The coronavirus disease of 2019 pandemic is driving significant change in the health-care system and disrupting the best practices for diabetic limb preservation, leaving large numbers of patients without care. Patients with diabetes and foot ulcers are at increased risk for infections, hospitalization, amputations, and death. Podiatric care is associated with fewer diabetes-related amputations, emergency room visits, hospitalizations, length-of-stay, and costs. However, podiatrists must mobilize and adopt the new paradigm of shifts away from hospital care to community-based care. Implementing the proposed Pandemic Diabetic Foot Triage System, in-home visits, higher acuity office visits, telemedicine, and remote patient monitoring can help podiatrists manage patients while reducing the coronavirus disease of 2019 risk. The goal of podiatrists during the pandemic is to reduce the burden on the health-care system by keeping diabetic foot and wound patients safe, functional, and at home.
At the time of this publication, the global pandemic of the novel coronavirus disease of 2019 (COVID-19) has infected more than 340,000 people worldwide and claimed 15,000 lives. In the United States, 36,000 have been infected and 475 dead so far. It has affected every state in the Union.
At the current trajectory, the health-care system will be pushed to the brink, exceeding the available supply of personal protective equipment, intensive care unit beds, and ventilators. Front-line providers will have to make decisions about rationing care based on the chances of survival.1 Governments have taken unprecedented actions to flatten the curve of the infection rate, which include social distancing, banning gatherings of people, quarantines, closure of businesses, and limiting movements outside the home. In addition to these actions, the health-care system is changing at lightning speed to accommodate the anticipated need of masses of pandemic patients. The governments and regulators are advising postponing or canceling all nonessential medical services and elective operations, which include many podiatric procedures.2,3 Some, if not many, of these strategies will be in place for 12 to 18 months, until herd immunity is in place through widespread vaccinations.4
However, the effects of the pandemic will be felt far beyond just those who are infected with the novel coronavirus. Because of the drastic containment and mitigation measures, other parts of the health-care system that are impacted are leaving fragile patients without necessary services. Wound centers, where many podiatrists provide care for diabetic foot ulcers, are closing or reducing their hours because they are located in the physical space of the hospital and also as a result of a provider shortage from emergency medicine and infectious disease doctors being repurposed away from the wound center.5 Diabetic foot ulcer procedures and operations may be misclassified as nonessential; however, without regular podiatric care,6–8 vascular diagnostics, or surgical intervention, these patients are at risk of quickly becoming infected, which will lead to an increase in amputations and deaths.9,10 Furthermore, people with diabetes represent a fragile population that is at increased risk of mortality from COVID-19.11 It is advisable to avoid unnecessary diabetes-related hospital admissions to reduce the risk of COVID-19 exposure in the hospital.
The sudden changes in the system are leading all health-care workers to find their new place in combating a common enemy, COVID-19. The importance of podiatry’s role in unburdening the system by preventing diabetic foot–related hospitalizations cannot be overstated.
However, podiatrists will have to quickly adapt the new pandemic system of care and change to provide services in new and unique ways. We strongly recommend implementing a triage system for lower extremity wounds and diabetic foot problems, which will drive the site and urgency of podiatric care (Table 1). We have identified the following changes in the health-care system impacting podiatrists and their patients and recommend strategies to perform best practices in the new pandemic standard of care for the at-risk diabetic foot.
Pandemic Diabetic Foot Triage System
Shift Away from Hospital-Based Care
We strongly discourage hospitals and regulators from declaring all “podiatric procedures” as nonessential, arbitrarily based on our degree or licensure. Podiatrists treat a wide range of foot and ankle problems that are urgent, including serious foot infections, gangrene, and traumas. However, few places is the podiatrist’s role and unique expertise as valued as on the hospital’s wound team and limb preservation unit. Good, regular podiatric care has been shown to reduce diabetes-related emergency room visits, hospitalization, length-of-stay, and amputations.12–17
A large percentage of outpatient wound centers are located in the physical space of the hospital, which is unique among all outpatient service lines, for both billing reasons (ie, hospitals charge facility fees) and safety considerations (ie, ability to respond to hyperbaric oxygen treatment emergencies). However, in the coming months, we anticipate that many wound centers will close because of guidance from the US Surgeon General, the Centers for Medicare & Medicaid Services (CMS), and state/local governments to reduce outpatient traffic in the hospital and nonessential services.
