Diabetic Foot Triage for Pandemic Medicine

  • It is pertinent to realize that not all patients with diabetic foot disease need to be admitted to the hospital at the onset of a flare.
  • Patients who are presenting with a moderate risk of amputations due to any type of infection in the lesion or because of ischemia should be treated on an outpatient basis if it is possible.
  • Patients that present with lesions that are infection-free are candidates for telemedicine.

How Long Will Pandemic Medicine Be Necessary?

The question at hand across the globe has been when and how will this worldwide pandemic come to an end? The consensus has weighed in that the belief is that the way to an end is by way of herd immunity. When enough people in the communities across the Earth are protected from the pathogen that it can no longer take hold and dies out may be the only way this will end, but this will only happen by way of immunization or herd immunity. Herd immunity occurs when the mass majority of the world’s population contracts COVID-19 and either dies or develops immunity to the pathogen.

By way of proper triage, diabetic foot patients can be kept safe in their own homes during subsequent waves of the virus that may occur before this pandemic is declared to be over and should be continued during the supposed “safe” times that come with the lulls in the confirmed cases and deaths.

Hurry Up and Wait

How do we all manage while we wait to find out what is going to happen and how? Lockdowns are being lifted at a slow rate, but metered steps are necessary. The United States has become the global hotspot for the virus and as states have begun to reopen we are seeing rising positive cases in many. The numbers are expected to rise because testing has been ramped up nationwide. The important data lies within the transmission rate.

Many Americans feel as though the governmental entities have moved too quickly in the phases of reopening “outside” but there seems to have been more population that has the opinion that sacrificial lives lost are necessary to restore normalcy and resurrect our dying economy. Now, we wait. We wait not for an end to the pandemic, but a resurgence. It has been called the second wave and most medical professionals say that it is inevitable. It will come. So while we wait, we need to prepare so that a multitude of preventable life loss does not occur.

According to Dr. Milton Packer, we are quite possibly entering into a “seasonal lull” that could give us valuable time to develop antivirals and better measures of therapeutically mitigating the consequences of cytokine storms that have taken tens of thousands of lives in the United States thus far.

This time should be used to make monumental progress in the development of a vaccine. More studies on hypoxemia are needed. Patients are presenting with oxygen saturations so low they should be critical and they are sitting up in bed texting on their phones and talking. The way COVID-19 is setting in in varying ways is still a mystery. Testing capabilities must continue to ramp up. A reorientation period used to refocus critical resources to make society and medicine’s response to the second wave more effective is needed and should be used wisely by the world, but specifically here in the United States.

Triage Protocol Administered Via Pandemic Medicine

The Journal of the American Podiatric Medical Association proposed a Pandemic Diabetic Foot Triage System to guide providers in the pursuit of keeping hospital beds available for COVID-19 patients and decreasing the risk of Coronavirus contraction for diabetic and other at-risk patients. The triage system includes the utilization of in-home visits, telemedicine, remote monitoring, and higher acuity in officer encounters.

By way of proper triage, diabetic foot patients can be kept safe in their own homes during subsequent waves of the virus that may occur before this pandemic is declared to be over and should be continued during the supposed “safe” times that come with the lulls in the confirmed cases and deaths. By shifting the site of the administration of health care during periods of virus transmission, the health care system’s burden is eased a bit.

It is pertinent to realize that not all patients with diabetic foot disease need to be admitted to the hospital at the onset of a flare. The International Working Group on the Diabetic Foot has recommended that all clinicians should be labeling the severity of every foot lesion they treat that is caused by diabetes. Making hospital admission a priority should only be applicable if the patient is at extreme risk for loss of their limb.

Patients who are presenting with a moderate risk of amputations due to any type of infection in the lesion or because of ischemia should be treated on an outpatient basis if it is possible. Shifting the care setting to the home through home care services in the algorithm for treating these patients is key. This is how we, as a collective, can help prepare for future waves of the Coronavirus or any other pandemics that may come.

Patients that present with lesions that are infection-free are candidates for telemedicine. E-visits with patients allow family members or caregivers to be present as well so that they can have a thorough understanding of treatment measures and the available options.

Many Americans feel as though the governmental entities have moved too quickly in the phases of reopening “outside” but there seems to have been more population that has the opinion that sacrificial lives lost are necessary to restore normalcy and resurrect our dying economy.

Begin to Make Alternate Services the First Option

When delivering care to patients that do not have a high likelihood of limb loss or other complications, the International Working Group of the Diabetic Foot greatly advocated clinicians demonstrating the choice to evaluate their patients at alternative sites like mobile health clinics and through home health care and/or telehealth.

The monumental shift toward virtual visits for patients through various telemedicine platforms has gained significant traction with the onset of the COVID-19 pandemic. Messaging apps like FaceTime and Skype are being utilized to provide easy and accessible routes for patients and caregivers to “meet up” for a virtual visit. Prudency is a requirement in the gathering of information when conducting visits on telemedicine platforms though. The same level of accuracy and professionalism must be used as would be demonstrated if the visit were in person. The professionals of the IWGDF have warned against making clinical decisions regarding treatment based on a photo solely. When photos are presented as part of the telemedicine procedures, the IWGDF suggests that more than one clinician evaluate the picture to improve diagnosis accuracy and follow up decisions with the corresponding treatment protocols.

Discussion Focal Points for Prevention of COVID-19

To assist patients in avoiding the contraction of the Coronavirus, the importance of basic hygiene should be a topic of discussion at every visit. Discussing general hygiene parameters with every patient should include the focal point of handwashing frequently for 20 seconds each time. Patient education propels safeguarding measures for them further against the transmission of COVID-19.

A final focal point for discussion with patients is the imperative need for continued glycemic control. The necessity of stable glucose levels helps diabetic foot disease patients out of the hospital and relatively free of complications. The motivation of patients to develop a daily routine for exercise will also help boost the maintenance of their health and wellness holistically.

The IWGDF as a Diabetic Foot Community Resource

The message the IWGDF delivers to the community of encouragement for clinicians to make a difference in their local communities to prevent the spread of COVID-19 and work to keep their patients out of the hospital is tremendously beneficial. Their goal and mission are to see better outcomes worldwide for diabetic foot patients.

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hwest

Heidi West is a medical writer that writes about healthcare and technology.

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