COVID-19: Issues related to wound care and telehealth management

INTRODUCTION — Chronic wounds are common occurring in 1 to 2 per 100,000 population in the United States [1]. Lower extremity chronic ulcers predominate with individuals with diabetes and those over 65 particularly affected [2,3].

Chronic wounds are commonly related to the same comorbidities that increase the risk for death from infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) [4,5]. Coronavirus disease 2019 (COVID-19) is highly contagious and spreads through human-to-human transmissions with a relatively long incubation period (median time of six days) [6]. During the incubation period, asymptomatic carriers can infect others [6]. Thus, during the care of patients with wounds, observing proper precautions is important to reduce the risk in this susceptible population. The task of protecting both high-risk patients and health care providers by minimizing exposure to SARS-CoV-2 is essential.

The spread of COVID-19 rapidly progressed to become a pandemic event, causing major disruption in health care services, including the care of patients with wounds [7-10]. Out of necessity, the delivery of wound care, which should be regarded as an essential medical service, shifted [11,12]. The major goals of wound care during this time have been to prevent serious wound complications to minimize hospitalization and surgery, when possible, rather than necessarily to complete wound healing.

The impact of COVID-19 on the care of patients who require wound care is reviewed. Other issues relevant to these patients pertaining to COVID-19 are reviewed separately. (See "COVID-19: Clinical features" and "COVID-19: Diagnosis" and "COVID-19: Management in hospitalized adults" and "COVID-19: Infection prevention for persons with SARS-CoV-2 infection" and "COVID-19: Hypercoagulability" and "COVID-19: Cutaneous manifestations and issues related to dermatologic care".)

INDIVIDUALS AT RISK — A wound is a disruption of the normal structure and function of the skin, possibly extending more deeply, and may be regarded as acute or chronic. Acute wounds in those who do not have risk factors for nonhealing generally resolve through defined stages of healing with basic wound care. Individuals with risk factors can develop a wound that is physiologically impaired due to a disruption of the inflammatory, proliferative, or regenerative phase of wound healing (figure 1). (See "Basic principles of wound healing" and "Risk factors for impaired wound healing and wound complications".)

Typical etiologies for chronic wounds include the following:

●Chronic venous insufficiency (See "Overview of lower extremity chronic venous disease" and "Diagnostic evaluation of lower extremity chronic venous disease" and "Compression therapy for the treatment of chronic venous insufficiency".)

●Pressure-induced skin and soft tissue injury (See "Epidemiology, pathogenesis, and risk assessment of pressure-induced skin and soft tissue injury" and "Clinical staging and general management of pressure-induced skin and soft tissue injury" and "Infectious complications of pressure-induced skin and soft tissue injury".)

●Diabetes (See "Clinical manifestations, diagnosis, and management of diabetic infections of the lower extremities" and "Evaluation of the diabetic foot" and "Management of diabetic foot ulcers".)

●Peripheral artery disease (See "Overview of lower extremity peripheral artery disease" and "Clinical features and diagnosis of lower extremity peripheral artery disease".)

●Malignancy or radiation (See "Approach to the differential diagnosis of leg ulcers", section on 'Malignancy' and "Management of radiation injury", section on 'Cutaneous syndrome'.)

●Surgical site infection (See "Overview of the evaluation and management of surgical site infection" and "Complications of abdominal surgical incisions" and "Wound infection following repair of abdominal wall hernia".)

●Other soft tissue infections (See "Acute cellulitis and erysipelas in adults: Treatment" and "Necrotizing soft tissue infections".)

●Trauma (See "Surgical management of severe upper extremity injury" and "Severe lower extremity injury in the adult patient" and "Severe upper extremity injury in the adult patient" and "Surgical management of severe lower extremity injury".)

●Complication of flap reconstruction (See "Complications of reconstructive and aesthetic breast surgery", section on 'Flap-related complications'.)

●Other less common causes (eg, vasculopathy, pyoderma gangrenosum) that may lead to ulceration (See "Approach to the differential diagnosis of leg ulcers", section on 'Less common causes'.)

Protecting patients

Risk for COVID-19 in patients with chronic wounds — A nonhealing wound is often a culmination of multiple underlying medical problems. Most patients with chronic wounds have multiple comorbidities, such as diabetes, hypertension, and chronic kidney disease. (See "COVID-19: Clinical features", section on 'Risk factors for severe illness' and "Risk factors for impaired wound healing and wound complications" and "Clinical assessment of chronic wounds" and "Overview of treatment of chronic wounds".).

These same risk factors place many patients with chronic wounds in a high-risk category for developing severe consequences if they become ill with COVID-19 (table 1). In a systematic review and meta-analysis of hospitalized patients with COVID-19, diabetes mellitus, hypertension, cardiovascular diseases, smoking, chronic obstructive pulmonary disease (COPD), malignancy, and chronic kidney disease were among the most common comorbid conditions [13]. In another review that analyzed data of 1590 laboratory-confirmed hospitalized patients across mainland China from 575 hospitals, the risk of serious outcomes in patients with COVID-19 was stratified by comorbidity status [14]. One-fourth of patients reported had at least one comorbidity, and just under 10 percent had two or more comorbidities. Patients with COPD, diabetes, hypertension, and malignancy were at risk of reaching the composite endpoints, which were admission into the intensive care unit (ICU), utilization of invasive ventilator, or death. Overall, the patients with any comorbidity yielded poorer clinical outcomes than those without. A greater number of comorbidities also correlated with poorer clinical outcomes [14,15]. In addition, delayed wound care results in more infections and hospital admissions, leading to increased amputations.

