Covid-19 and diabetic foot disease
These are unprecedented times, where a worldwide pandemic disrupts all aspects of daily clinical practice. However, providing care for people with diabetic foot disease remains crucial: as clinicians caring for these patients, we can play our (little) role in the Corona-crisis, by doing everything we can to keep people with diabetic foot disease outside the hospital. Every bed or every emergency room not taken up by a person with diabetic foot disease, gives room for patients suffering from Covid-19.
The pressure on the current healthcare system, may result in evidence-based care in accordance with IWGDF and other guidelines not being possible. Many clinicians around the world will face the same questions. On this page, IWGDF, Diabetic Foot Australia and D-Foot International, will collect these questions. We try to answer them as best we can, with the help of our global network of leading experts in diabetic foot disease.
Please be aware: these answers are not medical advice, and we do not assume any liability or responsibility for damages or injury to any person or property arising from any use of any information, idea, or instruction contained below. However, in the face of a global crisis, we hope that collectively we can make better decisions.
Do you have a question for our experts? You can soon pose it here – stay tuned.
Question: What would be your 3 priority recommendations to clinicians managing their patient with DFD to try and help them both stay free of hospital and COVID?
1 – Most patients with DFD do NOT need to be hospitalized. Hospitalization should generally be reserved for those with severe infection (i.e., systemic manifestations, suggesting possible sepsis) who require urgent diagnostic tests and surgical assessment, as well as antibiotic and supportive treatment. Implementing non-hospital care requires either a multi-disciplinary clinic or a well-established network of individual providers with agreed-upon referral arrangements, and they can work together digitally tor educe the number of clinicians needed per patient.
2 – Triage as soon as you can. Those with high risk of limb loss need to be seen by a multidisciplinary team. For others, consider alternatives such as telemedicine, setting up clinics in other locations away from the hospital (e.g. indoor gym, mobile health centers) or home visits. See a more extensive article about these aspects by Rogers, Lavery, Joseph and Armstrong here. See also the telemedicine topic below.
3 – Midfoot and deep forefoot ulcers will still need a total contact cast, but other ulcers may be treated with other offloading devices, even though you would normally treat them with a TCC. See also the offloading topic below.
Question: should we be shifting to telehealth? And if yes, how?
Answer: many clinicians around the world are now shifting to telehealth. The most frequently used method by our experts are photos in combination with instant messaging, as these are accessible for many patients or their carers. Be aware that diagnosing based on a photo is not very reliable, and even triaging for treatment urgency differs between clinicians (see the evidence here). If possible, try to obtain additional information, such as with temperature monitoring, or assess a photo with multiple clinicians.
Telehealth can not only be used for ulcer assessment, but also to provide self-care advice to your patients and their carers/nurses, to check their offloading and their dressings, and to discuss other questions. The reimbursement for telehealth differs per country. For the USA, this excellent article by Rogers and colleagues provides helpful guidance.
Also, see this video by David Armstrong for some inspiration.
Question: How to deal with offloading, when reducing contact with patients or visits from patients to my center?
Answer: We are facing this problem all the day here in Italy, and since outpatient clinics are still going on, we decided to go on with cast only in case of ulcer with high risk of worsening, like midfoot ulcer or deep forefoot ulcers (obviously only when without any sign of infection). For other plantar ulcers, we now use removable cast of protective shoes with offloading insole and appropriate dressing, and we ask patients and nurses to mail us every week a picture of the dressing and ulcer, organising where it is possible an outpatient clinic control every two weeks.
Question: how to diagnose infection when you do not see your patient in person?
Answer: to follow.
Question: What special equipment do I need in times of corona?
Answer: Keep paying very close attention to personal protective equipment.
Question: What should I discuss with my patients, beyond their ulcer?
Answer: First, discuss hygiene and protection in relation to the corona-virus, to ensure your patient is aware and capable of protecting themselves. Second, discuss glycemic control, which may be harder during a lockdown. Try to arrange support in glycemic control if needed. Third, discuss their daily exercise in times of lockdown. Try to motivate your patient to create an exercise routine compatible with their conditions, and with limited day-to-day variations.