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Wound care during COVID-19 pandemic

Giovanni Tinelli, MD, PhD, Simona Sica, MD, Giorgio Guarnera, MD, Dario Pitocco,
MD, Yamume Tshomba, MD

PII: S0890-5096(20)30545-8
DOI: https://doi.org/10.1016/j.avsg.2020.06.044
Reference: AVSG 5193

To appear in: Annals of Vascular Surgery

Received Date: 8 June 2020

Accepted Date: 17 June 2020

Please cite this article as: Tinelli G, Sica S, Guarnera G, Pitocco D, Tshomba Y, Wound care
during COVID-19 pandemic, Annals of Vascular Surgery (2020), doi: https://doi.org/10.1016/
j.avsg.2020.06.044.

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© 2020 Published by Elsevier Inc.

 1 Wound care during COVID-19 pandemic

3 Giovanni Tinellia, MD, PhD, Simona Sicaa, MD, Giorgio Guarnerab, MD, Dario Pitoccoc, MD,

4 Yamume Tshombaa, MD

5
a
6 Unit of Vascular Surgery, Fondazione Policlinico Universitario Gemelli IRCCS - Università

7 Cattolica del Sacro Cuore, Rome, Italy

b
8 Unità di Chirurgia Vascolare, Aurelia Hospital Roma, Rome, Italy.
c
9 Diabetology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica

10 del Sacro Cuore, Rome, Italy.

11

12 Corresponding author:

13 Giovanni TINELLI, MD, PhD

14 Chirurgia Vascolare, Polo CardioVascolare e Toracico

15 Fondazione Policlinico Universitario Gemelli IRCCS - Università Cattolica del Sacro Cuore

16 Largo Agostino Gemelli, 8

17 00168 Rome, Italy

18 giovanni.tinelli@policlinicogemelli.it

19

20 Authors’ conflicts of interest: none

21 Funding: This research did not receive any specific grant from funding agencies in the public,

22 commercial, or not-for-profit sectors.

23 Author contributions: Giovanni Tinelli: Conceptualization, Methodology, Writing, Supervion

24 Simona Sica: Data curation, Writing. Giorgio Guarnera: Conceptualization, Supervision. Dario

25 Pitocco: Conceptualization, Supervision. Yamume Tshomba: Conceptualization, Supervision.

26

1
27 Dear Editor,

28 The spread of the coronavirus COVID-19 has profoundly affected the way we conduct our medical

29 practices, resulting in a decrease in necessary medical care, including the wound healing specialty.

30 The actual period of COVID-19 pandemic limits the ability to practice wound healing in normal

31 conditions. Patients with vascular leg ulcers represent an extremely vulnerable population, with

32 poor quality of life caused by the pain directly related to both ulcer duration and ulcer area.[1]

33 These patients must not be overlooked due to the irreversible consequences that we will observe. If

34 ischemic and venous wounds are not treated or managed, the results could be drastic, such as

35 infections, sepsis, amputations, or even fatalities.

36

37 Doctors and patients’ point of view: two sides of the same coin

38 To dive deeper into the impact of COVID-19 on wound healing, we designed two surveys

39 (supplementary material, online), one targeting medical doctors and nurses involved in wound care,

40 and one targeting patients with arterial and venous leg ulcers and their caregivers. The surveys were

41 shared online using different social media platforms. The surveys were available from May 4 to

42 May 10, 2020 and were anonymous. Survey respondents were asked to identify their state of

43 practice (doctor/nurse) or their condition (patient/caregiver). All the respondents were from Italy.

44 The first survey was completed by 46 respondents, 34 (73.9%) medical doctors (MD), and

45 12 (26.1%) nurses. When asked if the COVID-19 pandemic affected the management of wound

46 dressings, 76.1% answered “yes”, showing that this is a widely shared problem among our

47 specialty. In 82.6% of cases, MD and nurses observed a decrease in patients’ appointments. In case

48 of missed appointments, contact with the patient was not maintained in 21.7% of cases. The most

49 used contact method was telephone calls (58.7% of cases), with messages as the second one

50 (43.5%). In half of the cases, MD and nurses have changed their dressing methods, by simplifying

51 it; but only in 17.4% they made a video to educate patients and caregivers on the proper way to

52 wound care.

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53 The patients and caregivers’ survey was completed by 39 respondents, 28 (71.8%) patients,

54 and 11 (30.8%) caregivers. From their point of view, only 22.6% of cases went to the wound clinic

55 as usual. In 59% of cases, the frequency of appointments at the clinic has drastically decreased. In

56 the case of missed appointments, 60.9% of cases did not maintain any type of contact with the

57 specialist. The dressings were made at home by familiars in 43.6% of cases, by the patient in

58 35.9%, and by a nurse in 17.9%. In the 12.8% of cases, the patients did not change the wound

59 dressing during the pandemic. In 20.5% of patients, an antibiotic was added to their usual therapy

60 and a painkiller in 5.1% of cases. During the pandemic, the type of dressing was simplified in

61 33.3% of cases. Nevertheless, in 15.4% of the patients said that the ulcer has worsened in terms of

62 dimensions, depth and exudation. Bar chart of the principal responses of both groups are presented

63 in the Figure.

