Care for Diabetic Foot Ulcers in Long-Term Care Residents
Diabetic foot ulcers are chronic wounds that negatively affect the morbidity, mortality and quality of life of diabetes patients. Diabetic patients who develop foot ulcers are at greater risk of heart attack, fatal stroke, and premature death. Unlike other types of chronic wounds, diabetic foot ulcers are more complicated and present unique treatment challenges especially when coupled with diminished tissue perfusion, neuropathy, and defective synthesis of proteins Lipsky, Holroyd, & Zasloff, 2008()
Diabetes foot ulcers are common around the world. It is estimated that close to 400 million people have diabetes in the world and 25% of these suffer from diabetes foot ulcers at one point in their lives. In the UK, it is estimated that between 5 and 8% of diabetic people have foot ulcers.
Apart from the health problem associated with foot ulcers, they also present economic problems. A study that was conducted in the U.S. found that the cost of treating one episode of foot ulcers could top $30,000 dollars in a period of two years. Between 1997 and 2007, it was found that patients were spending $18,000 on average to treat foot ulcers. A similar study conducted in Europe found that the direct and indirect costs related to treating foot ulcers were about 10,000 euros with the highest direct cost being hospitalization. This coupled with the estimate of people suffering from foot ulcers estimates that 10 billion euros are spent each year to treat diabetic foot ulcers in Europe Romon, Jougla, Balkau, & Fagot-Campagna, 2008()
Without early and targeted intervention, the wound brought about by the diabetic foot ulcers can lead to amputation of the toe or even the limb. In Europe, it is estimated that half a percent of people with diabetes are amputated and in the U.S., a study reported that more than three-quarters of the lower-extremity amputations of diabetic patients are as a result of foot ulceration. Amputation also increases the risk of mortality and studies show that about 50 to 65% of patients who are amputated die within five years of the amputation Crawford, 2008()
Experts believe that 85% of amputations in diabetic patients can be prevented when the foot ulcers are effectively managed. This requires a successful diagnosis and treatment of patients with diabetic foot ulcers using a holistic approach. Many studies show that interventions to diabetic foot ulcers differ especially in the context of multidisciplinary teams such as long-term care settings. This lack of coordination and active management of the foot ulcer may be a leading cause of amputation and low quality of life in patients. A study conducted in a single center in the U.S. found that 56% of patients with diabetic foot ulcers were clinically infected despite the patients being in long-term care Gonzalez, Johansson, Wallander, & Rodriguez, 2009.
This suggests that the health care providers are poorly trained to assess and treat foot ulcers. This paper recognizes the important of early treatment to the improvement of patients with diabetic foot ulcers and develops a standard of care to be used in long-term care residents.
Management of diabetic foot ulcers
Practitioners must manage diabetic foot ulcers with the aim of closing the wound. This prevents the ulcers from developing elsewhere in the patient’s feet and to preserve the limb in the long run. To achieve this goal, the management of the foot ulcers should start at an early stage to allow the patient to heal. The essentials to managing foot ulcers are treating the underlying processes that lead to the ulcers, ensuring adequate supply of blood to the foot, local care of the wound that includes control of any infection, and offloading of pressure Cheer, Shearman, & Jude, 2009()
Treating the underlying disease processes
To treat the underlying disease process, the health care provider must identify the underlying cause and where possible manage it or eliminate it. This may include treatment of severe ischemia, which causes rest pain, ulceration, and loss of tissue, achieving optimal control of the diabetic symptoms such as high blood pressure, nutritional deficiencies, and hyperlipidemia, and addressing the physical cause of trauma by examining the patient’s footwear for foreign bodies, proper fit, and wear and tear Cheer et al., 2009()
Ensuring adequate supply of blood
Proper and adequate blood supply can be achieved by advising the patient on proper footwear, effective foot care such as limiting walking if the ulcer is on the underside of the foot, and other strategies based on the presentation of the patient’s foot.
Optimal wound care
To achieve the objectives of management of diabetic foot ulcers, it is essential for wound care to be achieved. The emphasis should be on frequent inspection of the wound, bacterial control, moisture balance in order to prevent maceration, and repeated debridement.
