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:

   • hemodynamic and anatomic vascular assessment with revascularization
as necessary;
   • neurologic workup;
   • site-appropriate culture technique;
   • wound assessment that includes staging and grading of infection and ischemia;
   • site-specific bedside and intraoperative incision and debridement;
   • initiation and modification of culture specific and patient appropriate antibiotic therapy; and
   • appropriate postoperative monitoring to reduce the risk of reulceration and infection.

   A diabetic rapid response acute foot team (DRRAFT) may be an effort to combine the knowledge of certain specialties to promote limb salvage. The core of this interdisciplinary team model involves the ability to rapidly diagnose and provide treatment to patients with lower extremity complications of diabetes by utilizing the aforementioned seven basic skill sets. At the forefront of the team are members from podiatric surgery (“toe”) and members from vascular surgery (“flow”). These specialties, with adjunctive teams added as necessary, collectively possess the ability to fill the aforementioned skill sets.1

Exploring The SALSA Model Of ‘Toe & Flow’

Armstrong and Mills formed the Southern Arizona Limb Salvage Alliance in September 2008 in an attempt to create an interdisciplinary team to manage the myriad of factors that complicate the treatment of high-risk patients with diabetes. The management of the lower-extremity manifestations of diabetes mellitus is a complex task. Practitioners involved in diabetic limb salvage must address both the systemic and local factors that interact to generate significant comorbidity and mortality in this patient population.

   The major factors include vasculopathy and neuropathy, often in combination with foot deformity, which lead to the development of diabetic foot ulcers (DFUs).4-6 The literature is clear that infected diabetic ulcerations present a major risk factor for lower extremity amputation. Appropriate, timely management of DFUs includes addressing the underlying etiology as well as dealing with an infection that may be present.7

   It is unlikely that one individual medical or surgical specialty is able to manage all aspects of diabetic lower extremity disease and appropriately manage these patients. Data from the SALSA service provides evidence for a reduction in major amputation rates following the development of an interdisciplinary approach to limb salvage.8 Apart from the improved clinical outcomes associated with an interdisciplinary team approach, there are significant academic and clinical training opportunities that such teams present.

   For example, ease of interaction allows for close communication and enhances collaborations for clinical and research initiatives. Sometimes team members share novel perspectives that lead to improved patient outcomes and quick dissemination of clinical knowledge/ technique. This helps in the strengthening of clinical decision-making skills and aids in broadening the surgical skill set. Additionally, focused research activities in concert with good clinical practices benefit the healthcare community overall.

   When a patient is admitted, either to the inpatient or outpatient SALSA service (through a single “hot foot line”), the physician asks the question, “What is the quality of flow?” If the flow is inadequate, the “flow” portion of the team takes primacy as they work to improve the patient’s “plumbing” (vasculature) and subsequently send the patient to the “toe” side of the team. The “toe” team improves the “landscaping” (wound healing/reconstructive surgery).

   The critical ingredient is that the conjoined team rounds together regularly, sharing duties on the inpatient wards. When it comes to the outpatient wards, clinics are shared space as well. This allows for real time “curbside consultations.” Most agree that this absence of referral is the “secret sauce” in SALSA.

What The Research Reveals About Interdisciplinary Teams

As Rogers and Bevilacqua noted, studies worldwide have reported the success of multidisciplinary teams in reducing ulceration rates and preventing amputations.9 Researchers attribute much of this to prevention strategies and the combination of timely vascular interventions with the rising podiatric interface that allows for focused lower extremity care, reduction of hospitalizations, a robust referral system among subspecialties (especially endocrinology to address metabolic pathologies) and optimized wound healing.

   A success of a major institution/center allows for replicating the standard of care in rural or underserved areas. One can therefore implement the interdisciplinary model based on the available resources and scale up the model in a timely fashion to develop a sustainable mechanism for care delivery.

   In 2006, Eskelinen and colleagues studied the incidence of major amputations in patients with and without diabetes in Helsinki.10 They noted a decrease of 23 percent in diabetic amputations between 1990 and 2002, attributing it to increased interest in amputation prevention and more distal vascular procedures.