Because of this increased risk, efforts to decrease exposure to the virus are of the utmost importance in patients with chronic wounds. In addition to using the standard practices for preventing person-to person transmission (as mandated by governing health agencies), reducing the number of wound care visits, reducing the time interval, and selecting the optimal environment for wound care may help reduce exposure to COVID-19. (See 'Frequency of wound care visits' below and 'Triaging wound care' below.)

There is still some risk for transmission of COVID-19 from nurses or physicians, but with the use of personal protective equipment during care in an inpatient or outpatient environment, the risk is less likely. For the patient who requires care in the inpatient or outpatient hospital settings, the patient should wear a mask covering their nose and mouth. If they do not have a mask, one should be provided for them. (See "COVID-19: Infection prevention for persons with SARS-CoV-2 infection".)

Risk for chronic wounds in COVID-19 patients — In addition to the traditional risk factors for developing wounds (see "Risk factors for impaired wound healing and wound complications"), SARS-CoV-2 is associated with physiologic changes that may affect healing. Whether these changes promote de novo wound development or further impair healing of chronic wounds in patients infected with COVID-19 is unknown. However, these changes may contribute to the already increased risk for pressure-induced skin and soft tissue injury in patients with COVID-19 who require prolonged hospitalization. Pressure-induced injuries have been reported related to prone positioning and face masks [16-18]. (See "Epidemiology, pathogenesis, and risk assessment of pressure-induced skin and soft tissue injury" and "Prevention of pressure-induced skin and soft tissue injury".)

COVID-19-associated vascular skin lesions appear as violaceous macules with "porcelain-like" appearance, or livedo, non-necrotic purpura, necrotic purpura, thrombotic retiform purpura, and chilblain appearance [19-23]. The pathophysiology of these lesions is unclear but may include immune dysregulation, vasculitis, vessel thrombosis, or neoangiogenesis. Severe COVID-19 may define a type of microvascular injury syndrome mediated by activation of complement pathways resulting in the cytokine release including interleukin 6 from the endothelium in severe cases of COVID-19 and an associated procoagulant state. In addition, with downregulation of angiotensin-converting enzyme 2 in association with SARS-CoV-2 infection, accumulation of angiotensin II occurs, leading to vasoconstriction and increased vascular permeability [24]. Direct thrombogenic effects can also lead to tissue ischemia [25]. Additional pathways include T cell and type I interferon-driven inflammatory mediators from the mannan-binding lectin pathway activation and humoral-driven immune complex-mediated vasculitic cutaneous reactions with mild and moderate COVID-19 [26,27].

Clinical findings of acro-ischemia such as toe cyanosis, skin bulla, and gangrene with disseminated intravascular coagulation (DIC) were reported during the COVID-19 outbreak in Wuhan, China [28]. In a histopathological study, skin and lung tissue samples taken from five patients with respiratory failure and a purpuric skin rash showed significant deposits of the terminal complement components C5b-9 (membrane attack complex), C4d, and mannose binding lectin (MBL)-associated serine protease (MASP) 2 in the microvasculature, consistent with sustained, systemic activation of the alternative and lectin-based complement pathways [29]. The purpuric skin lesions similarly showed a pauci-inflammatory thrombogenic vasculopathy, with deposition of C5b-9 and C4d in both grossly involved and normal-appearing skin demonstrating small-vessel and capillary occlusion. SARS-CoV-2 can infect human cells that express the ACE2 receptor for the spike glycoprotein, creating a hypercoagulable state affecting multiorgan systems, which may explain the atypical cutaneous presentation [30]. In support of a hypercoagulable state is the demonstrated increased risk for pulmonary embolism, and amputations secondary to arterial thrombosis [31,32]. Due to the high incidence of thrombosis involving multiple organs, patients who exhibit signs of hypercoagulability are fully anticoagulated. (See "Direct oral anticoagulants (DOACs) and parenteral direct-acting anticoagulants: Dosing and adverse effects".)

A variety of other skin lesions/ulcerations are associated with COVID-19 and include more widely distributed manifestations (eg, exanthematous eruptions, vesicular eruptions, urticaria, papulovesicular rashes) and also more focal lesions that can occur in the extremities with relapsing manifestations (eg, livedo reticularis, painful acral papules, pruritic erythematous plaques, petechiae pernio-like lesions) [33-47]. Some of these skin lesions arise before the signs and symptoms more commonly associated with COVID-19 [35,48,49]. These lesions have also been seen in children [50]. Most heal spontaneously, and studies have reported no correlation between COVID-19 severity and healing [51,52]. However, the overall immunologic condition of the patient could impair wound healing depending on the severity of the COVID-19 infection. In addition, hypersensitivity reactions may occur with the vaccine. However, these similar reactions are mild, self-limited, and primarily due to type IV delayed dermal hypersensitivity reactions [53]. (See "COVID-19: Cutaneous manifestations and issues related to dermatologic care".)