Tissue debridement
Debridement of the tissues is essential to remove dead tissue form the wound to prevent occurrence of infection and promote healing of the wound. Debridement should be done repeatedly to maintain the wound. Debridement removes necrotic tissue and reduces pressure on the wound. It also allows the practitioner to fully inspect the underlying tissue. One further benefit of debridement is that it helps in draining pus or secretions from the wound and stimulates healing by optimizing the effectiveness of topical medication.
Only experienced practitioners conduct debridement to avoid damage to the patient’s blood vessels, nerves, and tendons. Choosing the wrong debridement method, or not debriding the wound appropriately can lead to deterioration of the patient with severe consequences.
Inflammation and control of infection
Wound care can also be achieved by controlling inflammation and the infection. Expert bodies such as the Infectious Diseases Society of America (IDSA) and the International Diabetes Federation (IDF) recommend diabetic foot ulcers should not be treated with systemic antibiotics unless they are infected wounds. Patients with superficial foot ulcers with mildly infected wounds should be started on empiric oral antibiotics targeting Staphylococcus aureus and ?-hemolytic Streptococcus. Alternate antibiotics should be sought if the results indicate resistance of the infection to the antibiotic Lipsky et al., 2012()
Topical antimicrobials should also be used to manage the infected wound. The biggest advantage of topical antimicrobials is that they do not drive resistance since they only act on the infected tissue and do not penetrate deeper into the soft tissue or intact skin. Topical antimicrobials reduce the bacterial load on the wound and protect the wound from further contamination Lipsky et al., 2008()
Moderate to severe tissue infections should be treated by starting the patient on broad-spectrum antibiotics and taking specimens of tissue or purulent secretions to identify the specific organisms in the wound. Parenteral antibiotics are recommended with the patient being switched to oral antibiotics if they are systemically better and results of specimen culture are available Lipsky et al., 2012()
To achieve a good balance of moisture in the wound, it is essential to use a suitable dressing that creates a moist environment and supports healing of the wound. The choice of dressing should depend on the location of the wound, extent of the wound, amount and type of the exudate, condition of the skin around the wound, predominant type of tissue on the surface of the wound, and compatibility with other forms of therapies. Other factors to consider are the risk of infection, patient quality of life, and trauma and pain when changing the dressing Lipsky & Hoey, 2009()
Pressure offloading
Pressure offloading is important in patients to redistribute pressure evenly. This is more important in patients with peripheral neuropathy. The best form of pressure offloading is total contact cast (TCC), which is a mold that prevents tissue damage and ulceration and reduces healing time by about 6 weeks. TCC, however, has the disadvantage of causing skin irritation thus the possibility of further ulcers, making bathing difficult, preventing daily inspection of the ulcer, and high cost.
TCC is contraindicated in patients with ischemia because of the increased risk of diabetic foot ulcers. They are also not recommended for patients with infected ulcers, or osteomyelitis because they do not allow for inspection of the wound. Removable devices are often used by are less effective because patients use them less during their normal daily activity.
Multidisciplinary foot care team
To provide the best standard of care, evidence suggests that multidisciplinary teams significantly improve the outcomes of diabetic foot ulcers. Over a period of 11 years, one study found that patients managed with multidisciplinary teams had 70% lower incidence of amputation. In England, a study showed that about one (1) in every five (5) patients with diabetic foot ulcers treated by a multidisciplinary team had a better outcome.
The IDF also recommends that specialist foot care teams should include doctors with special interest and knowledge in diabetes care, diabetes podiatrists, and trained nurses should be part of the team. For more severe cases, the team should also include vascular surgeons, orthotists, psychologists, orthopedic surgeons, and social workers. This mix of skills is associated with better patient outcomes as a result of brainstorming to provide the best standard of care.
Significance of a standard of care for diabetic foot ulcers in long-term care residents
Evidence from different studies constantly points at effective care of diabetic foot ulcers as the only way to prevent amputation. Furthermore, a diabetes expert group states that long-term care patients with diabetes are at increased risk of multiple comorbidities and frailty. This is because they are part of a system that is highly unstructured in terms of diabetes management and there is often no clinical responsibility on the health care providers Chin et al., 2008()
The prevalence of diabetes in long-term care institutions is estimated to be above 25%. This means one (1) in every four (4) patients in a long-term care institution has diabetes. This coupled with the deficiencies in providing diabetes care within long-term care institutions predisposes them to greater risk of diabetic foot ulcers Reddy & Cottrill, 2011.
