals and clinics the statement, and many hospitals changed their policies and deemed wound care essential.

Question: Is there any consideration for wound certified RNs to be included as “Nurse Specialists” for billing purposes?
Answer: I believe that one of the waivers, as well as language within the CMS Interim Final Rule With Comments, does in fact permit the billing of certified wound care nurses as nurse specialists during the public health emergency.

Question: Do you have any advice on how to set up wound care and vascular service in these times of pandemic?
Answer: Routine surveillance visits associated with duplex exam for small aneurysms, asymptomatic carotid arteries, and bypass graft surveillance can be delayed. This creates significant space on your schedule to allow the office to remain open with more distancing for those who need to be seen sooner. For wound care patients, we have increased the number of dressing changes performed by the Visiting Nurse Association (VNA) or family and reduced but not eliminated the frequency of in-person visits. Audio and video visits have rapidly ramped up and are a great asset but certainly have limits.

Question: As the COVID-19 situation has evolved, many reports indicate that that COVID inpatient utilization demands have not risen to predicted levels. If that is indeed true, how does that alter your expectations and demands for levels of care for wound patients?
Answer: Certainly it is true that across the United States most hospitals have not been overwhelmed. By reducing census prior to the COVID surge, most hospitals have created space for COVID patients. Although the number of COVID patients in most hospitals most of the time is modest, it should not be forgotten that the care of these patients is very laborious, use of PPE results in lots of inefficiencies, and the spacing requirements for non-COVID patients significantly reduces the capacity of hospitals, at least when working in the pre-COVID hours of operation.

Question: Is there a link between COVID-19 and deep vein thrombosis (DVT) or pulmonary embolism (PE) clinically? Or is there more of a correlation between patients who are non-ambulatory and DVT/PE?
Answer: Yes and yes. There is certainly an increase in thrombotic complications in COVID patients. This is exacerbated by the immobility and high-pressure ventilation required in many of these patients. Prophylactic anticoagulation is recommended for most COVID hospitalized patients. Because clinical supervision is high in many of these patients, there was a surge in requests for vascular ultrasound to rule out DVT. Digital ultrasound (DUS) is an intimate and potentially long encounter for a sonographer. In many cases, the demand for this testing outstripped the capacity of tech staff, and there was great concern about the exposure of our techs to infection. We have adopted a policy of reviewing all requests and calculating Wells scores to gauge the likelihood of DVT, as well as a DVT bleeding score, to weigh the bleeding risk. When patients are at low bleeding risk but high DVT risk, we recommend empiric anticoagulation and reserve DUS for patients with high bleeding risk or other compelling indications for the information. Delayed DUS in these patients post surge when they are non-infectious is then planned.

Question: How can we help patients with wound self-management given the pandemic and challenges arising as a result?
Answer: Video and audio calls directly with patients and family have been a great asset. In addition, for technologically challenged patients, we commonly coordinate with the VNA so we make the call when the VNA nurse is with the patient. Nursing staff make separate calls to coordinate medication and supply issues as well.

Question: What are your thoughts about patients using debridement tools at home on themselves like mechanical debridement with monofilament fiber pads?
Answer: I think that using gentle products like monofilament pads or even moistened gauze sponges to clear the light biofilm is great. Always a good idea, but more so now with significant reduction in the frequency of office visits and office debridements. It will be very interesting to see if wound healing and amputation rates increase significantly as a result of the decreased contact.

Question: Any special challenges for COVID patients whose wounds may require hyperbaric chambers?
Answer: We have continued hyperbaric oxygen for “non-COVID” patients but are now fully cleaning the chamber after every patient instead of the prior once daily full clean. This plus our distancing issues have resulted in our lowering our maximum from four patients per chamber per eight-hour day to two patients per chamber.

Question: I would like you to address the thrombogenesis that occurs in COVID-19 patients and associated cytokines and skin lesions.
Answer: Thrombosis is certainly an issue at all levels of the circulation. I have seen subcutaneous venous thrombus associated with COVID skin. Initially, we were classifying these as deep tissue injury, but when patients recover from COVID, their skin injuries generally seem pretty benign and often vanish without revealing any real wounds. We therefore stopped coding as ATI and created a term, “COVID skin.”

About the Panelists

Marcia Nusgart, RPh
Founder and Executive Director
Alliance of Wound Care Stakeholders
Marcia Nusgart, RPh, is the founder and Executive Director of the Alliance of Wound Care Stakeholders ("Alliance") a non-profit multidisciplinary association for physician specialty societies and clinical organizations whose members treat patients with wounds. It addresses regulatory and legislative issues impacting wound care. She also serves as Executive Director for the Coalition of Wound Care Manufacturers ("Coalition"). As Executive Director of the Alliance and the Coalition, she is viewed as a highly visible, respected and credible source of industry information for the Centers for Medicare and Medicaid Services and their contractors, Food and Drug Administration and the Agency for Healthcare Research and Quality as she advocates for appropriate public policy processes.