Patients admitted to intensive care units requiring multiorgan support are at higher risk of developing pressure injuries due to immobility, sedation, vasopressors, and hypoxia. Skin presentation may appear related to pressure; however, the extent of the skin damage reflects a more involved vascular inflammatory process [54].

In addition, to prevent the spread of COVID-19, the Centers for Medicare and Medicaid Services and the Centers for Disease Control in the United States provided guidance for residents in long-term facilities. Most residents were confined to their room, limiting their mobility [55]. Limited mobility is a risk factor for pressure injury development and loss of musculoskeletal fitness, resulting in secondary consequences such as fall risk and respiratory conditions [56]. (See "Epidemiology, pathogenesis, and risk assessment of pressure-induced skin and soft tissue injury".)

Protecting health care workers — Health care workers can expose themselves to SARS-CoV-2 when taking care of patients, including during the care of patients needing chronic wound care [57]. COVID-19 testing was not implemented for routine wound care.

SARS-CoV-2 is present in respiratory droplets [58,59], but little is known about the shedding of the virus in bodily fluids and associated risks. While SARS-CoV-2 has also been identified in saliva and mucosal secretions, there has been no identification of SARS-CoV-2 in wound tissue or fluid [58,60,61].

To prevent person-to-person transmission, home health care workers are mandated to wear a mask and gloves upon entering a patient's residence. Hospital policies may vary across health systems. In the hospital setting, governing policies should be followed. As PPE became more readily available, personnel were fitted with N95 masks with competency in donning and doffing PPE upon entering rooms with patients positive for COVID-19. For managing patients in routine care, face mask covering is required [62]. (See "COVID-19: General approach to infection prevention in the health care setting".)

TRIAGING WOUND CARE — Wounds can be treated in a variety of settings. A common model provides care in a dedicated location using an interdisciplinary approach (ie, wound care center). For chronic lower extremity wounds, the need for amputation is reduced when care is undertaken at a dedicated wound center [63-65]. During the COVID-19 pandemic, typical wound care paradigms have been severely affected (figure 2). Disruption of wound care centers, which are often closely associated with hospitals, required modifications to the delivery of wound care (figure 3). These include alterations in the goals of wound care and a shift in care to other health care environments, with greater emphasis on care in the home environment, which is a lower-risk environment for patients to receive wound care [11,12]. (See 'Goals of wound care' below.)

The tremendous stress put on health care systems as a result of the COVID-19 pandemic created the need for triage systems for better resource utilization to overcome obstacles, which have included shortages of personal protective equipment (PPE) and health care workers and reduced supplies [66,67]. Potentially useful classifications that can be used to triage patients with wounds are briefly reviewed.

Useful classifications

●Diabetic foot ulcer (and wounds in general) – For managing patients with diabetic foot problems, a triaging system was suggested to help inform the best setting in which to treat patients [68]. This system is applicable and can be extended to triaging a variety of wound etiologies and complications with only minor modifications [11]. Patients with wounds are categorized by wound severity as critical, serious, guarded, or stable (high- to low-priority groups 1 through 4, respectively) to determine the appropriate initial site of care (figure 4). Wound priority can be escalated or reduced depending on changes in the patient's condition. Low-priority wounds can be managed in the home by providing additional support to the patient through visiting nurse services with physician oversight through telehealth. Communication between providers can be assisted by using the SINBAD classification [69]. High-priority wounds will require additional services available in the clinic or hospital setting. (See 'Wound care delivery' below.)

The triage categories are as follows:

•Critical (priority 1) – Patients with Infectious Disease Society of America (IDSA [70]) severe (systemic signs of infection such as temperature >38°C, tachycardia, tachypnea, abnormal white blood cell count, or failed initial therapy), and some moderate infections (systemic signs), gas gangrene, sepsis, and acute limb-threatening ischemia should receive care in a hospital setting.

•Serious (priority group 2) – Patients with IDSA mild and some moderate infections, including those with osteomyelitis, chronic limb ischemia, dry gangrene, worsening foot ulcers, and active Charcot foot, should receive care in an outpatient clinic, office-based lab, surgery center, or podiatry office.

•Guarded (priority group 3) – Patients with improving foot ulcers and inactive Charcot foot (not yet in stable footwear) can receive care in a podiatry office, or at home, with oversight through telehealth.

•Stable (priority group 4) – Patients with uncomplicated venous leg ulcers, healed foot wounds or amputations, and inactive Charcot (in stable footwear) represent 94 percent of patient with diabetes who have wounds. These patients can be treated at home or through telehealth [68].