They often lack planned care and case management, dietary or nutritional guidance, input of experienced health professionals, and regular structure follow-up.
Diabetic patients in long-term care institutions such as nursing homes are a highly vulnerable and neglected group of individuals and they have a high prevalence of macro vascular complications that tremendously increase their susceptibility to infection. They also suffer from increased rates of hospitalization compared to ambulatory diabetic patients since they have low levels of physical and cognitive ability while in long-term care settings Abazari, Vanaki, Mohammadi, & Amini, 2012()
For patients with diabetes in long-term care institutions, the broad aims of care are as follows. The first aim is to maintain the highest possible quality of life and well-being of the patient without subjecting them to inappropriate and unnecessary medical and therapeutic interventions. The second aim is to provide sufficient support and opportunity for residents to manage their diabetes effectively. The last aim is to ensure that the residents get tailored care for diabetes, including regular follow-up depending on their clinical need Abazari et al., 2012()
Barriers to providing effective diabetes care in long-term care settings
Several important barriers prevent the diabetic patients in long-term care settings from receiving optimal care. First is that the care givers in these homes are inadequately trained in basic management of diabetic care. Several studies suggest poor or improper knowledge of diabetes management among the care providers in long-term care institutions. These studies have also reported inadequate patient education in these settings.
According to Cheer et al., 2009(Abazari et al. (2012)
, patient education is an integral part of management and prevention of diabetic foot ulcers. The treatment outcomes of diabetic foot ulcers improve significantly when the patient is well educated on their own medical status. This is because it directly impacts their ability to care for the wound, concordance with the treatment provided, and their reported quality of life. In long-term care institutions, a study found that inadequate patient and provider education increased the risk of diabetes complications and the economic burden of the disease. It is, therefore, essential for patient and family education to be an essential part of diabetes management )
A second obstacle is inadequate resources to deliver training and education to patients, family, and staff within long-term care institutions. Providing a comprehensive education on the many aspects of diabetes care is costly and most long-term care institutions tend to avoid this. Even where these resources for training are available, there is a lack of training facilities such as models, charts, and educational pamphlets to illustrate the information better. A study conducted in the U.S. found that there was no official planning of patient education services and this led to lack of supervision in provision of these services. Similarly, no budget was provided for these education efforts thus instruction and guideline had to use limited teaching methods and aids making it less effective Abazari et al., 2012()
Health illiteracy of the patients is also a huge concern. Many patients do not understand the importance of their health and their families as well lack this health literacy. Therefore, educating them on the risks and complications associated with diabetes health becomes difficult. As found in a study conducted in the U.S., many patients do not believe in the educational role of nurses. Therefore, they do not take the education from nurses seriously. This hinders the nurse from educating the patients on diabetes care and management Crawford, 2008()
Probably the largest obstacle in management of diabetes is the lack of national standards of care of diabetes. Though there are recommended standards of care in management of diabetes, these have not been widely implemented and care providers have also not been trained adequately Chin et al., 2008()
Rationale for standard care of diabetic foot ulcers
Experienced health professionals often use different judgments, decisions, recommendations, and actions to treat diabetic foot ulcers. An appreciation of the common standard of care for diabetic patients with foot ulcers is bound to improve the quality of life for this patients since it assures them of treatment based on the best available clinical evidence. In light of using the aforementioned standard of care, the clinician will be able to make the best clinical decision for the patient’s health. It also allows for considerations of the patient’s values and preferences to some extent to improve the patient’s quality of life.
This standard of care defined in the first part of this paper translates into clear goals of management of the diabetic foot ulcers and reflects the standard policies, procedures, and effort expected for each patient. Assessment of the foot ulcers is important to identify the best course of action. Secondly, the standard of care emphasizes the importance of a multidisciplinary team to ensure brainstorming of solutions and actions to improve the patient’s health.
