How To Form A Diabetic Limb Salvage Team

Manish Bharara, PhD, Christy L. Scimeca, DPM, Timothy K. Fisher, DPM, Heather R. Kimbriel, BS, Joseph L. Mills, MD, and David G. Armstrong, DPM, PhD, MD

Given the potential risk of amputation among people with diabetes, multidisciplinary teams are critical to facilitate timely diagnostic assessment and appropriate interventions. Accordingly, these authors review the literature on multidisciplinary care for this high-risk patient population and share insights from their experience on the vital skill sets needed to facilitate improved patient outcomes.

Patients with diabetes are prone to develop lower extremity ulcerations and infections, both of which serve as major risk factors for lower extremity amputation. The development of lower extremity complications of diabetes is associated with increased morbidity and mortality.

   It is the multifactorial nature of diabetes that results in limb loss, generally as a consequence of chronic wounds and poor vascular status. Clinical management of diabetic foot disease has significantly improved over the last two decades. Prevention by identifying individuals at high risk has been the most effective way to reduce the socioeconomic burden of the disease.

   The multifactorial pathology necessitates utilization of an interdisciplinary approach to address the specific and varying etiologies that combine to create lower extremity ulceration, infection and subsequent amputation.1

   Studies have demonstrated that the five-year mortality rate in patients with diabetes following major amputation is significant — greater even than many major forms of cancer.2 More recently, research has compared diabetic foot amputations to landmine related amputations. This intriguing comparison emphasizes the silent nature of the “warfare” and the sinister consequences on the life of patients/landmine victims. Diabetes around the globe results in one major limb amputation every 30 seconds with over 2,500 limbs lost per day.3

   The current United States healthcare system offers private, charity and university-based facilities. Each system segregates physicians into separate departments with little to no interaction between specialties. This presents a logistical challenge to utilizing the team approach and is likely the reason that the team approach is not in wider practice. In order to address this problem, the facility must create a separate unit or center. This unit must then recruit the appropriate people with expertise in subspecialties to streamline the healthcare delivery with the intent to achieve superior outcomes.

   There are three models of limb salvage teams currently employed and they differ by which department/allopathic subspecialty podiatry is affiliated with in the given facility. These models include: Southern Arizona Limb Salvage Alliance’s (SALSA) vascular surgery and podiatry model, Georgetown University’s plastic surgery and podiatry model, and the endocrinology and podiatry model. Each model offers distinct advantages based on the subspecialty paired with podiatry.

A Closer Look At Vital Skills For Multidisciplinary Teams

The components of a limb salvage team are predicated on the pathology at presentation. The core of the team typically starts with clinicians caring for the structural and surgical aspects of the foot (podiatric surgeons) along with clinicians caring for the vascular integrity of the lower extremity (vascular surgeons). For a more comprehensive care model, other specialties of the team may include internal medicine, diabetology, infectious disease, physical therapy, plastic surgery, nursing, emergency medicine and prosthetics.

   Appropriate utilization of the aforementioned interdisciplinary team approach will help to address the varying factors associated with lower extremity ulceration and reduce amputation.

   This interdisciplinary limb salvage team utilizes seven basic skills in order to improve the quality and efficiency of patient care, and thereby improve the overall outcomes and reduce the amputation rates. These seven skills are:

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