   In a retrospective study in the Netherlands, Van Houtum and co-workers noted a 34 percent decrease in diabetes-related lower extremity amputations from 1991 to 2000.11 These authors attributed the decrease to an increased use of multidisciplinary teams.

   Pedrosa and colleagues studied Brazil’s national effort at reducing lower extremity amputations by creating 20 satellite diabetic foot clinics.12

   In 2007, Ancichini and co-workers conducted a five-year prospective study of diabetic and non-diabetic amputations in Italy.13 They found fewer hospitalizations for diabetic foot lesions following the implementation of a referral system for high-risk feet and a multidisciplinary team.

   Canavan and colleagues studied the incidence of diabetic and non-diabetic amputations before and after the establishment of a more organized diabetic foot care program in the United Kingdom.14 The relative risk of a person with diabetes undergoing a lower extremity amputation decreased from 46 times that of a person without diabetes to 7.7 times at the end of the five years, according to the study.

   In 2006, Wrobel and co-workers examined the high-low amputation ratio at 10 Veterans Affairs hospitals.15 They found six factors associated with fewer amputations: addressing all foot care needs; appropriate referrals; ease in recruiting staff; confidence in staff; available stand-alone specialized diabetic foot care services; and providers attending diabetic foot care education. The study also noted that specialized limb preservation services decreased the amputation rate by 82 percent.

   Armstrong and colleagues recently noted that the formation of the SALSA team lead to an overall reduction in amputations.16 Data from the SALSA center noted that surgeries moved from urgent and reactive to more preventive and proactive.

In Conclusion

Treating the diabetic foot but moreover the patient with diabetes is a frequently challenging yet ultimately rewarding experience. As the incidence of diabetes continues to grow in the developed and developing world, the likelihood of treating someone with diabetes and significant comorbidities is guaranteed.

   Even with continued control of the disease, the complications and risk factors for lower extremity involvement remain high. Small, frequently neglected foot problems, such as calluses, corns, ingrown nails and dry scaly skin, may be signs that signal the development of more significant problems. Early recognition and diagnosis of these factors in combination with aggressive preventative measures and a team approach will all be beneficial in the treatment of the diabetic foot with the ultimate goal of amputation reduction and prevention.

   Diabetic foot disease imposes a significant socioeconomic burden on the national health resources and mandates aggressive and proactive, preventative assessments. We cannot overstate the benefits of prevention to the patients and the healthcare providers. Prevention provides a resource sparing environment where we can treat potential problems with timely interventions without the use of expensive treatments and diagnostic modalities.

   Such a mechanism stratifies patients into risk groups that suggest times to follow up, ranging from every one to two months to annually. These follow-ups for patients with diabetes help identify (and treat) the presence of the predisposing factors for ulceration and amputation (neuropathy, vascular disease and deformities), based on the American Diabetes Association’s consensus statement and detailed protocol. If pathology exists, it mandates more frequent evaluation of the diabetic foot based on the accepted risk stratification system.

   To this end, research by our unit and others has led to the American Diabetes Association’s “Comprehensive foot exam and risk assessment” guidelines, which have been clinically validated and includes the peripheral vascular disease component that was absent in previous guidelines.17 Our proposed “irreducible team” model is consistent with this risk stratification. This systemic approach in concert with risk stratification and focused care may further reduce the excessive disease morbidity.

   Dr. Bharara is a Research Fellow at the Southern Arizona Limb Salvage Alliance (SALSA) in Tucson, Ariz. He is a post-doctoral research fellow at the Dr. William M. Scholl College of Podiatric Medicine’s Center for Lower Extremity Ambulatory Research (CLEAR) at Rosalind Franklin University of Medicine and Science.

   Dr. Scimeca is a Research Associate at SALSA.

   Dr. Fisher is a Limb Salvage Fellow of SALSA.

   Ms. Kimbriel is the Managing Director of SALSA.

   Dr. Mills is a Professor of Surgery and Chair of the Vascular and Endovascular Surgery Department at the University of Arizona College of Medicine. He is the Co-Director of SALSA.

   Dr. Armstrong is a Professor of Surgery at the University of Arizona College of Medicine and is the Director of SALSA. He is the Founder of CLEAR at Rosalind Franklin University of Medicine and Science.


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