In some cases that are not critical, podiatrists can shift the site of hospital-based wound care and surgical procedures to ambulatory surgery centers and podiatry offices. The Centers for Disease Control and Prevention has made recommendations on preparing your practice for COVID-19, including materials that can be printed and posted outside and inside the office.18 Some patients that require revascularization can be referred to office-based laboratories that are extensions of vascular surgery, cardiology, or radiology outpatient offices.
Increased Use of Telemedicine and Remote Patient Monitoring
The Centers for Disease Control and Prevention is recommending that providers leverage telemedicine whenever possible to protect patients and staff from COVID-19.18 The federal and state governments have been relaxing telemedicine regulations for providers. The Office of Civil Rights at the Department of Health and Human Services, the agency that enforces the Health Insurance Portability and Accountability Act of 1996, has issued an advisory that providers can now use standard video chat applications that are available on phones and computers during the national emergency.19 In our experience using FaceTime and Google Glass in wound-based assessment,20,21 combinations of “store and forward” photographs, short message service text, or text video chat are useful to screen for infection and evaluate wound progress.
The CMS relaxed requirements so that providers can now bill Medicare to see new patients (previously limited to established patients) in any area of the country, in all care settings, at the same rates as regular in-person visits.22 Medicare has also eliminated the requirement that the provider have a license in the state where the patient is being seen by telemedicine.
Especially for high-risk patients without active ulcerations, remote patient monitoring (RPM) shows great promise in identifying areas of impending injury/tissue loss, in identifying presence or absence of infection, and in other areas of cardiometabolic care. Remote patient monitoring through temperature-sensing devices meets CMS guidelines for a physiologic measure and has robust data as an early warning system for diabetic foot ulcers in high-risk patients.23–26 These patients were typically seen in podiatry offices every 2 to 6 months for preventative visits to reassess changes and risk for ulceration, but with RPM, this interval could be pushed out longer and the podiatrist notified when a problem is imminent. The CMS has also allowed for reimbursement for RPM in many circumstances. Descriptions of CMS-recognized telehealth visits, online digital visits, and remote patient monitoring are listed in Table 2.
CMS-Recognized Telehealth Visits, Online Digital Visits, and Remote Patient Monitoring
It is important to note that state licensing requirements still apply. However, many states have relaxed licensure requirements for telemedicine and sometimes physical practice for the period of the state’s emergency declaration. The Federation of State Medical Boards is maintaining a list of states that have waived licensing requirements in response to COVID-19.27 Finally, ensure your malpractice carrier covers you for virtual visits, especially across state lines, if that is desired.
More In-Home Visits
The use of home health is expected to expand rapidly as more patients are treated at home, some with regular telemedicine check-ins from a provider. Podiatrists can order home health visits and dressing changes, and/or prescribe dressings and antibiotics to be used at home by the patient.
All indications are that podiatrists will be seeing a reduced regular workload over the next 12 to 18 months with cancelation of clinics and elective operations, increased patient no-show rate, and reduced demand for some foot and ankle care. There are opportunities for podiatrists to play a larger role in in-home care. House calls can be conducted with lower extremity examinations for infection and peripheral artery disease, and podiatrists can perform simple wound procedures in the home. Podiatrists can provide application of intricate dressings and offloading during a home visit and escalate a patient that requires a higher level of care. A review of care provided in the epicenter of the COVID-19 pandemic in Italy urges the consideration of community-based care where doctors may be performing more house calls because home care and mobile clinics prevent patient movements and relieve pressure on hospitals.28 Obviously, COVID-19 infection risks to the patient and provider have to be mitigated through the proper use of personal protective equipment.29–32
A Call to Action
All hands are on deck preparing to treat the expected wave of COVID-19 patients. Podiatrists must mobilize to provide organized care of the diabetic at-risk foot in a shifting environment and system. Our goal is to reduce the burden on the health-care system by keeping patients safe, functional, and at home during the COVID-19 pandemic.
