Ulcers: closing the gaps

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Diabetes affects up to 34% of skilled nursing facility residents, putting them at risk for lower-extremity ulcers.
Diabetes affects up to 34% of skilled nursing facility residents, putting them at risk for lower-extremity ulcers.

More than 25% of seniors age 65 and older have diabetes, and as many as 34% of nursing home residents battle the disease — a rate higher than any other population. 

That's according to statistics from the American Diabetes Association and the Centers for Medicare & Medicaid Services. 

Diabetes can damage organs, diminish vascular and arterial health, and cause neuropathy that raises the risk for ulcers, amputations and death. Some studies have shown roughly 1 in 5 infected foot ulcers lead to amputation, and the mortality rate for those with a lower-extremity amputation is just two to five years. 

The costs associated with treating diabetic ulcers add insult to injury. Even if a lower-extremity diabetic ulcer doesn't lead to amputation, most recent estimates show that people with diabetes-associated lower-extremity wounds cost the Medicare program more than $9 billion annually. 

An ever-growing burden, naturally, is falling on long-term care providers. Many, unfortunately, are not up to speed on the latest caregiving protocols and innovations — and it's showing.

“Treating and preventing diabetic wounds is very complicated and a lot is involved,” says Nick Haralambis, RN, a healthcare product consultant for HD Supply. “Wounds are tough to heal, but vascular wounds are very challenging.” 

Fortunately, technology continues to improve, he says, and when used in conjunction with all other critical facets of care, the odds improve for effective diabetic wound prevention and treatment.  

Set the stage

Although most diabetic ulcers are preventable, wounds may be present when a diabetic resident is admitted to a facility — and there may be times when ulcers still surface, despite vigilant care. Regardless of how a diabetic ulcer presents itself, care experts assure the wounds can be properly managed and treated through coordinated assessment, planning, proper care and targeted training.

“When wounds develop, quick and correct treatment can make the difference between an abrasion that heals in a few weeks and an infected bone that leads to amputation,” notes Gunnar Johannsson, M.D., the head of Medical Affairs for Kerecis. 

Any diabetic wounds present at initial resident assessment should be promptly identified and a care plan must be implemented to treat the wounds and prevent further skin breakdown, adds Julia Melendez, RN, BSN, JD, CWOCN, National Clinical Director for Joerns Healthcare. 

“There has been an emphasis on differentiating diabetic ulcers from other lower extremity wounds, such as those caused by pressure injury and lower extremity arterial disease,” she says, adding that effective treatment depends on correctly identifying the underlying causes and then eliminating or controlling those causes to optimize topical wound management. 

Diabetic ulcers usually offer some telltale signs to help caregivers make a more accurate diagnosis. Diabetic ulcers typically occur on the ball of the foot or the bottom of the big toe. Ulcers on the sides of the foot are often due to ill-fitting shoes, and heel ulcers caused by poor pressure management can also develop. Typical characteristics of diabetic wounds include even wound margins, cellulitis or underlying osteomyelitis, granular tissue present (unless peripheral vascular disease is present) and low to moderate drainage. 

“A thorough foot assessment should be conducted in residents that present to the facility with a diabetes diagnosis,” Melendez adds. This includes monitoring skin hydration, inspecting the surfaces of the feet, looking for the presence of, location and distribution of calluses, and the presence of cracks and fissures, she says. “A callus can increase the pressure and shear exerted on the underlying tissue during walking, which can lead to an ulcer. Cracks and fissures also can predispose the foot to breakdown.”

Diminished or absent foot sensation or foot deformities, palpable pulses, a warm foot, and subcutaneous fat atrophy also can signal ulcer development and risk factors for diabetic wounds. 

Caregivers also must be aware that early stages of wound development can be deceptive.

“A thick callus can initially hide an ulcer,” explains Johannsson. “Caregivers should always expect the worst when a diabetic patient has a wound on a weight-bearing surface, such as the soles of the feet.”

As soon as symptoms of skin breakdown appear, a multidisciplinary approach is necessary to address all factors contributing to the ulcer formation. 

“These ulcers occur because of problems with microcirculation in the feet, possible calcification of larger arteries, neuropathic changes that result in loss of sensation, and bone changes that can cause deformities and pressure points in the foot,” says Therese Laub, LPN, CWS, wound and product specialist for Gentell. “The better controlled the factors are that contribute to the ulcer formation, the faster the ulcer will heal.”

Disciplines that can help stabilize these problems include the wound care nurse, physical therapist, orthopedist, podiatrist, dietician, endocrinologist, vascular surgeon, diabetes educator, neurologist, nephrologist and infection disease professional, Laub says.

Dressed for success

Today, the market is brimming with innovative wound care products and technologies that can help hasten healing, reduce the rate of infection, deliver better pain relief, and reduce the number and frequency of dressing changes. 

