best practice guidelines: wound management in diabetic foot ulcers

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DFU WOUNDMANAGEMENTRecommendations from the IWGDF 26 on theuse of offloading interventions in treating uncomplicatedneuropathic foot ulcers are: Pressure relief should always be part of thetreatment plan for an existing ulcer TCCs and non-removable walkers are thepreferred interventions Forefoot offloading shoes or cast shoesmay be used when above ankle devices arecontraindicated Conventional or standard therapeutic footwearshould not be used 101 .However, in many countries, recommendeddevices are not available and all that can be offeredis cushioning constructed from items fromlocal shops (eg, kitchen sponges, upholsteryfoams etc). In many regions of the world, walkingbarefoot or with poorly protective sandals isnormal. Replacing these by advising shoe wearmay be culturally unacceptable or create otherfoot problems 105 . The use of trainers or sportsshoes is recommended by some clinicians,which may provide another option to custombuiltfootwear where this is not accessible 106 .Patients should also be advised to limit standingand walking and to rest with the foot elevated 7 .The introduction of medical insurance schemesthat do not pay for preventative care has beena significant factor in lack of care in patientswith diabetes in recent years. These schemesalso limit what equipment can be offered to apatient.The hallmark of an appropriately offloadedwound is a noticeable lack of undermining atthe wound’s edge at follow up 74 .Amputation and post-amputationcareLower-extremity amputation often results in disability and a loss of independence;amputation is often more costly than limb salvage 25According to the IDF guideline, amputationshould not be considered unless a detailedvascular assessment has been performed byvascular staff 27 .Amputation may be indicated in the followingcircumstances 27 : Ischaemic rest pain that cannot be managedby analgesia or revascularisation A life-threatening foot infection that cannotbe managed by other measures A non-healing ulcer that is accompanied bya higher burden of disease than would resultfrom amputation. In some cases, for example,complications in a diabetic foot renderit functionally useless and a well performedamputation is a better alternative for thepatient.Around half of patients who undergo an amputationwill develop a further DFU on the contralaterallimb within 18 months of amputation. Thethree–year mortality rate after a first amputationis 20–50% 107 . In a six-year follow-up study,almost 50% of patients developed critical limbischaemia in the contralateral limb, but theseverity of the DFU and amputation level wassignificantly lower than in the unilateral limb. Thismay have been due to prompt intervention madepossible by increased patient awareness 108 .Patients at high risk for ulceration (such aspatients who have undergone an amputation fora DFU) should be reviewed 1–3 monthly by a footprotection team 1 . At each review patients' feetshould be inspected and the need for vascularassessment reviewed. Provision should be madefor intensified footcare education, specialist footwearand insoles, and skin and nail care. Specialarrangements should be made for people withdisabilities or immobility 1 . The Scottish IntercollegiateGuidelines Network (SIGN) recommendsspecialist diabetes podiatrist input for patientswith a history of amputation and ulceration 37 .Although amputation incidence may notreflect the quality of local healthcare delivery,there is a need for more consistent deliveryof diabetes care 70 , with the involvement of anMDFT and patient education.318 BEST PRACTICEBEST PRACTICEGUIDELINESGUIDELINES:FOR SKINWOUNDAND WOUNDMANAGEMENTCARE ININEPIDERMOLYSISDIABETIC FOOTBULLOSAULCERS
