Introduction

Hospital-acquired pressure injuries (HAPIs) and amputations were already a major health concern before the pandemic, but with the spread of COVID-19 and global shutdowns, amputation numbers have increased significantly in light of recent changes to the health care system. The COVID-19 pandemic has not only led to widespread coronavirus infection, but also has given rise to a higher incidence of HAPIs and amputations. How did this happen, and where do we go from here?

Increase in HAPI and Amputation Rates During the COVID-19 Pandemic

For individuals infected with and hospitalized because of the novel coronavirus, the use of lifesaving medical equipment may come at a high cost.¹ Since the start of the pandemic, HAPIs have increased significantly, likely the result of prolonged prone positioning and equipment designed to support respiration.¹ Regardless of these risk factors, health care leaders and workers have shown resilience and quick problem solving during the pandemic. The number of HAPIs had rose considerably during March through May of 2020, although it may be on the decline since the pandemic’s onset.² Case numbers are still high, but health care facilities have been actively combating HAPIs ever since the Centers for Medicare & Medicaid Services (CMS) first labeled these injuries as Never Events.³

Despite clinicians’ success with HAPIs, cases of preventable amputations continue to rise. During this pandemic, many primary care services have had to close, have provided limited services, or have moved to telehealth. As a result, patients do not receive the same level of care as previously for wounds and diabetic foot management.⁴ This change has led to more severe infections, increased hospitalizations, and, finally, more amputations.

With the rise in amputations, there are certain factors to keep in mind. The pandemic has led to some beneficial developments in health care: increased access to home care services, improved telehealth services, and an expanded resource bank for patient education. For wound care, however, it has disrupted the typical model and frequency of care. Research indicates that healing time for diabetic foot ulcers is directly related to the frequency of care.⁵ A faster wound healing time means less risk for infection and, ultimately, amputation. During the first height of the pandemic, care options were limited, and patients were encouraged to stay home or seek only emergency medical care.

People with diabetes often require assistance to complete thorough skin checks because of poor eyesight or an otherwise limited ability to see the feet. Given that health care has been limited in frequency and has transitioned to telehealth services, it is possible that many early signs of diabetic foot ulcers have been missed and are discovered only when they require significant management.⁶ Then, even when amputation is considered, surgery may be delayed, thus leading to an increase in major versus minor amputations. Many health care facilities also have implemented a triage system for surgical procedures to prevent the spread of COVID-19. Surgical procedures have been broken into tiers, and surgeons must determine the immediacy of surgical need. The decisions are not easy or straightforward, and many patients have felt the consequences.⁵

Additionally, wound care standards of practice have been impacted by supply chain disruptions.⁵ The pandemic has led to increased delivery time secondary to delays and a decreased availability of supplies. This means that some wound dressings, topical antimicrobials, and orthotics or protection devices may not be consistently available. Wound care clinicians have made changes to wound care practices based on what supplies are available.

Overall, the COVID-19 pandemic has changed the way health care is provided to those with pressure injuries, fragile skin, and diabetes, and thus these patients have not been able to receive the same level of health care as before the pandemic.

Strategies for Reducing Amputation Rates

Health care facility leaders need a quick and sustainable solution to the problem of increased amputations and the ulcers and injuries that cause them. Edmonds et al⁷ suggested a four-step approach to reducing the rate of amputations:

1. Prevent the development of ulcers more effectively.
2. Heal ulcers faster.
3. Educate patients more thoroughly.
4. Train health care providers to provide effective care within a sufficient time frame.

Overall, the recommendations point to a need for improved primary, as well as wound care delivery. During this pandemic, health care providers have not been able to provide the essential components of care that aid in hospitalization prevention, including:

1. Patient and caregiver education.
2. Improved diet.
3. Guided medication management.
4. Promotion of physical activity.⁸

Preventative medicine can come from many different disciplines. It may be time to look for other ways that health care entities can provide this care when primary care physicians are not available or when in-person visits are not advisable.

One way this can be done is through improvements in telemedicine. Before the pandemic, telehealth services were rarely a primary method of health care delivery. However, telehealth has been used for delivering services to patients with diabetes for over 20 years, and the research has shown promising results.⁵ Now, with an increased demand for remote services, telehealth services are used on a larger scale. In wound care specifically, telemedicine and home health services have been used more frequently since the start of the pandemic.⁹ The exception is in patients with severe wounds or wounds that are life-threatening. However, the decreased burden on in-person services can increase access to patients and meet the needs at various levels of wound development and treatment.

Conclusions

HAPIs and amputations both have increased during the COVID-19 pandemic.¹⁰ The difference, however, is that health care facilities have been prepared to quickly remediate the rise of HAPIs, whereas systems for amputation prevention are still lacking. The pandemic has provided clear evidence that stronger telemedicine and home health systems are needed for wound care and prevention.

References

1. Martel T, Orgill DP. Medical device-related pressure injuries during the COVID-19 pandemic. J Wound Ostomy Continence Nurs. 2020;47(5):430-434. doi:10.1097/WON.0000000000000689
2. Polancich S, Hall AG, Miltner R, et al. Learning during crisis: the impact of COVID-19 on hospital-acquired pressure injury incidence. J Healthc Qual. 2021;43(3):137-144. doi:10.1097/JHQ.0000000000000301
3. Centers for Medicare & Medicaid Services (CMS). Fact sheet: eliminating serious, preventable, and costly medical errors - never events. 2006. Accessed December 28, 2021. https://www.cms.gov/newsroom/fact-sheets/eliminating-serious-preventabl…
4. Casciato DJ, Yancovitz S, Thompson J, et al. Diabetes-related major and minor amputation risk increased during the COVID-19 pandemic. J Am Podiatr Med Assoc. Published online November 3, 2020. doi:10.7547/20-224
5. Oropallo A. COVID-19: issues related to wound care and telehealth management. UpToDate. July 2020. Accessed January 4, 2022. https://www.uptodate.com/contents/covid-19-issues-related-to-wound-care…
6. Robbie J, Phillips A, Odiase C, et al. ACT NOW! Reducing amputations during the COVID-19 pandemic and beyond. Diabetic Foot J. 2021;24(2). Accessed January 4, 2022. https://diabetesonthenet.com/diabetic-foot-journal/act-now-reducing-amp…
7. Edmonds M, Phillips A, Holmes P, Odiase C, Robbie J, Grumitt J, Halloum H. To halve the number of major amputations in people living with diabetes, “ACTNOW.” Diabetes Prim Care. 2020;22(6):1-5.
8. Viswanathan V, Nachimuthu S. Major Lower-limb amputation during the COVID pandemic in South India. Int J Low Extrem Wounds. Published online May 28, 2021. doi:10.1177/15347346211020985
9. Driver VR, Couch KS, Eckert KA, et al. The impact of the SARS‐CoV‐2 pandemic on the management of chronic limb‐threatening ischemia and wound care. Wound Repair Regen. 2021;30(1):7-23. doi:10.1111/wrr.12975
10. Polancich S, Hall AG, Miltner R, et al. Leaning during crisis: the impact of COVID-19 on hospital-acquired pressure injury incidence. J Healthc Qual. 2021;43(3):137-144. Accessed January 17, 2022. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8210579/#:~:text=During%20…

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