Negative-pressure wound therapy devices continue to be useful for treating diabetic foot ulcers. Newer models are more compact and efficient, allowing for weekly applications. 

“This, on average, can decrease wound care frequency from three times a week to one time a week,” says Sandy Hughes, BSN, RN, CWOCN, COS-C, board of director treasurer for the Wound, Ostomy and Continence Nurses Society. 

Hyperbaric oxygen chambers also are being used with good effect, she says. 

NPWT is less traumatizing to elderly residents, due to the infrequency of dressing changes, adds Susan Cleveland, BSN, RN, WCC, CDP, director of nursing services ICP Inc., and current board of director secretary for the National Association Directors of Nursing Administration/Long Term Care. 

Topical growth factors and bioengineered skin substitutes are other notable developments, as are biologics made from intact fish skin.

“Natural fish skin is rich in Omega-3 fatty acids, which relieve pain, reduce inflammation and provide a barrier for bacterial ingrowth,” Johannsson explains.

Iodine products also have been overhauled, leading to safer, more controlled application.

“Although highly effective, iodine can be toxic if introduced in large amounts in a short period of time,” says Ben Coffey, director of operations and new product development for Nurse Rosie Products. Controlled-release iodine is now available in a foam bandage and is regulated by the amount of exudate in the wound bed, he explains. 

“As iodine kills the bacteria, the amount of exudate decreases, which slows the release of iodine and prevents it from reaching toxic levels,” Coffey says.

Topical collagen products offer wound healing benefits as well by improving deposition of new tissue and attracting wound healing cells. Studies also show topical insulin can promote wound healing by stimulating proliferation and migration of macrophages and keratinocytes, according to Cleveland. 

“Other emerging strategies include tissue engineering techniques, such as use of stem cells and gene therapy, for achieving wound closure and offering a potentially new regenerative approach in wound care,” she says.

Studies also are being done on lipids in the wound environments and how they interact with inflammation and pain. 

Wound care-specific software programs are available to help caregivers navigate recommended products for each wound. 

“The way these programs operate is by taking information about a wound, such as its size, depth, amount of exudate and age, and then advising which wound care products are recommended, which products are reimbursable by Medicare and Medicaid, and how many can be billed per week,” says Coffey. 

Most common error

New-and-improved products and therapies aside, experts are quick to point out that positive outcomes still hinge on vigilant adherence to key wound care practices, such as effective wound debriding and offloading.

“By far, the most common mistake is failure to debride a wound on a regular basis,” says Coffey. A stage three or stage four pressure ulcer can be mistaken as a stage one ulcer due to the amount of necrotic tissue in the wound bed that makes the wound appear much shallower and smaller than it really is, he explains. “Bacteria also feed on necrotic tissues, which causes chronically infected wounds to become more severe.” 

When a foot wound begins to surface, immediate offloading is imperative because walking on an ulcer can make it larger. Worse, if infection is present, putting pressure on the wound can force the infection deeper into the foot, notes the ADA.  

Total contact casting is considered the gold standard for offloading diabetic foot ulcers; unfortunately, it's an underused technique in long-term care because facilities may lack the availability of clinicians trained in the technique. As Laub points out, though, the casting can be applied by a podiatrist. 

No news is good news

Still, experts agree that the best wound is one that never has a chance to develop. Vigilant monitoring and management of blood glucose levels is critical for preventing diabetic complications, including foot ulcer formation. 

“[Testing for] blood sugar just once a day does not give enough information about how effectively the diabetes management is working,” Laub emphasizes. “Whenever someone is diagnosed with diabetes, when medication is changed or added, or when new symptoms occur, frequent testing of blood sugar is critical to determine how to better adjust medications or lifestyle changes.” 

Other comorbidities, such as lower-extremity vascular problems, also should be identified and managed, reminds Melendez.

Good nutrition is important; however, the American Medical Directors Association now recommends more liberal diets for diabetics in long-term care, versus restrictive therapeutic diets that can sometimes lead to dehydration, undernutrition and unintentional weight loss. While carbohydrate intake should be taken into consideration, “no concentrated sweets” or “no sugar” diets are no longer recommended. A consistent carbohydrate meal plan that allows for a wide variety of food choices may be more beneficial for both nutritional needs and glycemic control in those with type 1 diabetes or type 2 diabetes on mealtime insulin, the ADA noted in its February 2016 position statement, “Management of Diabetes in Long-term Care and Skilled Nursing Facilities.”

Last, but not least, caregivers should not overlook the importance of proper footcare. This includes conducting full foot inspections daily and any time a resident's shoes are removed, and ensuring that residents only wear properly fitted shoes and socks that aren't too tight or trap moisture.

“Wearing bad or tight shoes, having unkempt nails or walking barefoot are sure ways to risk developing an ulcer,” says Johannsson.