Integrated care approachINTEGRATEDCARE APPROACHDFUs are a multifaceted condition and no one individual or clinical specialty shouldbe expected (or should attempt) to address all aspects of management in isolationMULTIDISCIPLINARY FOOTCARETEAMEvidence consistently highlights the benefits ofMDFTs in the outcomes of DFUs. Over 11 years,one study found total amputations fell by 70%following improvements in footcare services,including multidisciplinary team work 109 .However, in England around one-fifth ofhospitals providing inpatient care for peoplewith diabetes have no MDFT 5 . Furthermore, inmany areas of the country there are no clearpathways for referring patients at increasedrisk or high risk of developing DFUs, as recommendedby NICE 5 .All the major guidelines recommend thatpatients identified with new DFUs should bereferred to a dedicated MDFT 1,4,7,26,27,37,110 .There are many different considered opinionsabout which disciplines should be incorporatedin an MDFT.The IDF recommends that a specialist footcareteam will include doctors with a special interestin diabetes, people with educational skillsand people with formal training in foot care(usually diabetes podiatrists and trained nurses).For comprehensive care, this team wouldbe enhanced by vascular surgeons, orthopaedicsurgeons, infection specialists, orthotists,social workers and psychologists (Box 6).Guidelines aside, it will be local resources thatdictate the skill mix and scope of any footcareteam. In the UK there is a move towards havinga core team of specialist diabetes podiatrists,medical specialty consultants, orthotistsand surgeons, which works with additionalrelevant disciplines (such as nurses and generalpractitioners) almost in a virtual manner.The key is the ability to gain immediate accessto relevant healthcare professionals (such as avascular surgeon) as needed.In many countries it is not only specialistequipment that may be unavailable, but alsothe specialist practitioners themselves, suchas podiatrists, vascular surgeons or plastertechnicians and so on. While the MDFT willbe managing the ongoing challenges of DFUcare, non-specialist practitioners can play akey role in the early detection of problemsand prompt referral to the team.PATIENT FOOTCARE EDUCATIONPatient education should be an integral partof management and prevention. Treatmentoutcomes will be directly influenced bypatients’ knowledge of their own medicalstatus, their ability to care for their woundand concordance with their treatment 13,38 .It is vital that patients should know who tocontact if a DFU develops or recurs, includingemergency numbers for the MDFT and outof-hourscontact details 37 .The development of an ulcer is a major eventand a sign of progressive disease. It is importantto discuss the impact of the ulcer on lifeexpectancy with the patient. Education shouldbe offered on ways in which patients canhelp to improve outcomes by making lifestylechanges (eg smoking cessation) and workingwith practitioners to reduce the risk of recurrenceand life-threatening complications 13 .A Cochrane systematic review found thateducating people with diabetes about theneed to look after their feet improves theirfootcare knowledge and behaviour in theshort term. There was insufficient evidencethat education alone, without any additionalpreventive measures, effectively reduces theoccurrence of ulcers and amputations 111 .According to the IWGDF, patient educationshould be provided in several sessions usinga variety of methods based on standardeffective communication techniques. It isessential to evaluate whether the patient hasunderstood the messages, is motivated to actand has sufficient self-care skills 7 . Rememberthat elderly and disabled patients may needhome or special care 45 .Practitioners should ensure patients understandthe aims of treatment, how to recogniseand report the signs and symptoms of(worsening) infection and the need for prompttreatment of new wounds 7,17 .BOX 6: Recommended levelsof foot care in acute and communitysettings 71. General practitioner, diabetespodiatrist and diabeticnurse2. Diabetologist, surgeon(general and/or vascular,plastic and/or orthopaedic),infectious dieases/microbiologyspecialist, diabetespodiatrist and diabeticnurse3. Specialised foot centre withmultiple disciplines specialisedin foot careBEST PRACTICE GUIDELINES: WOUND MANAGEMENT IN DIABETIC FOOT ULCERS 19
Page 1 and 2: INTERNATIONAL BEST PRACTICEBEST PRA
Page 3 and 4: INTRODUCTIONIntroductionDFUs are co
Page 5 and 6: AETIOLOGY OFDFUsAetiology of DFUsTh
Page 7 and 8: ASSESSING DFUsFIGURE 5: Procedure f
Page 9 and 10: ASSESSING DFUsBOX 1: Signs of sprea
Page 11 and 12: DFU WOUNDMANAGEMENTDFU wound manage
Page 13 and 14: DFU WOUNDMANAGEMENTHydrosurgical de
Page 15 and 16: DFU WOUNDMANAGEMENTantimicrobial ag
Page 17 and 18: DFU WOUNDMANAGEMENTTABLE 6: Wound m
Page 19: DFU WOUNDMANAGEMENTexclusion of inf
Page 23 and 24: REFERENCES1. National Institute for
Page 25 and 26: REFERENCES94. International Consens

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