●Possible limb-threatening ischemia – For patients with lower extremity wounds and possible chronic limb-threatening ischemia (CLTI) (figure 5), the Wound, Ischemia, foot Infection (WIfI) threatened limb classification system can also help stratify and triage patients. A higher clinical stage increases the risk for amputation. The presence of infection and advanced wound grades are the major drivers for higher clinical stage and the need for inpatient care. (See "Classification of acute and chronic lower extremity ischemia", section on 'WIfI (Wound, Ischemia, foot Infection)'.)

•For patients with low-stage limbs (stage 1/very low risk), monitor and treat via telehealth.

•For patients with intermediate-stage limbs (stage 2/low risk and some stage 3/moderate risk), provide face-to-face care in an office or wound care center.

•For patients with some stage 3/moderate risk and most high-stage limbs (stage 4/high risk), admit for inpatient care, provided the hospital has capacity.

●Pressure-induced skin and soft tissue injury – The National Pressure Injury Advisory Panel (NPIAP), the governing body for classification (table 2) and treatment of pressure-induced skin and soft tissue injuries (formerly called pressure ulcers), did not provide specific triage recommendations. However, patients with infected pressure-induced skin or soft tissue injury would classify as Priority 1 as described for the diabetic foot ulcers above. Prevention of pressure-induced injury during prone positioning includes using pressure redistribution surface and positioning devices, repositioning medical devices, and avoiding contract over areas of prior pressure injury [71]. Adequate staffing to reposition the patient helps to avoid friction sheer. Positioning frequency is dependent on the patient's activity, ability to independently reposition, and tissue tolerance. "Turning" is limited to microshifts and changing the position of the head, arms, and upper body according to "swimmer position" protocols [24]. Soft silicone multilayered foam over pressure points and under medical devices is recommended.

Skin manifestations that are purpuric or nonblanchable purple skin lesions seen with COVID-19 are not consistent with deep tissue pressure injury (DTPI) because they lack pressure-induced injury. Skin changes likely represent tissue ischemia due to thrombosis. Skin changes can appear purpuric progressing to necrosis. If vessels are thrombosed, reperfusion is not achievable even in the presence of offloading. After confirming that the skin change is not due to pressure, wound care providers should not label these skin changes as DTPI, but rather potential skin manifestations from COVID-19. (See "Clinical staging and general management of pressure-induced skin and soft tissue injury".)

Proper nutrition contributes to the prevention of pressure injuries and has a significant role for patients who are critically ill. Infections, such as COVID-19, lead to a hypermetabolic state and increase the risk for nutritional deficiency [72]. Nutrition support can be delayed in severely ill patients with COVID-19. Patients being ventilated with prone positioning receive significant amounts of sedation and paralytic agents, which slow digestive function resulting in decreased absorption of nutrients. Additionally, development of diarrhea, which can damage the skin, creates incontinence-associated dermatitis (IAD) and further increases the risk for pressure injury [73].

Promotion of home care — To expand sites available for treating patients during the pandemic, delivery of care from health care providers in the home setting was promoted to reduce the risk of COVID-19 transmission [11]. During the initial phase of the pandemic, the US Department of Health and Human Services Office for Civil Rights had relaxed rules regarding the use of Health Insurance Portability and Accountability Act (HIPAA)-compliant software to perform telehealth visits [74]. HIPAA-compliant telehealth services became available and can now help assist in the continuity of care for patients who are unable to travel.

Wound consults by telehealth also can be performed on hospitalized inpatients, in the emergency department, or in an extended care facility. Additionally, providers can bill for similar services provided in a wound care setting at a patient's home setting. Health care practitioners should include their legal and billing teams as early in the process as possible and check with their malpractice insurance carrier to ensure coverage for the telehealth service provided [75]. For CMS reimbursement, a provider can be licensed in a state other than the patient's state of residence, but providers should check with the respective state medical boards. [76,77]. In the home, CMS directed providers to use the telehealth reimbursing office evaluation and management codes with Place of Service 02 for Medicare Telehealth Visits. Since it is not feasible to perform all the components necessary to properly code for visits, providers can use time-based coding.

WOUND CARE IS ESSENTIAL — Wound care services were initially regarded as a nonessential service during the pandemic crisis, and many wound care practices were reduced. Compared with prepandemic, data from the Quarterly Services Survey (QSS) indicate that some of the largest drops in health revenue were in ambulatory care settings such as physicians' offices and in outpatient care centers [78]. 

Without adequate care, patients with chronic wounds are at risk for developing infection, which increases the risk for limb complications and potentially loss of limb and life [15,64,68,79,80]. In addition, if the frequency of debridement is reduced, wound healing times become prolonged, using additional resources. Wound deterioration among those who do not receive adequate off-loading (eg, diabetic foot ulcers) or compression treatments (eg, chronic venous ulcers) has been reported [11,15]. Offloading can be challenging in prone positioning; offloading boots may help alleviate pressure points [81].

Goals of wound care — For patients with noncritical wounds (eg, stable ulceration, dry eschar), the general aim for wound management during the pandemic primarily has been to ensure a virus for both patients and health care providers. The wound care community must accept that the goal is not necessarily to complete ulcer healing or wound closure, though this may occur.

