Best feet forward: How to target DFUs

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Best feet forward: How to target DFUs
Best feet forward: How to target DFUs
Managing skin breakdown of any kind is a pervasive challenge for long-term care providers, but diabetic foot ulcers typically earn a spot near the top on caregivers' lists of most dreaded wounds. And for good reason.

Roughly one in five infected diabetic foot ulcers leads to amputation, according to statistics from the American Diabetes Association. People over age 75 are at greatest risk. Even if a foot ulcer doesn't lead to amputation, the economic and personal impact can be significant, costing nearly $45,000 to treat in the first two years of diagnosis.

While diabetes often causes a chain reaction of medical problems, diabetic foot ulcers also can seriously impede a resident's quality of life and ability to be active.

“Diabetes is a serious disease and when you layer an ulcer on top of that, you have a very big problem on your hands,” says James Spahn, MD, FACS, a retired surgeon with more than 30 years of experience in soft tissue survival and pressure ulcer prevention and treatment.

Because diabetes affects the autonomic nervous system, common complications, among others, may be neuropathy, decreased sensory perception and slow healing. And each can spell trouble where diabetic foot ulcers are concerned, warns Spahn, founder of pressure ulcer prevention product maker EHOB Inc.

“The problem I see in long-term care is that there's not enough being done to stay on top of the clinical health of these individuals, so these ulcers — and infections — can really sneak up on them. If facilities don't get a better handle on these patients now, it's only going to get worse.”

Diabetes affects nearly 20% of Americans over the age of 65, according to, and another quarter of the senior population fits the criteria for impaired glucose intolerance. What's more, nearly half of elderly diabetics fail to properly control their blood glucose levels.

“That means there's a good chance that by the time a diabetic is admitted into skilled nursing, they're already at a deficit and at real risk for developing a diabetic foot ulcer,” says Lee Rogers, DPM, associate medical director of the Amputation Prevention Center at Valley Presbyterian Hospital in Los Angeles. Rogers, who also chairs the American Diabetes Association's foot care council, says his facility sees five or six skilled nursing residents arriving with severe diabetic ulcers via ambulance each day.

“Diabetics are not like every other patient,” he says. “They need extra care and attention. You have to be diligent if you're going to successfully treat and prevent these decubitus ulcers.”

Digging deeper to treat
Experts agree that the first and most critical line of defense against diabetic foot ulcers is a dedicated care team. Comprehensive risk and skin assessments are critical, although a lack of qualified wound care specialists means they don't always get the attention they deserve.

“This can delay administration of appropriate care or result in the delivery of suboptimal care. The end result is an ulcer can get progressively worse and remain open for a prolonged period of time,” says Christopher Cashman, president and CEO of SANUWAVE Health.

At minimum, facilities should staff a nurse certified in comprehensive foot and nail care. Certification programs, such as those offered by the Wound, Ostomy and Continence Nurses Credentialing Board, not only allow nurses to treat and prevent basic foot and nail care issues that can contribute to DFUs, but also help them independently assess and refer high-risk residents. They are encouraged to share basic knowledge to other caregivers, notes one certified wound specialist and dermatology advanced practice nurse.

“I recommend that each facility consider employing or contracting with such a clinician,” says Cynthia Ann Fleck, BSN, MBA, RN, ET/WOCN, CWS, vice president of clinical marketing for Medline Industries Inc., and past director of the Association for the Advancement of Wound Care. “Teaching basic measures to frontline caregivers can decrease the [risks for] developing these wounds.”

Parkside Villa in Middleburg, OH, is aggressively targeting DFUs with a multidisciplinary approach. Upon admission, each resident undergoes a comprehensive risk and skin assessment by the admitting nurse, and a certified wound nurse performs another head-to-toe assessment within 24 hours as an added safeguard. Each day thereafter, nursing assistants carefully assess each resident, and they do it again during bathing, which, if residents approve, occurs twice weekly.

“On top of that, nurses also do their own head-to-toe assessments twice a week,” says wound nurse Cheryl Kneier, LPN, WCC. “Assessments are critical. It's a team effort.”

Expanding the care team
Increasingly, the multidisciplinary team includes another key player: an in-house podiatrist who performs basic foot and nail care, identifies and addresses foot and gait problems, and assists caregivers in treating and preventing DFUs. It's a prudent approach that wound experts say all skilled nursing facilities should consider.

“This is a good idea — practical and necessary to save money and lives,” believes Jeremy Graff, DPM, podiatrist and certified wound specialist for the Texas Center for Foot and Ankle Surgery and the Texas Center for Advanced Wound Care. Graff, who works in a long-term care facility alongside a skilled wound care team, has seen better diabetic foot ulcer healing rates and closure periods as a result. “Other programs under the direction of a podiatric physician would also be beneficial, including training staff on what to look for, how to look for it, and the proper steps to take when [risks] are identified.”

