¶ … 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...

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…