Frequency of wound care visits — For patients with exposure to SARS-CoV-2, it is essential to maintain the frequency and level of care needed for wound healing or at a minimum to prevent wound deterioration. The optimal frequency of wound care visits differs for various types of wounds, and telehealth service can be employed.

In a large review, 39,750 wounds associated with 17,849 patients were seen in 115 clinics [82]. Diabetic foot ulcers seen at a frequency of 7.5 times or more per four weeks healed faster than the wounds seen at intervals of two weeks or less. More frequent wound care visits enabled clinicians to identify issues that impair wound healing, including patient compliance issues, challenges that might affect adherence to the treatment, early signs of infection, whether home nursing services are carried out appropriately, and whether the wound needed debridement. Increased patient interaction also reduced social isolation, which had a positive influence on patients. The authors recommend that patients be seen at least once every two weeks, preferably more often [82]. Another study found similar results, with diabetic foot ulcers and venous leg ulcers closing over twice as fast on average for weekly compared with the every-other-week visits [83]. One study suggested even more frequent debridement. In a review of over 150,000 wounds of all etiologies, wounds that were debrided every <1 week healed faster than wounds that were debrided every 1 to 2 weeks or >2 weeks [84]. As an example, for diabetic foot ulcers, the median time to heal for weekly or higher-frequency debridement was 21 days compared with 64 and 76 days for one- to two-week or two-week or more intervals between debridement, respectively.

Wound deterioration and need for re-evaluation or intervention are determined based on clinician and nurse discretion and the following criteria:

●Increasing necrotic tissue

●Appearance of any signs of infection

●Failure to show signs of healing in a timely manner

●Appearance of excessive fibrotic tissue that requires sharp debridement

Wound dressings/adjuncts — Standard wound care practices can be followed. However, supplies of wound dressings, orthotics, and other adjuncts to wound care may become limited, necessitating a change in wound care practices or requiring sourcing from other suppliers. National mail-order suppliers are a useful alternative. In addition, internet sourcing of some products can supplement or supplant local sources temporarily. For clinicians with less experience with wound care, selecting a wound dressing can be aided by becoming familiar with the major categories of dressings and applications (table 3), by using a decision aid (table 4) that may include various smartphone apps, or by using a protocolized approach (such as from their local wound care center) [85]. Wound dressings can be disposed of in a standard trash bin for subsequent medical disposal (except for sharps). (See "Basic principles of wound management" and "Basic principles of wound management", section on 'Topical therapy' and "Basic principles of wound management", section on 'Wound dressings'.)

Wound care adjuncts such as hyperbaric oxygen, topical oxygen therapy, or negative pressure wound therapy can also be used as indicated, provided they are available. (See 'Surgery' below and "Negative pressure wound therapy" and "Hyperbaric oxygen therapy".)

Infection — The risk of infection is high for patients with certain types of wounds. In one review of patients with diabetic foot ulcers, more than 50 percent of patients became infected during the course of treatment [86]. Infection increases resource utilization; the need for hospitalization; surgery; and, for lower extremity wounds (particularly ischemic wounds), amputation [87]. While Centers for Disease Control (CDC) in the United States recommend limiting empiric antibiotics, their use was liberalized for those with mild infection. The type of antibiotics has not changed (gram positive for wounds not associated with diabetes, gram-positive and gram-negative coverage for patients with diabetes). (See "Clinical manifestations, diagnosis, and management of diabetic infections of the lower extremities" and 'Triaging wound care' above.)

Surgery — The Centers for Medicare and Medicaid (CMS) in the United States issued a recommendation to limit elective surgery and procedures in early stages of the COVID-19 pandemic [88]. The American College of Surgeons (ACS) provided guidance to assist decision-making regarding the performance of surgery during the pandemic, which can be used for future crisis events [89]. Procedures are classified into three tiers:

●Tier 1: Postpone surgery or perform at ambulatory surgery center

●Tier 2: Postpone surgery, if possible, or consider ambulatory surgery center

●Tier 3: Do not postpone

The goals of surgical triage are to minimize potential COVID-19 exposure to staff and patients, conserve critical supplies and equipment for acute patients with COVID-19, reduce intensive care unit and inpatient bed usage, and free up staff to be re-deployed for pandemic patients [11,90]. Standalone ambulatory surgery centers (ie, locations that are not directly involved with care of COVID-19 patients) can provide an alternative location for surgical care. As restrictions on the conduct of elective surgery are relaxed, a surgical scheduling may require that patients who can will continue to wait for surgical care.

Prior to elective surgery and other procedures, COVID testing is necessary. Protocols vary from one hospital system to another. In the author's hospital system, all patients undergoing elective surgery must have COVID-19 testing performed within 72 hours before the procedure. The results of the test must be negative before proceeding with elective surgery. If the result is positive, the patient must wait two weeks and undergo repeat testing before proceeding.

Skin grafting/cellular tissue-based products and safety — There are ample data demonstrating the efficacy of cellular tissue-based products in accelerating wound healing compared with standard wound care (ie, wet to moist dressings) (table 5). There are several types of cellular tissue-based products, some of which are processed from donor tissues (living, deceased) (figure 6). (See "Skin substitutes".)

