Footing the bill
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The morbidity associated with diabetic foot ulcers is significant. Approximately one-quarter of diabetic elders who develop a foot ulcer also succumb to a subsequent bone infection. In addition, as many as 25% of those with infected diabetic wounds will undergo an amputation.
In fact, an amputation resulting from such a wound occurs every 30 seconds, according to the American Diabetes Association. Many amputees require a second amputation within two to three years.
“Even a small neuropathic ulcer can take someone from an ambulatory setting, such as assisted living, to the hospital and even to the grave very quickly,” notes wound care specialist Cynthia Fleck, RN, BSN, ET/WOCN, president of the American Academy of Wound Management and vice president of clinical marketing for Medline Advanced Skin and Wound Care.
The financial impact of diabetic wounds is equally sobering, costing facilities upward of $10,000 per episode to treat—and far more if the wound leads to an amputation. The good news is 90% of amputations are preventable, and many times, the wounds themselves are, as well.
“The bad news is some [providers] aren't doing what's necessary to drive positive outcomes in elderly diabetics,” explains David G. Armstrong, DPM, Ph.D., professor of surgery at the University of Arizona College of Medicine in Tucson.
Bridging the gaps
Numerous factors contribute to inappropriate or insufficient diabetic wound management. For starters, as many as half of all diabetics are undiagnosed, and because the elderly often have other medical conditions that can mirror diabetes symptoms, proper treatment often is delayed.
The “paramount connection” between vascular disease and diabetes is particularly noteworthy, according to Fleck. She explains that the incidence of vascular disease is four times higher in those with diabetes and those risks continue to increase with age. “Both vascular disease and high blood sugar can reduce blood flow to the lower extremities, especially the feet.”
Another relatively common shortcoming in the skilled nursing setting is caregivers' ability to effectively differentiate between diabetic wounds and pressure ulcers.
Diabetic ulcers tend to occur below the ankle and typically on the plantar aspect of the foot, over the metatarsal heads and under the heel, according to Fleck. “Think of it in terms of where the rubber meets the road and where the toe hits the toe box with every step.”
Although pressure indeed plays a role in both types of wounds, experts agree that caregivers who aren't able to make the distinction could very well be missing the opportunity to address the diabetes itself and prevent future wounds and diabetes-related complications.
“It's important to recognize that a diabetic wound is a symptom of a greater problem. While it's obviously important to manage and heal the wound, it's imperative that the underlying cause of that wound is properly and consistently addressed,” says geriatrician Jamehl Demons, MD, assistant professor, department of internal medicine, Wake Forest University Baptist Medical Center, Winston-Salem, NC. The medical center notably is home to the J. Paul Sticht Center on Aging.
An inside-out approach
Optimizing all aspects of the resident's physical, nutritional and psychosocial well-being is necessary for ensuring proper treatment and driving maximum benefits, adds Elizabeth Trevino-Miller, director of wound care marketing for Kinetic Concepts Inc., San Antonio.
“Clinicians may sometimes wrongly consider all diabetic foot ulcers to be the same for treatment purposes. In all situations, the underlying wound etiology and comorbidities must first be addressed and treated,” she says.
“Before starting any wound care treatment, it is important to define treatment aims, objectives and clinical end points. In some circumstances, the objective will be to avoid further complications and to control symptoms, rather than to influence time of healing.”
Making that connection requires the development of a comprehensive—yet individualized—diabetes and wound management plan, with a multidisciplinary care team at the foundation.
“The goal is to prevent future damage, minimize current damage, ensure maximum function, improve quality of life and prevent or delay amputation. And to do this, you need a team approach,” says Allys Ansah-Arkorful, RN, a wound care nurse at Shervier Nursing Care Center, a long-term care facility associated with Bon Secours New York Health System, Riverdale, NY.
Teamwork is key
The ideal scenario? Consistent collaboration among physician, certified wound specialist, educator, frontline caregivers, nutritionist, physical and occupational therapists, dietitian, consultant pharmacist, podiatrist, and vascular specialist, experts agree.
“Facilities must have a plan in place to identify, treat and prevent wounds in the elderly population. These plans need to be specific to the individual [resident],” says Marion Waugh, RN, CWOCN, nurse manager of nursing services for Emory Wesley Woods Wound Therapy Clinic in Atlanta. “Evaluation of these plans and treatments must be on a routine basis and done by knowledgeable personnel. Collaboration of [the care team] and family is essential to make this successful.”
Ongoing education is also key to ensuring that staff are well-versed on proper protocol for diabetic residents, and are following proven diabetic care and wound prevention and management practices. Such practices include thorough daily skin assessment, proper off-loading, repositioning and debridement, proactive blood sugar and edema management, limb revascularization, and proper use of accepted skin and wound care products, among other approaches.
“One of the biggest challenges that must be addressed relates to debridement. Many wound care people in this country are not good debriders and that's a huge problem,” stresses Gary Gibbon, MD, president and CEO of Quincy Medical Center in Quincy, MA.
He explained that proper debridement requires total removal of necrotic tissue. Calluses, which some caregivers mistakenly believe protect the skin, must also be removed.
“Many times, there's an abscess underneath. The sooner we debride that thickened skin the sooner we can address the wound and reduce the risk for additional complications.”
Failure to identify onset of infection, which can be subtle in a diabetic, is another relatively common mistake. The same can be said for failing to keep wounds and surrounding skin moist to prevent cracks and crevices that can increase the risk of infection.
“Moreover, this might lead to dermatitis, which increases the potential for itching and scratching,” explains Lison Plante, medical education manager at Smith & Nephew Inc., Largo, FL.
A step in the right direction
Aside from practicing due diligence to promote good health of diabetic residents through glucose management, proper hydration and a proper diet (ideally, one that's flavorful, low in simple carbohydrates and rich in protein), caregivers also must conduct thorough daily skin assessments.
“This is one of the most critical steps. Diabetics often develop neuropathy which means they don't have the gift of pain and can develop a serious wound without even knowing it,” Armstrong says. “People, including physicians and nurses, are conditioned to respond to pain, so the fact that a devastating wound can develop so silently is what makes this such a sinister problem.”
Effective assessment requires empowerment of staff, residents and families so they know the changes to look for and are able to familiarize them with normal skin discolorations, lumps and bumps. “One of the things long-term care really has going for it is there are so many different people touching the resident. Strengthening the lines of communication and empowering those people to identify and consistently document changes earlier rather than later is essential. Don't just assume that it's nothing or that someone else has already documented it. There's no such thing as being too careful.”
Proper pressure off-loading for non-ambulatory residents is another big piece to the diabetic wound management puzzle. “Diabetics who aren't moving their heels can start to develop a wound in just 15 minutes,” stresses Katherine Rowland, RN, MBA, chief clinical officer for National Healing Corp., Boca Raton, FL.
Having diabetics' feet examined by a podiatrist at least annually and, ideally, every six months, and encouraging the use of proper-fitting footwear also play key roles in wound prevention. Shoes should be wide enough and feature a generously sized toe box to prevent tugging and friction.
Residents also should be encouraged to wear white socks, which make it easier to spot blood or other wound exudate, and they (and their caregivers) should be taught that the first thing to go into a shoe is their hand to feel for raised edges, pebbles or other objects that may have found their way inside.
“I can't stress enough the importance of proper footwear. It's one of the factors that can have the biggest impact, yet it's also one that is most frequently overlooked,” says Steven Tillet, DPM, a podiatric expert for the American Podiatric Medical Association. “The right footwear may not heal a wound, but it sure can go a long way toward preventing it.”