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Management of diabetic foot complications


Organization and preventative care

Organization of the diabetic foot care team

This chapter addresses the questions of how does one set up a multidisciplinary team for the management of diabetic foot, and who should be involved.

Summary
  • Patients with diabetes frequently have a multitude of complicating issues, not only lower extremity complications, but also chronic renal disease, cardiac disease or gastrointestinal disturbances. A multidisciplinary medical team is therefore essential.
  • In the earliest wound care center, The Joslin-Deaconess Foot Center, diabetologists, podiatrists and vascular surgeons were included. This center allowed for management and coordination of care for diabetic foot ulcers, vascular disease and medical management of diabetes.
  • To provide comprehensive treatment, other key specialties must also be available, including plastic surgery, orthopedic surgery, infectious disease, physical therapy and prosthetists/orthotists.
  • Timely communication by all members of the patient management team is key to the success of diabetic foot disorder treatment. Such communication can be greatly facilitated by the creation of a dedicated unit in the hospital for patients with diabetic foot problems. There are several advantages of such an approach, including:
    • Patients being comanaged by the vascular surgical and podiatry teams are seen together, ensuring timely and direct communication
    • Physicians are consulted directly while on rounds, with patients seen immediately, diagnostic tests reviewed and ordered, and recommendations directly communicated, allowing for immediate formation and execution of a plan
    • Rounds can be conducted in a more efficient manner
    • Appropriately trained nursing staff, case managers and physical therapists can be assigned to deal with the specific requirements of diabetic patients with wounds.
  • Many of the same characteristics as those of a dedicated hospital unit are incorporated into outpatient wound care centers, which are often run in a multidisciplinary fashion, with specialists such as podiatrists, vascular surgeons, general surgeons and plastic surgeons.
  • The ultimate goal in the care of a patient with a diabetic foot problem should always be total wound healing and limb salvage, it is important to always keep this goal in mind.

Giurini JM, Pomposelli Jr FB. In: The diabetic foot: Medical and surgical management. Edited by Veves A, Giurini JM, LoGerfo FW. Humana Press, 2012. doi: 10.1007/978-1-61779-791-0_23

Foot care and the prevention of recurrent ulcers

In this chapter, the necessary standards of care for the prevention of recurrent ulcers are discussed.

Summary
  • The precursor to amputation is most often ulceration, which is often preventable. However, despite increasing awareness, the occurrence of amputations is increasing.
  • Some of the issues include those related to the provision of foot care. Currently, while an established pathway of care exists, this pathway is complicated and is beyond the resources of most multidisciplinary care teams.
  • Patients with diabetic foot ulcers are usually seen by general practitioners, district nurses, practice nurses and community podiatrists, with varying levels of expertise and often no specific training in diabetic foot complications.
  • Potential solutions to the problem of preventing foot ulceration include the development of realistic integrated pathways that are simple to follow.
  • Implementation of standardized care should take place, with all diabetic patients undergoing foot examination and being placed into appropriate risk classifications:
    • Low risk – normal sensation, palpable pulses
    • Increased risk – neuropathy or absent pulses
    • High risk – neuropathy or absent pulses plus deformity or skin changes or previous ulcer (within the previous 15 months)
    • Ulcerated foot/active foot disease.
  • Preventative education may be helpful if the patient understands the advice and is empowered to help themselves. They should be told their risk classification and given appropriate tailored information, including information on how to recognize a foot emergency and where to seek help.

King L. In: Management of diabetic foot complications. Edited by Shearman C. Springer-Verlag London, 2015. doi: 10.1007/978-1-4471-4525-7_14

Contents

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  1. Epidemiology
  2. Clinical features and diagnosis
  3. Management
  4. Organization and preventative care