The ability to extend their use outside the typical care environments in which they are used is limited. Most cellular tissue-based products are applied in wound centers or in the operating room since the use of cellular tissue-based products or biologics requires clinicians or facilities in the United States to have a tissue license. Licensing maintenance requires keeping a log of all living and nonliving skin equivalents, which includes the type of skin substitute, name of manufacturer, temperature monitoring for storage of cellular tissue-based products, dates received from the manufacturer, and date of application. In addition, the facility is inspected annually by the US Department of Health. With reduction in performance of nonemergency surgical procedures, the demand for tissue allografts may be reduced. In the United Kingdom, living donor programs for amniotic membrane were temporarily suspended, and deceased tissue donation activity was reduced in line with surgical demand [91].

International practice in screening tissue donors for COVID-19 is variable [91]. Data are limited quantifying viable virus in bodily fluids and various tissues; no data are available on viremia during the incubation period, for asymptomatic infection, or following resolution of symptoms. For symptomatic patients, detection rates for viral nucleic acid in the blood range from 1 to 15 percent [92,93]. Respiratory viruses are not known to be transmitted via tissue allografts; for similar viruses, SARS-CoV and MERS-CoV, there have been no documented cases of transmission through tissue transplantation [94]. Donated tissue for skin allografts is decellularized and rendered nonimmunogenic. Many of the processes used have antiviral properties. As an example, high-dose gamma irradiation was shown to inactivate coronaviruses. (See "Skin substitutes" and "Reconstructive materials used in surgery: Classification and host response", section on 'Allograft processing'.)

WOUND CARE DELIVERY — All aspects of the health care system have needed to collaborate and accommodate the sudden changes introduced to contain COVID-19. The COVID-19 pandemic necessitated shifts not only in the site but also the goals of wound care. The home setting was promoted to reduce the risk of COVID-19 transmission. (See 'Promotion of home care' above.)

Remote care — For eligible patients, home health services can be arranged during the initial patient encounter with the clinician (face-to-face or virtual visit). The treating clinician directs the care of the patient and reorders any supplies that are needed through the home health nurse.

For a patient to receive home health care assistance to manage a wound, a face-to-face encounter certification is typically required. A patient would generally be evaluated in an office setting by a clinician who would deem the patient homebound due to:

●Pain severely limiting mobility

●Requirement of an assistive device for mobility

●Safety risk due to gait instability

●Immunocompromised status secondary to oncology diagnosis

●Open wound potential for infection

Rather than seeing the patient in the office or clinic, the patient encounter can be initiated via a telehealth platform, if the patient is capable. For some patients, telehealth alone may be appropriate, but for most, a combination of approaches in the home is anticipated. A streamlined process can be created to establish wound care in the home or a nursing facility with telehealth and face-to-face encounters, when necessary. At the author's institution, the hospital mandated that telehealth comprise 30 percent of clinical practice, including wound services. (See 'Telehealth' below.)

Home care services also include social services and physical therapy. Social services also provide at-home meals to those eligible. The goals of skilled nursing care at home typically include assessment of pain, monitoring for adverse reaction to wound treatments, and patient education regarding signs and symptoms of infection. In addition to typical in-home nursing services (blood draws for laboratory testing, wound cultures), a visiting physician can provide additional services more typically performed in a clinic setting, such as wound debridement, complete vascular assessment, and more advanced wound care (eg, contact casting).

Remote wound care can take place in the home (self-care, nursing services) or at an extended care facility.

●Self-care – Self-care is an acceptable option if the patient (or family or other caregiver) can perform wound cleansing and dressing changes with ease and can communicate any problems or complications with their clinician as they arise. Proper instruction of techniques for wound care is essential. As an example, a patient or family caregiver may be able to provide routine dressing changes for a small surgical site that has become infected.

●In-home visits – For more complicated wounds (eg, deep wound packing, negative pressure wound therapy, compression therapy) or circumstances in which the patient (or lay caregivers) cannot or do not wish to engage in wound care, home health service will be required.

●Extended care facilities – To minimize the risk of COVID-19 and death among their residents, extended care facilities had implemented serious isolation measures and bans on all visitors, which can include outside wound care providers during the crisis. Appropriately trained staff in the extended care facility should be able to provide wound care that meets the goal of stabilizing wounds and preventing infection. Nursing staff at extended care facilities can use telehealth services for virtual consultations and treatment recommendations including orders for medications and supplies. (See 'Telehealth' below.)

Outpatient care — When home visits cannot be performed or would be inadequate as in the case of more complex wounds, the patient will need to be seen in the clinician's office, which may or may not be located at a wound care center. A complete examination can be performed, and laboratory studies obtained. In some settings, noninvasive vascular testing (eg, pulse volume recordings, ankle-brachial indices, duplex ultrasound, perfusion studies), can also be obtained. At the author's institution, patients are screened 24 hours prior to an office visit for flu-like symptoms and redirected to a telehealth visit if the patient reports testing positive for COVID-19.

