Diabetic Foot Ulcer Standard of Care in Long-Term Care

Introduction

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 protein synthesis (Lipsky, Holroyd, & Zasloff, 2008).

Diabetic foot ulcers are common around the world. It is estimated that close to 400 million people have diabetes worldwide, 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 percent of diabetic people have foot ulcers.

Apart from the health problems associated with foot ulcers, they also present significant economic problems. A study conducted in the US 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 to treat foot ulcers. A similar study conducted in Europe found that the direct and indirect costs of treating foot ulcers were approximately 10,000 euros, with hospitalization representing the highest direct cost. Combined with prevalence estimates, this suggests 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, wounds caused by diabetic foot ulcers can lead to amputation of the toe or even the entire limb. In Europe, it is estimated that 0.5% of people with diabetes undergo amputation. In the US, one 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 to 65% of amputated patients die within five years (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 vary considerably, especially in multidisciplinary settings such as long-term care facilities. This lack of coordination and active management may be a leading cause of amputation and reduced quality of life. A study conducted at a single center in the US found that 56% of patients with diabetic foot ulcers were clinically infected despite being in long-term care (González, Johansson, Wallander, & Rodríguez, 2009). This suggests that healthcare providers are insufficiently trained to assess and treat foot ulcers. This paper recognizes the importance of early treatment and develops a standard of care for use with long-term care residents.

Practitioners must manage diabetic foot ulcers with the goal of closing the wound. This prevents ulcers from developing elsewhere on the patient's feet and preserves the limb over time. To achieve this goal, management should begin at an early stage. The essentials of managing foot ulcers include treating the underlying processes that lead to ulcers, ensuring an adequate blood supply to the foot, local wound care that includes infection control, and pressure offloading (Cheer, Shearman, & Jude, 2009).

Management of Diabetic Foot Ulcers

To treat the underlying disease process, the healthcare provider must identify the root 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 the physical causes of trauma by examining the patient's footwear for foreign bodies, proper fit, and wear and tear (Cheer et al., 2009).

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

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

Debridement of tissue is essential to remove dead tissue from the wound, prevent infection, and promote healing. It should be performed repeatedly to maintain the wound. Debridement removes necrotic tissue, reduces pressure on the wound, and allows the practitioner to fully inspect the underlying tissue. An additional benefit 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.

Wound care can also be advanced by 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 wounds are infected. Patients with superficial foot ulcers and mildly infected wounds should be started on empiric oral antibiotics targeting Staphylococcus aureus and β-hemolytic Streptococcus. Alternative antibiotics should be sought if results indicate resistance to the initial antibiotic (Lipsky et al., 2012).

Topical antimicrobials should also be used to manage infected wounds. Their main advantage is that they do not drive resistance, since they act only on 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 starting the patient on broad-spectrum antibiotics and collecting tissue or purulent secretion specimens to identify the specific organisms present. Parenteral antibiotics are recommended initially, with the patient switched to oral antibiotics once they are systemically improved and specimen culture results are available (Lipsky et al., 2012).

To achieve appropriate moisture balance in the wound, a suitable dressing that creates a moist environment and supports healing is essential. 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 include the risk of infection, patient quality of life, and trauma or pain experienced during dressing changes (Lipsky & Hoey, 2009).

Pressure offloading is important for redistributing pressure evenly — particularly in patients with peripheral neuropathy. The most effective method is the total contact cast (TCC), a mold that prevents tissue damage and ulceration and reduces healing time by approximately six weeks. TCC has disadvantages, however, including skin irritation that can cause further ulcers, difficulty bathing, prevention of daily wound inspection, and high cost.

TCC is contraindicated in patients with ischemia due to the increased risk of diabetic foot ulcers, and is not recommended for patients with infected ulcers or osteomyelitis, as it prevents wound inspection. Removable devices are often used as alternatives but are less effective because patients tend not to use them consistently during daily activity.

Evidence suggests that multidisciplinary teams significantly improve outcomes for 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 experienced a better outcome.

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

The IDF also recommends that specialist foot care teams include physicians with expertise 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 skills is associated with better patient outcomes through collaborative problem-solving to deliver the best standard of care.

Evidence from multiple studies consistently identifies effective care of diabetic foot ulcers as the primary means of preventing amputation. A diabetes expert group has noted that long-term care patients with diabetes face increased risk of multiple comorbidities and frailty. This is partly because they exist within a system that is highly unstructured in terms of diabetes management, with often no clearly assigned clinical responsibility among healthcare providers (Chin et al., 2008).

The prevalence of diabetes in long-term care institutions is estimated to exceed 25%, meaning that one in every four patients in such a setting has diabetes. Combined with the deficiencies in diabetes care delivery within these institutions, residents are predisposed to a greater risk of diabetic foot ulcers (Reddy & Cottrill, 2011). They often lack planned care and case management, dietary or nutritional guidance, input from experienced health professionals, and regular structured follow-up.

Diabetic patients in long-term care institutions such as nursing homes represent a highly vulnerable and frequently neglected group. They have a high prevalence of macrovascular complications that substantially increase their susceptibility to infection. They also experience higher rates of hospitalization than ambulatory diabetic patients, owing to lower levels of physical and cognitive functioning in long-term care settings (Abazari, Vanaki, Mohammadi, & Amini, 2012).

For diabetic patients in long-term care institutions, three broad aims of care have been identified. The first is to maintain the highest possible quality of life and wellbeing without subjecting residents to inappropriate or unnecessary medical and therapeutic interventions. The second is to provide sufficient support and opportunity for residents to manage their diabetes effectively. The third is to ensure that residents receive tailored diabetes care, including regular follow-up based on their individual clinical needs (Abazari et al., 2012).

Conclusion

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