Diabetic Foot Ulcer Care Standards in Long-Term Care Settings

Introduction

Diabetic foot ulcers are chronic wounds that negatively affect the morbidity, mortality, and quality of life of people living with diabetes. 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 protein synthesis (Lipsky, Holroyd, & Zasloff, 2008).

Diabetic foot ulcers are common worldwide. It is estimated that close to 400 million people have diabetes globally, and 25% of these suffer from diabetic foot ulcers at some 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 problems associated with foot ulcers, they also present significant economic burdens. A study conducted in the United States found that the cost of treating one episode of foot ulcers could exceed $30,000 over a two-year period. Between 1997 and 2007, patients spent an average of $18,000 treating foot ulcers. A similar study conducted in Europe found that the direct and indirect costs related to treating foot ulcers were approximately 10,000 euros, with hospitalization representing the highest direct cost. Combined with the estimated number of people suffering from foot ulcers, this suggests that 10 billion euros are spent each year treating diabetic foot ulcers in Europe (Romon, Jougla, Balkau, & Fagot-Campagna, 2008).

Without early and targeted intervention, wounds caused by diabetic foot ulcers can lead to amputation of a toe or even an entire limb. In Europe, it is estimated that half a percent of people with diabetes undergo amputation. In the United States, a study reported that more than three-quarters of lower-extremity amputations in diabetic patients result from foot ulceration. Amputation also increases the risk of mortality; studies show that approximately 50–65% of amputated patients die within five years of the procedure (Crawford, 2008).

Experts believe that 85% of amputations in diabetic patients can be prevented when foot ulcers are effectively managed. This requires successful diagnosis and treatment using a holistic approach. Many studies show that interventions for diabetic foot ulcers differ considerably, especially in the context of multidisciplinary teams such as those found in long-term care settings. This lack of coordination and active management may be a leading cause of amputation and reduced quality of life. A study conducted in a single center in the United States found that 56% of patients with diabetic foot ulcers were clinically infected despite receiving care in long-term settings (Gonzalez, Johansson, Wallander, & Rodriguez, 2009).

This finding suggests that health care providers are often poorly trained to assess and treat foot ulcers. This paper recognizes the importance of early treatment in improving outcomes for patients with diabetic foot ulcers and proposes a standard of care to be used in long-term care settings.

Management of Diabetic Foot Ulcers

Practitioners must manage diabetic foot ulcers with the aim of closing the wound. This prevents ulcers from developing elsewhere on the patient's feet and preserves the limb in the long run. To achieve this goal, management should begin at an early stage to allow the patient to heal. The essentials of managing foot ulcers include treating the underlying processes that lead to ulcers, ensuring an adequate supply of blood to the foot, providing local wound care that includes infection control, and offloading 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 or eliminate it. This may include treatment of severe ischemia — which causes rest pain, ulceration, and tissue loss — achieving optimal control of diabetic symptoms such as high blood pressure, nutritional deficiencies, and hyperlipidemia, and addressing physical causes of trauma by examining the patient's footwear for foreign bodies, proper fit, and wear and tear (Cheer et al., 2009).

Ensuring Adequate Blood Supply

Proper and adequate blood supply can be achieved by advising the patient on appropriate footwear, effective foot care such as limiting walking if the ulcer is on the underside of the foot, and other strategies tailored to the presentation of the patient's condition.

Optimal Wound Care

To achieve the objectives of diabetic foot ulcer management, effective wound care is essential. The emphasis should be on frequent wound inspection, bacterial control, moisture balance to prevent maceration, and repeated debridement.

Tissue Debridement

Debridement of tissue is essential to remove dead tissue from the wound, prevent infection, and promote healing. Debridement should be performed repeatedly to maintain the wound in an optimal state. It removes necrotic tissue, reduces pressure on the wound, and allows the practitioner to fully inspect the underlying tissue. An additional benefit of debridement is that it helps drain pus or secretions from the wound and stimulates healing by optimizing the effectiveness of topical medication.

Only experienced practitioners should perform debridement to avoid damage to the patient's blood vessels, nerves, and tendons. Choosing the wrong debridement method, or failing to debride the wound appropriately, can lead to deterioration with severe consequences.

Inflammation and Control of Infection

Wound care also requires controlling inflammation and infection. Expert bodies such as the Infectious Diseases Society of America (IDSA) and the International Diabetes Federation (IDF) recommend that diabetic foot ulcers should not be treated with systemic antibiotics unless the wound is clinically infected. Patients with superficial foot ulcers and mildly infected wounds should be started on empiric oral antibiotics targeting Staphylococcus aureus and beta-hemolytic Streptococcus. Alternate antibiotics should be sought if results indicate resistance (Lipsky et al., 2012).