Basic procedures such as surgical debridement, application of cellular tissue-based products, and other therapies can also be performed in the office setting. To reduce the utilization of hospital services, it may be desirable to expand the procedural capability in the office or wound center setting to include other procedures (eg, more extensive debridement, minor amputation, abscess drainage). To accomplish this, appropriate space as well as identification of additional equipment and medications would be needed to safely perform these procedures.

In addition to the ability to perform more extensive debridement, additional advantages of the wound center include better access to subspecialty care (eg, infectious disease specialists, podiatry, vascular surgery). Typically, there are more options for wound care, and supplies are typically more plentiful. Other therapies may also be initiated more easily (eg, hyperbaric oxygen, negative pressure wound therapy, compression therapy, offloading). However, wound care centers that were located within a hospital setting during the crisis may not have been available for use, and care in this setting may an increase the risk for COVID-19 exposure. Strategies to reduce risk in the outpatient setting are discussed separately. (See "COVID-19: Evaluation of adults with acute illness in the outpatient setting".)

Inpatient care — While the risk of COVID-19 transmission for wound patients is higher for the acute care hospital setting compared with other health care settings, hospitalization may be unavoidable for patients with high-priority wounds.

Patients who develop the following conditions associated with wounds should be treated in a hospital setting:

●Some moderate and all severe infections, systemic inflammatory response syndrome, sepsis

●Wet or gas gangrene

●Limb-threatening ischemia (acute-on-chronic disease)

In addition to using mandated precautions to prevent person-to-person transmission of SARS-CoV-2, care of these patients may be modified in the following manner:

●For patients presenting with lower extremity wounds and without evidence of limb-threatening infection (eg, wet gangrene) or acute ischemia, if surgical revascularization is indicated, it may be deferred until after managing the acute wound issue.

●For patients with wound infection or cellulitis in association with chronic venous insufficiency or lymphedema, wound debridement, compression therapy, and antimicrobial therapy can be initiated. Vascular evaluation can be deferred to outpatient setting.

●For patients with localized osteomyelitis, debridement and antimicrobial therapy may be sufficient in the interim, allowing definitive management to be delayed.

Local wound care is initiated as the patient is discharged, and step-by-step instructions are provided for follow-up either in person or via telehealth. Clinicians must determine on a case-by-case basis whether hospital-based diagnostic studies (eg, vascular ultrasound, computed tomographic [CT], and magnetic resonance [MR] angiography) can be postponed. Diagnostic tests should only be performed if their results will change immediate management.

The goal is to reduce the length of hospital stay, performing only the necessary tests and procedures and coordinating any anticipated care or other services early to facilitate discharge as soon as possible [11]. Discharge planning includes coordination of care with the home health agencies and home durable medical equipment and supply companies. In addition, office or wound care center resources are required to follow up with home care providers to ensure that more complex home plans of care are properly followed.

TELEHEALTH — The main requirement for initiating telehealth is patient accessibility via smart phone or computer. Any of several online computer/smartphone applications and services, as well as hospital-based telehealth platforms, can be used. Most nurses have access to a telehealth communication platform to help keep track of medical information, such as the vitals, physical examination, wound measurements, and the progress of the wound. Verbal consent of the patient or legal guardian is required for telehealth or telephonic communication [95].

Any of these allow a virtual appointment with the patient, during which the patient can discuss their history and concerns. The patient can be scheduled for a weekly telehealth visit with a nurse, and patients with deterioration of wound progress can be directed back to the office for further evaluation (algorithm 1).

Types — There are three main types of virtual services that the health care providers can offer: telehealth visits, virtual check-ins, and e-visits [74]. The accessibility of the provider, home care agency, and patient will dictate what form of telehealth is provided. Telehealth visits seem to be the most useful in evaluating the wound patient [11].

●Telehealth visits – When conducting Medicare telehealth visits, the provider must establish an interactive audio and video telecommunication system that permits real-time communication with the patient at home. These visits are considered the same as in-person visits and are paid at the same rate as in-person visits. The patients can receive care in any health care facility or in their home, and the patients can be new or established.

●Virtual check-ins including telephonic communication – Virtual check-ins entail a brief communication service between established Medicare patients and practitioners over a telephone, through video or image, secure text messaging, email, or use of a patient portal to avoid unnecessary trips to the doctor's office.

●E-visits – Established Medicare patients can also use e-visits, which means that the patient may have non-face-to-face, patient-initiated communication with doctors using online patient portals [74].

