It is extremely beneficial to have close interaction with the patient’s primary care physician for help with diabetic control or management of other co-morbidities such as renal disease or congestive heart failure that could affect healing. It is also effective to have a dietitian both for diabetes management and increased protein intake to aid wound healing. If the patient has significant infection, infectious disease consultation may be appropriate. We work with all of these providers at our facility for comprehensive care of each patient. A multidisciplinary approach has been associated with better outcomes in treating diabetic ulceration since many health-related factors may affect wound healing.17-19
Proven Strategies To Prevent Lower Extremity Amputation
From 2009 to 2012, amputation rates at our facility dropped 77.3 percent as a result of the staff employing basic strategies in both prevention and wound care. This occurred despite the consistent rates of new foot ulcers that arise each year in patients with diabetes. A study by Apelqvist and colleagues in 1994 demonstrated that treatment of diabetic foot ulcers costs significantly less than amputation, making reduced amputation rates a benefit to both patients and the healthcare system at large.1
A combination of factors contributed to the aforementioned success at our facility, including early referral of high-risk patients to podiatry, improved access to care, a multidisciplinary approach to patient management and continuity of care by each wound care provider. Other preventive strategies included patient foot care education, shoe gear and orthotics or bracing, surgical correction of deformity in at-risk patients and regular, long-term follow-up.
Early access to care for at-risk patients is of significant importance. Many patients receive referrals to the podiatry service for basic foot care education as well as routine foot care. We are lucky to have a health technician trained to perform nail and callus care who also educates patients on diabetic foot care. This routine care leads to early identification of problems. We can therefore refer patients immediately to a provider, which prevents many problems due to the frequent foot evaluations and repeated reminders of how patients should care for their feet. Several studies have demonstrated that foot care education is important in foot ulcer and amputation prevention.2-4
When patients receive referrals for ulcer treatment, we attempt to see them for their initial visit within a week. Earlier intervention has led to better success with healing in our experience. We assign the patients to one provider who sees them weekly or sometimes more often, providing continuity of care.
A Closer Look At The Initial Care For Referred Patients
The initial exam routinely involves vascular and neurological assessment as well as evaluation of foot deformity possibly contributing to the ulceration and a detailed evaluation of the wound. If pedal pulses are not palpable, we order non-invasive arterial studies and obtain a vascular consult as appropriate based on the results. We take X-rays at the first visit to rule out any evidence of osteomyelitis and assess any deformity that might be contributing to the wound. The X-ray images also serve as a comparison if the ulcer becomes worse in the future.
Wound management consists of cleansing, debridement and the use of a variety of local wound care products. We utilize antibiotics if indicated and of course manage serious infections with surgical debridement and hospitalization. If the wound probes to bone and X-rays are negative, additional imaging studies such as magnetic resonance imaging or bone scans can rule out bone infection. If infection is present, surgical or antibiotic management occurs depending on many factors beyond the scope of this article.