New COVID-19 Guidelines From The International Working Group On The Diabetic Foot

Imagine this scenario for a moment. It is early March and the weather is unseasonably spring-like. Your busy suburban podiatry practice has a full schedule that day. Amid rising concerns surrounding the rapid spread of the COVID-19 virus, you and your staff are taking all the recommended precautions. In the waiting area, the chairs are spread a good distance apart, your staff is wiping down the office every hour, hand sanitizer is out front and available for all to use, and you are constantly reminding yourself not to touch your face. 

The first patient of the day is new to the practice. He is an 85-year-old male with diabetes who presents with a mildly infected toenail that is causing him pain. The patient is accompanied by his son, who unbeknownst to you, has just returned from an international business trip where he caught the novel coronavirus. The virus has been multiplying inside him ever since. While you are examining his father, he excuses himself to use the restroom. While in the restroom, the son coughs and neglects to wash his hands. He touches the door handle both when leaving the restroom and when re-entering the treatment room, leaving viral particles behind. 

Your assistant enters the treatment room to deliver requested supplies. As she touches the door handle, the virus transfers onto her hands. Just before she puts exam gloves on, she scratches an itch on her nose and the viral particles transfer to her face. Meanwhile, the next patient that enters the restroom will also come in contact with the viral particles that remain on the door knob. And this is only one way in which COVID-19 spreads.

We have learned a lot about the coronavirus in the past few months. Most of America has been urged to shelter in place and practice social distancing to help reduce the spread of the virus. We are all very much aware that we are navigating unprecedented times in medicine. COVID-19 is disrupting many aspects of our clinical practices. As podiatrists, we are essential caregivers for our patients, especially those that suffer from diabetic foot disease. We play an important role during this outbreak by ensuring that the continuity of care of our at-risk patient population is maintained while limiting their exposure to COVID-19. Vigilance can keep our diabetic patients free from hospital admissions and will allow hospital beds to remain open for patients suffering with COVID-19. 

To help in these efforts, the International Working Group on the Diabetic Foot (IWGDF) have released a set of guidelines for clinicians who treat the diabetic foot.¹ The IWGDF document provides three priority recommendations.¹

1. Not all patients with diabetic foot disease need to be hospitalized. The group suggests that hospitalizations be reserved only for patients showing systemic manifestations of severe infection (such as sepsis) that require urgent diagnostic testing, surgical intervention, antibiotic therapy or other supportive care. The group urges against hospitalization for initial assessments of diabetic foot diseases including most cases of infection and ischemia. Clinicians can pursue diagnostic tests, such as non-invasive vascular assessments, X-rays, lab tests and cultures, and start a patient on oral antibiotic therapy for mild to moderate infections outside of the confines of a hospital. The IWGDF advocates a multidisciplinary approach with clinicians working together to provide proper patient care. 
2. Triage patients as soon as you can. The IWGDF suggests that clinicians classify the severity of all diabetic foot lesions. Priority admissions should only apply for those patients at high risk for limb loss. The group recommends that patients with moderate risk of limb loss due to infection or ischemia be treated in an outpatient setting when possible. Including home care services in the treatment algorithm of these patients is key. For those patients without infection, telemedicine visits with the patient, family or other caregivers are also recommended options. 
3. Consider alternative services. When caring for patients with less likelihood of limb loss or complications, the IWGDF advocates that clinicians consider evaluating patients in alternative locations such as mobile health centers, via home visits or via telemedicine. The shift toward virtual patient visits via telemedicine platforms is gaining traction. Using messaging apps such as FaceTime and Skype provide easy and accessible ways for patients and caregivers to communicate. It is prudent to obtain as much information as possible when conducting such visits. The IWGDF cautions against solely making clinical decisions based on a photo alone. They also suggest that multiple clinicians evaluate photos to improve accuracy of diagnosis and proper treatment protocols. 

The office scenario detailed at the start of this column demonstrates the importance practicing good basic hygiene. Clinicians should continue to discuss general hygiene parameters with patients, including the need for frequent hand washing. Educating patients will help to further safeguard them against the spread of the coronavirus. 

The IWGDF also suggests discussing the importance of continued glycemic control. Keeping glucose levels in check will help keep patients with diabetes problem-free and out of the hospital. Providers should also encourage patients to wear their prescribed offloading devices at home as much as possible. Motivating patients to create an appropriate daily exercise routine will also aid in maintaining their overall health and wellness. 

The IWGDF remains a tremendous resource for the diabetic foot community. The group’s message encouraging clinicians to act locally during the COVID-19 outbreak will help keep many patients free from hospital admissions and help achieve better outcomes globally. 

Dr. Cole is the Medical Director of the Wound Care Center at University Hospitals Ahuja Medical Center in Beachwood, Ohio. She is also an Adjunct Professor and Director of Wound Care Research at the Kent State University School of Podiatric Medicine.

Reference

1. International Working Group on the Diabetic Foot. COVID-19 and diabetic foot disease. Available at: https://iwgdfguidelines.org/covid-19/ . Accessed April 1, 2020.