For people with diabetic foot complications, access to care and regular physical examinations are crucial to achieving good outcomes and avoiding hospitalizations. Both were a challenge in 2020, especially during the early days of the COVID-19 pandemic.
During Friday’s Mini-Symposium The Impact of COVID-19 on Foot Care in Diabetes, two diabetic foot care specialists discussed how they adapted and found ways to monitor and provide care to their patients during the pandemic. The session can be viewed by registered meeting attendees at ADA2021.org through September 29, 2021. If you haven’t registered for the Virtual 81st Scientific Sessions, register today to access all of the valuable meeting content.
“The COVID-19 pandemic required a rapid shift in best care practices,” said Brian M. Schmidt, DPM, Assistant Professor in the Department of Internal Medicine, Division of Metabolism, Endocrinology, and Diabetes, University of Michigan Medical School. “This had a huge impact on patients with diabetic foot ulcers and other complications because most of the time those patients were seen exclusively in face-to-face interactions.”
In the early phase of the pandemic at the onset of shelter-in-place restrictions, Dr. Schmidt said his institution implemented “STRIDE protocol”— strategies to reduce severe diabetic foot infections and complications during epidemics.
“The goals of this protocol were to maintain maximum available beds for patients afflicted with COVID-19, to preserve PPE (personal protective equipment) for health care workers, and to maintain physical and social distancing,” he said. “The fourth goal, and it cannot be overstated, is that we wanted to maintain our goal and our vision of preventing lower extremity amputations.”
STRIDE was a triage-based electronic medical records system in which the care team began by examining the records of patients who were seen in the clinic during the 90 days preceding shelter-in-place orders, as well as records of patients who were expected to be seen in the next 90 days.
“We wanted to identify whether they were high risk or whether they were low risk,” Dr. Schmidt said. “The low-risk patients would then be put into a telemedicine portal where we would maintain contact with them through weekly or biweekly visits. If they were later deemed to be higher risk at some time point, they then would be shifted to our limited, but still open clinic.”
As shelter-in-place orders were lifted, Dr. Schmidt said patients and providers almost unanimously returned to face-to-face encounters, but he noted that the pandemic taught the care team important lessons about the value and feasibility of virtual care.
“Integration of virtual care and electronic medical records has been shown to help in rapid triage,” he said. “Virtual care is an important tool in targeted foot care service delivery, and in fact may help in reducing the need for hospital visits and may achieve limb and life outcomes in motivated patients with foot complications.”
Laura Shin, DPM, PhD, Assistant Professor of Clinical Surgery, Department of Vascular Surgery, Keck Medicine, University of Southern California, also discussed how her institution used telemedicine and other communication strategies to stay connected and provide care to patients.
“During the COVID lockdown, not only did we have shutdowns for the different clinics around the area, but also the emergency rooms were virtually impossible for these patients to get to,” Dr. Shin said. “The pandemic lockdowns included cancelation of a lot of our outpatient hospital services. This included lab work, vascular studies, and radiology. So getting care to these high-risk patients who are not only at high risk for developing complications related to COVID, but also have complications related to diabetic foot was really quite challenging.”
As part of the care team’s strategy to expand the use of telemedicine in the acute care setting, Dr. Shin said information packets were provided to patients, families, and caregivers that included instructions for a “three-minute foot exam” to assist providers in prescribing care and identifying high-risk limbs.
“Comprehensive foot exams are highly recommended and really vital to improve outcomes. So just like in the doctor’s office, we had patients fill these out, or the caregivers fill them out and let us know what patients were at the highest risk,” she said. “A large part of us being able to treat these patients as best we could, especially with using different telemedicine technologies, was the ‘foot selfie.’ If they were flexible or agile enough, they could take the pictures themselves using their cell phones, or have a family member or caregiver take the pictures.”
Providing comprehensive, user-friendly resources and maintaining open lines of communication were the keys to providing optimal care to patients and preventing severe complications during the pandemic, Dr. Shin said.
“With COVID-19, we have learned a lot about accessing patients,” she said. “Utilizing different tools and avenues for telemedicine was extremely helpful for us and for our patients with diabetes and diabetic foot care needs. And although it’s not a replacement for inpatient visits, I think we were still able to manage to keep a lot of these patients safe, keep them out of the hospital, and keep them moving in the world.”