Financial Disclosure: None reported.
Conflict of Interest: None reported.
References
- 1↑
Cha AE: Spiking U.S. coronavirus cases could force rationing decisions similar to those made in Italy, China. Available at: https://www.washingtonpost.com/health/2020/03/15/coronavirus-rationing-us/. Accessed March 21, 2020.
- 2↑
Centers for Medicare & Medicaid Services: Non-emergent, elective medical procedures, and treatment recommendations. Available at: https://www.cms.gov/files/document/31820-cms-adult-elective-surgery-and-procedures-recommendations.pdf. Accessed March 22, 2020.
- 3↑
Solis S: Coronavirus response: hospitals must cancel colonoscopies, knee replacements; abortions can continue as scheduled. Available at: https://www.masslive.com/coronavirus/2020/03/coronavirus-response-hospitals-must-cancel-colonoscopies-knee-replacements-abortions-can-continue-as-scheduled.html. Accessed March 21, 2020.
- 4↑
Baker P, Sullivan E: U.S. virus plan anticipates 18-month pandemic and widespread shortages. Available at: https://www.nytimes.com/2020/03/17/us/politics/trump-coronavirus-plan.html. Accessed March 21, 2020.
- 5↑
Alliance of Wound Care Stakeholders: Alliance COVID-19 response and guidance. Available at: https://www.woundcarestakeholders.org/news/studies-and-publications/alliance-covid-19-response-and-guidance. Accessed March 21, 2020.
- 6
Blanchette V, Brousseau-Foley M, Cloutier L: Effect of contact with podiatry in a team approach context on diabetic foot ulcer and lower extremity amputation: systematic review and meta-analysis. J Foot Ankle Res 13: 15, 2020.
- 7
Armstrong DG, Boulton AJM, Bus SA: Diabetic foot ulcers and their recurrence. N Engl J Med 376: 2367, 2017.
- 8
Rogers LC, Andros G, Caporusso J, et al.: Toe and flow: essential components and structure of the amputation prevention team. JAPMA 100: 342, 2010.
- 9↑
Hingorani A, LaMuraglia GM, Henke P, et al.: The management of diabetic foot: a clinical practice guideline by the Society for Vascular Surgery in collaboration with the American Podiatric Medical Association and the Society for Vascular Medicine. J Vasc Surg 63 (suppl): 3S, 2016.
- 10↑
Krzanowski M, Partyka L: “Global vascular guidelines on the management of chronic limb-threatening ischemia” is an important milestone, but some questions remain. J Vasc Surg 71: 348, 2020.
- 11↑
Ruan Q, Yang K, Wang W, et al.: Clinical predictors of mortality due to COVID-19 based on an analysis of data of 150 patients from Wuhan, China. Intensive Care Med 46: 846, 2020.
- 12
Skrepnek GH, Mills JL, Armstrong DG: Foot-in-wallet disease: tripped up by “cost-saving” reductions? Diabetes Care 37: e196, 2014.
- 13
Sloan FA, Feinglos MN, Grossman DS: Receipt of care and reduction of lower extremity amputations in a nationally representative sample of U.S. elderly. Health Serv Res 45: 1740, 2010.
- 14
Gibson TB, Driver VR, Wrobel JS, et al.: Podiatrist care and outcomes for patients with diabetes and foot ulcer. Int Wound J 11: 641, 2014.
- 15
Skrepnek GH, Mills JL Sr, Armstrong DG: A diabetic emergency one million feet long: disparities and burdens of illness among diabetic foot ulcer cases within emergency departments in the United States, 2006-2010. PLoS One 10: e0134914, 2015.