As the Alliance’s Executive Director, she organized its efforts in writing two articles, “ An Economic Evaluation of the Impact, Cost and Medicare Policy Implications of Chronic Non-Healing Wounds” (ISPOR’s Value in Health 2018), and “Consensus Principles for Wound Care Research Obtained Using a Delphi Process (Wound Repair and Regeneration May/June 2012). She has also submitted wound care quality measures to the Centers for Medicare and Medicaid Services (CMS) and tackled issues relating to coverage, coding and payment for wound care procedures and products.

She holds a Bachelors of Science in Pharmacy from the Ohio State University (1976). She currently serves on the Boards for five distinct organizations: the Ohio State University College of Pharmacy, Kestrel Health Information (WoundSource), and Jewish Social Services Agency of Greater Washington.

Lee C. Rogers, DPM
Director
American Board of Podiatric Medicine

Mark D. Iafrati, MD, FACS
Chief, Vascular Surgery
Tufts University School of Medicine
Mark D, Iafrati MD, FACS is a Graduate of Harvard College and Tufts Medical School. His is the chief of vascular surgery at Tufts Medical Center and the director of the Center for wound healing at Tufts. Dr Iafrati is the Author if 78 Peer reviewed Journal articles and 16 text book chapters. He has special interest in the venous disease management and serves as the chair of the health policy committee and a member of the board of the American Venous forum.

Paul J. Kim, DPM, MS, FACFAS
Medical Director, Wound Program
University of Texas Southwestern Medical Center
Paul J. Kim, DPM,is the Medical Director of the Wound Program atthe University of Texas Southwestern Medical Centerin Dallas, Texas. He is also a Professor in the Departments ofPlastic SurgeryandOrthopaedic Surgeryat UT Southwestern.

Dr. Kim received a Bachelor of Arts degree,magna cum laude, in psychology and biology from the University of Colorado at Boulder in 1995. He earned a Doctor of Podiatric Medicine degree at the Ohio College of Podiatric Medicine in 2002, receiving multiple honors. He then completed a surgical foot and ankle residency program in 2005 at Inova Fairfax Hospital in Falls Church, Virginia. Dr. Kim also received a Master of Science Degree in Clinical Research Management from Arizona State University in 2012. He is a Fellow of the American College of Foot and Ankle Surgeons.

Dr. Kim has received intramural and extramural research grants in wound care, diabetic limb salvage, and tendon pathology. He has chaired multiple committees related to research, evidence-based medicine, and the diabetic limb for national and international organizations.

He is a national and international speaker and has authored over 150 basic science, clinical manuscripts, and book chapters on foot and ankle medicine and surgery topics, with a specific interest in the diabetic limb.

Karen Ravitz, JD
Health Care Policy Advisor
Alliance of Wound Care Stakeholders
Karen S. Ravitz J.D. is the Health Care Policy Advisor for the Alliance of Wound Care Stakeholders. She has been involved in health care issues for over 20 years. For over three years she was the Associate Director of the Government Affairs Department at the American Physical Therapy Association (APTA). She has a working knowledge of the regulations that apply to physical therapists and has conducted seminars and sessions teaching physical therapists and physical therapy students issues related to the profession, including fraud and abuse and the Health Insurance Portability and Accountability Act (HIPAA) provisions. During her time at the APTA, Karen was instrumental in obtaining coverage for the use of electrical stimulation for the treatment of wounds.

Prior to her work at the APTA, Ms. Ravitz was the Director of Government Affairs for the National Pressure Ulcer Advisory Panel as well as at ASCO Healthcare (now Genesis Health Ventures). She also has worked on Capitol Hill as a legislative assistant.

Karen earned her law degree from the University of Baltimore and her undergraduate degree from the University of California, Los Angeles.

Stephanie Woelfel, PT, DPT, CWS, FACCWS
Certified Wound Specialist, Director of Clinical Physical Therapy - Hospital Outpatient
University of Southern California
Stephanie Woelfel has20+ years in wound management across various practice settings; is the current Vice President of the Academy of Clinical Electrophysiology & Wound Management of APTA; and is the APTA liaison to the National Pressure Injury Advisory Panel (NPIAP).

Emily Greenstein, APRN,CNP, CWON
Certified Nurse Practitioner
Sanford Health
Emily Greenstein is a Certified Nurse Practitioner at Sanford Health in Fargo, ND. She received her BSN from Jamestown College and her MSN from Maryville University. She is board certified as an Adult-Gerontology Nurse Practitioner through the American Academy of Nurse Practitioners. She has been board certified in Wound and Ostomy Care for the past 9 years. She treats patients with acute and chronic wounds, serves as chair for the SVAT committee and is involved in many different research projects. She serves as a blogger for Wound Source. Emily has served as an expert reviewer for the WOCN Society, the Journal for WOCN, and Wounds Journal.

About the Alliance of Wound Care Stakeholders
The Alliance of Wound Care Stakeholders: The Alliance is a nonprofit multidisciplinary trade association of health care professional and patient organizations whose mission is to promote quality care and access to products and services for people with wounds through effective advocacy and educational outreach in the regulatory, legislative, and public arenas.

The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.