Efficacy — Multiple studies have pointed to the efficacy of telehealth for improving wound care outcomes as well as high patient satisfaction rates with these services [96-99]. Telehealth has been used to care for patients with diabetes for over two decades with good results [100]. In a meta-analysis that included two trials, 213 patients treated using telehealth were compared with 301 patients treated with usual care [96,101,102]. The telehealth system comprised a trained nurse who collected data and took digital images of the wound. Collected data included questions about quality of life, such as nutrition, movement, and pain levels, as well as patient satisfaction with the treatment. The information was then sent to the physician for decision-making. Complete ulcer healing (odds ratio 0.86, 95% CI 0.57-1.33), healing time (43 versus 45 days), and amputation rate (6.2 versus 7.7 percent) were similar between the groups. The telehealth group had a significantly higher mortality rate (4.1 percent [8 of 193] versus 1.2 [1 of 181]) without clear underlying reasons. No adverse events were attributed to using telehealth. The studies in the systematic review also reported that supplementing outpatient clinic visits with telehealth consultations increased the frequency of complete healing and the healing rate of diabetic foot ulcers, as well as reduced frequency of limb amputation. Several studies reported good patient satisfaction with their telehealth experience [97-99].

Telehealth has also been widely used in many countries to provide cost-effective and less resource-demanding medical care. The first conceptual framework for telehealth implementation during outbreaks was published in 2015 [103]. Telehealth was shown to be helpful in treating patients during the severe acute respiratory syndrome–associated coronavirus (SARS-CoV), Middle East respiratory syndrome coronavirus (MERS-CoV), Ebola, and Zika viruses [104,105]. At the time of the COVID-19 pandemic, telehealth, especially video consultation, was promoted to reduce the risk of transmission. However, most countries lack a regulatory framework to authorize, integrate, and reimburse the service. A call to adopt the necessary regulatory changes supporting wide implementation of telehealth during the COVID-19 pandemic for countries without the integrated service was made [103].

Challenges and barriers — There are many technical barriers to telehealth services. Adequate internet capability, whether wired (ethernet) or wireless, of the provider and patient is essential and determines the speed and image quality in demonstrating wounds to the provider. Some patients are unable to download the appropriate applications owing to the age of their devices. Older devices have less memory capacity for the newer apps needed for telehealth. Increasing the broadband capability allows faster transmission of video images and less "freezing." Poor image quality makes it difficult to provide a proper diagnosis.

Patients who lack resources for data transmission and photos via a smartphone may resort to correspondence via the hospital or patient portal system, if available. The patient can email photos or discuss their concerns directly with their provider over the phone (ie, telephonics). With email, there may be delays in transmission of patient health information due to its encryption.

It is also important to note that coding and billing reimbursement for telephonics differs from telehealth face-to-face visits.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: COVID-19 – Index of guideline topics" and "Society guideline links: Telehealth and telemedicine".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topics (see "Patient education: COVID-19 overview (The Basics)" and "Patient education: COVID-19 and pregnancy (The Basics)" and "Patient education: COVID-19 and children (The Basics)" and "Patient education: COVID-19 vaccines (The Basics)")

SUMMARY AND RECOMMENDATIONS

●Chronic wounds – Chronic wounds are common and are often related to the same comorbidities (eg, diabetes, hypertension, obesity, chronic kidney disease) that increase the risk for death if the patient becomes infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). During the care of patients with wounds, observing proper precautions is of the utmost importance to reduce the risk in this susceptible population. The risk of transmission is likely less in the home care setting with appropriate precautions, compared with other health care settings. (See 'Protecting patients' above.)

●Wound healing and SARS-CoV-2 – SARS-CoV-2 is associated with physiologic changes that may affect healing. Whether these changes promote de novo wound development or further impair healing of chronic wounds in patients infected with COVID-19 is not known for certain. Patients with COVID-19 can present with novel vascular skin lesions which may represent the sequelae of microvascular injury. Hospitalized patients with COVID-19 have an increased risk for thrombotic events, which can include arterial thrombosis. (See 'Risk for chronic wounds in COVID-19 patients' above.)

●Triaging wound care – Timely wound care is important to prevent complications and reduce the time to healing. Disruption of wound care paradigms led to modifications in the delivery of wound care. A triaging system can be used to help identify the most appropriate location to treat patients who require wound care. The general aim for wound management during the COVID-19 pandemic has been to ensure a level of wound care that prevents deterioration while limiting unnecessary in-person visits to minimize exposure to the virus for both patients and health care providers. (See 'Triaging wound care' above and 'Goals of wound care' above.)

●Wound care delivery – Delivery of wound care in the home setting is promoted to reduce the risk of COVID-19 transmission, and barriers to telehealth services access have been reduced.

•During the COVID-19 pandemic, patients were considered homebound and thus qualify for home care services for wound care regardless of the type of wound. Remote wound care can take place in the home (self-care, in-home visits) or at an extended care facility. (See 'Promotion of home care' above and 'Remote care' above.)

•The accessibility of the provider, home care agency, and patient will dictate what form of telehealth (telehealth visits, virtual check-ins, e-visits) is provided. Telehealth visits seem to be the most useful in evaluating the wound patient.

•The model of wound care adopted during the pandemic, which places emphasis on remote care, can help manage patients in the future. (See 'Telehealth' above.)

•When remote care visits cannot be performed or would be inadequate, as in the case of more complex wounds, the patient will need to be seen in the clinician's office or treated in the hospital (eg, severe infection, limb-threatening ischemia). Prior to undergoing surgery, the patient may require symptom screening or COVID-19 testing, depending on the location of the procedure and institutional practices. (See 'Surgery' above.)