That's precisely what's happening at Lima Estates, an ACTS Retirement-Life Community in Media, PA. Charge nurse and wound care specialist Darien Tully, RNBC, WCC, boosted her DFU-related knowledge by working with the in-house podiatrist.

“It's a service I would highly recommend for continuity of care, as well as wound healing,” she says.

If daily, in-house access to a podiatrist isn't feasible, facilities should partner with foot specialists for as-needed consultation and training. Many podiatric physicians are willing to contract with skilled nursing providers for scheduled “foot clinics” or individual treatment, Fleck says.

Based on risk, Fleck says she recommends a neuropathic foot screening that includes a Semmes-Weinstein Monofilament exam, and skin and nail assessments. These can identify current foot problems and initiate a proper care and treatment plan.

“These simple diagnostics, along with an ankle brachial index, can be performed by a licensed nurse in most cases. A podiatrist can then offer referral of care if the resident is assessed as needing further care,” she says.

High-risk residents should be referred to foot care specialists for ongoing preventative care and lifelong surveillance, she adds.

Parkside Villa, along with seven other Legacy Health Services facilities, recently stepped up its diabetic foot care efforts by partnering with a group of podiatrists that makes weekly rounds, and provides assessments, chart review and foot care — including bedside wound debribement.

“Our goal is to heal one person a week, and this is an important step in reaching that goal,” Kneier explained optimistically.

Tapping the right tools
Caregivers may be the best weapon in the DFU treatment and prevention arsenal, but there are some promising technologies that can make them even more effective. Computers are one of them.

Management of DFUs “can be supported with software that provides clinical pathways from resources of evidence-based medicine,” notes Sheila Cougras, director of quality for Net Health Systems Inc.

Documenting wound care, compliance and healing progress is another critical task that can be assisted with software-driven clinical documentations tools, she adds.

Smartphones and tablet computers also are effective. Rogers recently started a pilot program to allow wound-related video communication with nursing homes via iPhones and iPads. Although hands-on assessments are undoubtedly beneficial, he says the technology allows physicians to evaluate a wound without the need to transport the resident to a hospital or clinic.

“You really can tell a lot about a wound from a two-dimensional image,” he assures.

Thermographic imaging is also aiding early DFU detection. A thermal infrared image, along with a visual digital image, can detect at-risk tissue, as well as early-stage injury in the subcutaneous tissue that would otherwise be invisible to the naked eye.

“A wound begins with inflammation. Thermography has real applications in long-term care because it can identify inflammation and help predict who is likely going to develop an ulcer,” says Rogers.

Regenerative technologies that kick-start the normal healing process also are catching on, and resulting in improved wound granulation and closure, and lower recurrence rates. SANUWAVE's dermaPACE technology, for example, delivers high-energy acoustic pressure waves to DFUs and involves just four 20-minute non-invasive procedures over a two-week period. In a 12-week clinical trial, this protocol, in conjunction with wet-to-dry dressings, was shown to significantly reduce ulcer size and hasten complete wound closure.

“By 12 weeks, the average percent reduction in the size of the target ulcer in patients treated with dermaPACE was 54%, compared to only 7% in patients [in the control group],” says Cashman.

Further, the clinical trial showed that DFUs closed by dermaPACE are likely to stay closed, he adds.

Back to basics
Still, experts reason that some of the best wound care approaches are often the simplest. While Rogers advocates fitting high-risk diabetics (including those who have had wounds in the past, but currently show no signs of skin breakdown) with pressure-relieving heel protectors — ideally, the kind that Velcro around the resident's calf — he says properly-fitting shoes are one of the most important, yet oft-overlooked, items in the DFU-prevention toolbox.

“One of my biggest pet peeves is seeing [residents] walking without shoes. The fat pads under the foot diminish with age, so there's less protection — and diabetics are often neuropathic, which means they'll keep taking the exact same step because they won't feel pain from tissue damage,” Rogers says. “I prefer diabetic shoes and there are even diabetic slippers that offer better support and protection. But make sure residents don't sleep in shoes. The heel resting on the hard surface of the shoe can actually cause [wounds].”

Above all, though, the DFU experts stressed that no one product will ever override the benefits of good care, ongoing assessments, and diligent detective work to determine a diabetic foot ulcer's underlying cause.

“Everyone wants to jump to a device, but those really should come last. When you do use a device, know why you're using it and what your expectations are,” says Spahn. “Think it through. You don't need to stick a person on an expensive mattress if they have a wound on the sole of their foot, for example. And if a vascular problem is the underlying cause of a wound the worst thing you can do is stick the person in a bed or chair and have their whole cardiovascular system collapse.”

Spahn says that caregivers should also ensure that neuropathic residents aren't unknowingly banging or pressing their feet up against bed rails, walls or other hard surfaces, he says.

“Pay attention. Open your eyes,” Spahn advises. “Some of the best solutions are right in front of you, and they don't cost a thing.”