64

65 Management of leg ulcers

66 Successful management of leg ulcers is crucial for preventing long-term morbidity and lowering the

67 risk of amputations. This can be achieved with a multifaceted approach, with the patients and their

68 caregivers at the centre.

69 Telemedicine should be considered the best way to prevent the spread of COVID-19 and provide

70 relevant care to chronic wound patients at the same time. It is important for the specialist to:

71 • Always keep the contact with the patient, including telephone calls and photos of the lesion

72 bi-weekly

73 • Assess by phone the presence of signs and symptoms: pain, redness, heat, swelling, drainage

74 (description of the consistency and color), fever, chills, and increased pain

75 • Educate the patients and their family to how to perform the wound care

76 • Simplify the dressing and consider the support of an explanatory video

77

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78 Moreover, the shift from hospitals to community care places has increased demand for family

79 caregivers, a valuable constant during these uncertain times.

80 Social distancing measures must involve also caregivers, who always have to wear personal

81 protective equipment (PPE) during wound care and maintain physical distance between them and

82 the patient. Vascular leg ulcers pose a heavy emotional burden on the caregivers, similar to other

83 major diseases, and lower only to what was observed for oncological and persistent vegetative

84 status patients.[2] Even more in this period, patients but also their caregivers need to be

85 psychologically supported.

86 To conclude, wound care with a regular follow-up needs to be considered as an essential service,

87 requiring a regular provider-patient interaction.

88

89 References:

90 1. Guarnera G, Tinelli G, Abeni D, Di Pietro C, Sampogna F, Tabolli S. Pain and quality of

91 life in patients with vascular leg ulcers: an Italian multicentre study. J Wound

92 Care2007;16:347-51

93 2. Tabolli S, Tinelli G, Guarnera G, Di Pietro C, Sampogna F, Abeni D. Measuring the Health

94 Status of Patients with Vascular Leg Ulcers and the Burden for their Caregivers. Eur J Vasc

95 Endovasc Surg2007;34:613-618

96

97

4
 98 Figure legend:

99 Figure: Bar chart of the responses by doctors/nurses (blue) and patients/caregivers (orange)

100 regarding wound care.

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101 SUPPLEMENTARY MATERIAL
102
103 Survey targeting medical doctors and nurses involved in wound care
104 1. Has the COVID-19 pandemic affected your management of wound dressing for vascular
105 ulcers?
106 Yes
107 No
108
109 2. Has your wound clinic (ambulatory wound dressing) been stopped?
110 Yes
111 No
112 Reduced
113
114 3. Have you noticed a decrease in the frequency of patients' appointments you have been
115 following?
116 Yes
117 No
118
119 4. In case of a missed appointment, did you keep in contact with the patient?
120 Yes, directly with the patient
121 Yes, through a family member
122 No
123
124 5. What kind of contact did you maintain?
125 Telephone calls
126 Video calls
127 Messages
128 None
129
130 6. Regarding wound dressing, did you have to make educational videos for the patients and
131 family members?
132 Yes
133 No
134

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135 7. Have you changed the dressing method by simplifying it?
136 Yes
137 No
138
139 8. Have you introduced new medications in the patients' therapy?
140 No
141 Antibiotic
142 Heparin
143 Painkiller
144
145 Survey targeting patients with arterial and venous leg ulcers and their caregivers
146 1. Has the COVID-19 pandemic affected your management of wound dressing for vascular
147 ulcers?
148 Yes
149 No
150
151 2. How many times did you go to the specialist's clinic for the dressing during this period?
152 As usual
153 Every 15 days
154 Once
155 Never
156
157 3. In case of a decrease in the frequency of the appointments, which type of contact did you
158 maintain with the specialist?
159 Telephone calls
160 Video calls
161 Messages
162 None
163
164 4. How often did you send photos of the ulcer to the specialist?
165 Periodically
166 Once
167 Never
168

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169 5. Who made your dressing during this period?
170 A relative
171 A caregiver
172 Nurse at home
173 I did it by myself
174 I have never changed the dressing
175
176 6. Have you changed the type of dressing?
177 Yes
178 No
179
180 7. Have you introduced new medications in your therapy?
181 No
182 Antibiotic
183 Heparin
184 Painkiller
185
186 8. Have you changed the type of dressing?
187 Yes
188 No
189
190 9. In this period the lesion:
191 Has worsened
192 Remained unchanged
193 Has improved
194