- 16
Skrepnek GH, Mills JL Sr, Lavery LA, et al.: Health care service and outcomes among an estimated 6.7 million ambulatory care diabetic foot cases in the U.S. Diabetes Care 40: 936, 2017.
- 17
Sumpio BE, Armstrong DG, Lavery LA, et al.: The role of interdisciplinary team approach in the management of the diabetic foot: a joint statement from the Society for Vascular Surgery and the American Podiatric Medical Association. JAPMA 100: 309, 2010.
- 18↑
Centers for Disease Control and Prevention. Prepare to care for COVID-19: get your practice ready. Available at: https://www.cdc.gov/coronavirus/2019-ncov/healthcare-facilities/practice-preparedness.html. Accessed March 21, 2020.
- 19↑
HHS.gov. Notification of enforcement discretion for telehealth for telehealth remote communications during the COVID-19 nationwide public health emergency. Available at: https://www.hhs.gov/hipaa/for-professionals/special-topics/emergency-preparedness/notification-enforcement-discretion-telehealth/index.html. Accessed March 21, 2020.
- 20↑
Armstrong DG, Rankin TM, Giovinco NA, et al.: A heads-up display for diabetic limb salvage surgery: a view through the Google looking glass. J Diabetes Sci Technol 8: 951, 2014.
- 21↑
Armstrong DG, Giovinco N, Mills JL, et al.: FaceTime for physicians: using real time mobile phone-based videoconferencing to augment diagnosis and care in telemedicine. Eplasty 11: e23, 2011.
- 22↑
Centers for Medicare & Medicaid Services: Medicare telemedicine health care provider fact sheet. Available at: https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet. Accessed March 22, 2020.
- 23
Lazo-Porras M, Bernabe-Ortiz A, Sacksteder KA, et al.. Implementation of foot thermometry plus mHealth to prevent diabetic foot ulcers: study protocol for a randomized controlled trial. Trials 17: 206, 2016.
- 24
Frykberg RG, Gordon IL, Reyzelman AM, et al.: Feasibility and efficacy of a smart mat technology to predict development of diabetic plantar ulcers. Diabetes Care 40: 973, 2017.
- 25
Reyzelman AM, Koelewyn K, Murphy M, et al.: Continuous temperature-monitoring socks for home use in patients with diabetes: observational study. J Med Internet Res 20: e12460, 2018.
- 26
Armstrong DG: Subscription prescription: remote patient monitoring using smart shoes, socks and insoles. J Wound Care 28 (suppl 9): S3, 2019.
- 27↑
Federation of State Medical Boards: States waiving licensure requirements/renewals in response to COVID-19. Available at: https://www.fsmb.org/siteassets/advocacy/pdf/states-waiving-licensure-requirements-for-telehealth-in-response-to-covid-19.pdf. Accessed March 21, 2020.
- 28↑
Nacoti M, Ciocca A, Giupponi A, et al.: At the epicenter of the Covid-19 pandemic and humanitarian crises in Italy: changing perspectives on preparation and mitigation. NEJM Catalyst 1: 1, 2020.
- 29
Lawrence PF, Gloviczki P: Global vascular guidelines for patients with critical limb-threatening ischemia. J Vasc Surg 69: 1653, 2019.
- 30
Lipsky BA, Senneville É, Abbas ZG, et al.: Guidelines on the diagnosis and treatment of foot infection in persons with diabetes (IWGDF 2019 update). Diabetes Metab Res Rev 36 (suppl 1): e3280, 2020.
- 31
Boulton AJM, Armstrong DG, Hardman MJ, et al.: Diagnosis and Management of Diabetic Foot Infections, American Diabetes Association, Arlington, VA, American Diabetes Association, 2020.
- 32
Fitzgerald RH, Mills JL, Joseph W, et al.: The diabetic rapid response acute foot team: 7 essential skills for targeted limb salvage. Eplasty 9: e15, 2009.