Clinical decision support is also important to achieve the best quality of care for diabetic foot ulcers. This standard of care, though a manual reminder of the specific preventive and curative care services, provides specific recommendations to improve care practices, reduce medication errors, enhance delivery of preventive services, and improve adherence to standards of care. On a more practical level, this standard of care when coupled with charts will provide appropriate decision support as part of the workflow of the health care provider and deliver decision support when needed. It is, therefore, essential for each long-term care facility to have charts or computer generated decision support if using an electronic health records (EHR) system.
The emphasis on a multidisciplinary team approach is essential for effective management of diabetic foot ulcers. Each member of the practice team depending on their expertise will enable the team to be responsive to the preferences, values, and best practice for the patient. The team will ensure a patient-centered approach to delivering the best care for diabetic foot ulcers is achieved through development of individualized care plans and effective team member communication to coordinate delivery of care.
Conclusion
Management of diabetic foot ulcers in long-term care institutions differs from one institution to another, and based on the care provider. To ensure better and more effective management of foot ulcers, it is essential for a standard of care to be followed by all persons undertaking management of diabetic foot ulcers.
Management of foot ulcers should be started as soon as they are discovered. Trained health care professionals in a multidisciplinary team should manage diabetic foot ulcers. The multidisciplinary team should consist of podiatrists, orthotists, nurses, diabetologists, and physicians. This team should regularly assess the ulcers on the patient’s feet and have access to all facilities they require to provide the best care based on the proposed standard of care.
References
Abazari, P., Vanaki, Z., Mohammadi, E., & Amini, M. (2012). Inadequate investment on management of diabetes education. J Res Med Sci, 17(8), 792-798.
Cheer, K., Shearman, C., & Jude, E.B. (2009). Managing complications of the diabetic foot. BMJ: British Medical Journal, 339(7733), 1304-1307. doi: 10.2307/25673416
Chin, M.H., Drum, M.L., Jin, L., Shook, M.E., Huang, E.S., & Meltzer, D.O. (2008). Variation in Treatment Preferences and Care Goals among Older Patients with Diabetes and Their Physicians. Medical Care, 46(3), 275-286. doi: 10.2307/40221655
Crawford, F. (2008). Uncertainties Page: How Can We Best Prevent New Foot Ulcers in People with Diabetes? BMJ: British Medical Journal, 337(7669), 575-576. doi: 10.2307/20510758
Gonzalez, E.L.M., Johansson, S., Wallander, M.A., & Rodriguez, L.A.G. (2009). Evidence-based public health policy and practice: Trends in the prevalence and incidence of diabetes in the UK: 1996-2005. Journal of Epidemiology and Community Health (1979-), 63(4), 332-336. doi: 10.2307/20720950
Lipsky, B.A., Berendt, A.R., Cornia, P.B., Pile, J.C., Peters, E.J.G., Armstrong, D.G., . . . Senneville, E. (2012). 2012 Infectious Diseases Society of America Clinical Practice Guideline for the Diagnosis and Treatment of Diabetic Foot Infections. Clinical Infectious Diseases, 54(12), 1679-1684. doi: 10.2307/23213413
Lipsky, B.A., & Hoey, C. (2009). Topical Antimicrobial Therapy for Treating Chronic Wounds. Clinical Infectious Diseases, 49(10), 1541-1549. doi: 10.2307/27799388
Lipsky, B.A., Holroyd, K.J., & Zasloff, M. (2008). Topical vs. Systemic Antimicrobial Therapy for Treating Mildly Infected Diabetic Foot Ulcers: A Randomized, Controlled, Double-Blinded, Multicenter Trial of Pexiganan Cream. Clinical Infectious Diseases, 47(12), 1537-1545. doi: 10.2307/40308324
Reddy, M., & Cottrill, R. (2011). Healing Wounds, Healthy Skin: A Practical Guide for Patients with Chronic Wounds: Yale University Press.
Romon, I., Jougla, E., Balkau, B., & Fagot-Campagna, A. (2008). The Burden of Diabetes-Related Mortality in France in 2002: An Analysis Using Both Underlying and Multiple Causes of Death. European Journal of Epidemiology, 23(5), 327-334. doi: 10.2307/40284054
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