Topical antimicrobials should also be used to manage infected wounds. The primary advantage of topical antimicrobials is that they do not drive resistance, since they act only on the infected tissue and do not penetrate deeper into soft tissue or intact skin. Topical antimicrobials reduce the bacterial load on the wound and protect it from further contamination (Lipsky et al., 2008).

Moderate to severe tissue infections should be treated by initiating broad-spectrum antibiotics and collecting tissue or purulent secretion specimens to identify the specific organisms present. Parenteral antibiotics are recommended initially, with the patient being switched to oral antibiotics once they are systemically stable and culture results are available (Lipsky et al., 2012).

To achieve a good moisture balance in the wound, it is essential to use a suitable dressing that creates a moist environment and supports healing. The choice of dressing should depend on the location and extent of the wound, the amount and type of exudate, the condition of the surrounding skin, the predominant tissue type on the wound surface, and compatibility with other therapies. Additional factors to consider include the risk of infection, the patient's quality of life, and trauma and pain when changing the dressing (Lipsky & Hoey, 2009).

Pressure Offloading

Pressure offloading is important for redistributing pressure evenly across the foot. This is particularly critical in patients with peripheral neuropathy. The most effective form of pressure offloading is the total contact cast (TCC), a molded device that prevents tissue damage and ulceration and reduces healing time by approximately six weeks. TCC, however, has disadvantages: it can cause skin irritation leading to further ulcers, makes bathing difficult, prevents daily inspection of the ulcer, and involves high cost.

TCC is contraindicated in patients with ischemia due to the increased risk of further ulceration, and is also not recommended for patients with infected ulcers or osteomyelitis, as it does not allow for wound inspection. Removable devices are often used as alternatives but are less effective because patients tend not to wear them consistently during daily activities.

Multidisciplinary Foot Care Team

Evidence strongly supports the use of multidisciplinary teams to improve outcomes for patients with diabetic foot ulcers. Over an 11-year period, one study found that patients managed by multidisciplinary teams had a 70% lower incidence of amputation. In England, a study showed that approximately one in every five patients with diabetic foot ulcers treated by a multidisciplinary team had a better outcome than those who were not.

The IDF also recommends that specialist foot care teams should include physicians with special interest and knowledge in diabetes care, diabetes podiatrists, and trained nurses. For more severe cases, the team should also include vascular surgeons, orthotists, psychologists, orthopedic surgeons, and social workers. This mix of expertise is associated with better patient outcomes through collaborative problem-solving and coordinated care delivery.

Significance of a Standard of Care for Long-Term Care Residents

Evidence from multiple studies consistently points to effective care of diabetic foot ulcers as the primary means of preventing amputation. Furthermore, a diabetes expert group notes that long-term care patients with diabetes are at increased risk of multiple comorbidities and frailty. This is because they exist within a system that is often highly unstructured in terms of diabetes management, with little formal clinical responsibility assigned to health care providers (Chin et al., 2008).

The prevalence of diabetes in long-term care institutions is estimated to exceed 25%, meaning one in every four residents has diabetes. Combined with the well-documented deficiencies in diabetes care within these settings, this places residents at substantially greater risk of diabetic foot ulcers (Reddy & Cottrill, 2011). Long-term care residents often lack planned care and case management, dietary or nutritional guidance, access to experienced health professionals, and regular structured follow-up.

Diabetic patients in long-term care institutions such as nursing homes represent a highly vulnerable and often neglected population. They have a high prevalence of macrovascular complications that greatly increase their susceptibility to infection. They also experience higher rates of hospitalization compared to ambulatory diabetic patients, in part because they have lower levels of physical and cognitive ability (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 without subjecting residents to inappropriate or unnecessary medical interventions. The second aim is to provide sufficient support and opportunity for residents to manage their diabetes effectively. The third aim is to ensure that residents receive tailored diabetes care, including regular follow-up based on individual clinical need (Abazari et al., 2012).

Conclusion

Management of diabetic foot ulcers in long-term care institutions varies considerably from one institution to another and from one care provider to the next. To ensure better and more effective management of foot ulcers, it is essential for a standard of care to be followed by all persons involved in managing diabetic foot ulcers.

Management of foot ulcers should begin as soon as they are discovered. Trained health care professionals working within a multidisciplinary team should manage diabetic foot ulcers. This team should consist of podiatrists, orthotists, nurses, diabetologists, and physicians who regularly assess ulcers and have access to all facilities required to provide the best care according to the proposed standard. Widespread adoption of such a standard has the potential to significantly reduce amputation rates, improve patient quality of life, and reduce the substantial economic burden that diabetic foot ulcers impose on individuals and health systems alike.

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