The Role of Podiatry in Skilled Nursing Facilities Amid COVID-19 Pandemic

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One of the Most Common Wounds Observed in Skilled Nursing Facilities and Podiatry’s Role in Treatment

One of the most common wounds that occur in skilled nursing facilities is the diabetic ulcer. When a podiatrist notices a diabetic ulcer, the realization that their presence can be directly linked to the presence of peripheral arterial disease, heart attacks, strokes, renal disease, and amputation will prompt the podiatrist to take action with testing and referrals for the patient.

In the United States, someone is diagnosed with diabetes every 17 seconds. Every day 230 Americans will battle the challenge of lower-limb amputation. More than 60% of nontraumatic amputation in America occurs in diabetics. Comprehensive foot care programs can reduce amputations by 45-85%. 1.2 million people develop a foot ulcer every year, and that statistic seems to keep rising. 2.9 million people have a history of foot ulceration. 85% of the lower-limb amputations that occur in the United States occur after a foot ulcer battle. The five-year mortality rate in these patients ranges from 39 to 68% based on various studies.

Podiatrists as Part of an Interdisciplinary Wound Care Management Team

Podiatrists can quickly recognize ulcerations on lower limbs of skilled nursing facility patients, therefore making them a valuable member of the multidisciplinary wound care management team required to lower the risk of amputation in these patients.

A lower extremity exam performed by a podiatrist views the patient from four key viewpoints which are vascular, dermatologic, orthopedic, and neurological. The assessment of all four of these key points is essential in the proper treatment of a lower extremity wound. Overlapping etiologies within the four areas can serve to complicate the wound and the treatment.

Based on the exam findings, the podiatrist is the essential referral source to bring other specialists on the team that will focus on other systems in the patient’s body. The contributions podiatrists have made to the rapid emergence of the wound management specialty is evidence that supports the fact that successful wound care treatment should be the first step rather than a push for amputation. Podiatric expertise regarding the biomechanics and structural deformities of lower extremities is a key component to the healing of diabetic, neuropathic, and other ulcerations in the feet of skilled nursing facility residents.

The Team Approach to Wound Management

Podiatrists are the catalyst for communication among a variety of specialists. Internal medicine physicians are primary care physicians for adults. Endocrinologists diagnose and treat disorders of the endocrine glands and hormones such as types I and II diabetes. Infectious disease specialists are physicians that are trained in internal medicine who specialize in the diagnosis, treatment, and management of infectious diseases. Vascular surgeons are doctors who treat conditions that alter the performance of the vascular system.

The treatments may involve surgery, but vascular surgeons also treat conditions with non-surgical treatment options. Interventional cardiology is a subspecialty of cardiology. Through the utilization of intravascular catheter techniques with fluoroscopy, these specialists treat valvular and congenital diseases as well as diseases of the coronary arteries. Neurologists specialize in the anatomy, function, and disorders that involve the patient’s nerves and nervous system. Wound care specialists are health care providers who have been trained specifically in the care and treatment of all types of wounds, including those that are acute and chronic. A social worker may also be involved with a wound care patient’s case. Not all these specialists will be on the team, but any of these are possibilities.

The podiatrist quite often serves as the team builder for a wound care patient as well as performing the duties of the podiatrist such as treatment of ulceration. It is the podiatrist who will instruct care staff on offloading. The debridement of devitalized tissue is a part of the treatment. If it is found that the tissue cannot be revitalized, a partial amputation may be needed. The podiatrist will perform this as well as utilizing negative pressure devices for healing. The podiatrist is the core of the wound care team.

How Podiatrists and Wound Care Physicians are Providing Care to Skilled Nursing Facilities During the Pandemic

Since the onset of the novel coronavirus pandemic, it has become increasingly apparent that the need for telehealth infrastructure for health care providers is now an essential component of health care clinics across the United States. According to the New York Daily News, the pandemic is likely to last 18 to 24 months and come and go in waves.

Skilled Nursing facilities have turned to telehealth for specialist and therapeutic visits for their residents to protect them from contracting the virus while maintaining the continuum of care. Approximately eight of every ten deaths in the United States have been in adults aged 65 or older. For this reason, skilled nursing facilities have stopped allowing traffic into their buildings outside of their staff.

The nurses in skilled nursing facilities facilitate rounds with the physician via any two-way video communication platform. The nurse can show the physician the patient’s foot and the provider can view the patient from different angles as he/she requests the nurse to move the camera up and down or left to right. The provider will chart regarding the patient as he/she makes recommendations for treatment. Any needed lab work can be performed in-house at the facility.

Although seeing a patient bedside is ideal, telehealth makes it possible to provide seamless care for residents. It is safe, quick, efficient, and cost-effective. Patients find the process lightly unfamiliar initially, but once they are accustomed to the process, they are happy. Being able to see their provider once a week still gives the resident a sense of comfort and care. The specialist can talk face-to-face with the patient and answer any questions that may arise.

Because family members cannot visit the resident, they may have questions as well. It is up to individual providers to make themselves available to their patient’s family members. Some choose to have the facility handle any questions there may be. It is important to keep in mind that this is a stressful time for family members, as they cannot visit with their loved one(s) unless it is through video or a window visit. They may be having a hard time getting through this pandemic as many of us are.