Getting a leg up

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There are more than 80,000 lower extremity amputations annually on diabetic patients in the United States.
There are more than 80,000 lower extremity amputations annually on diabetic patients in the United States.

Maybe it started as a blister caused by a wrinkled sock in a too-tight shoe. Or perhaps the resident's toe was nicked during a recent toenail trimming. 

Whatever the cause, foot ulcers are among the most common reasons diabetic patients in long-term care are hospitalized. In fact, according to the American Podiatric Medical Association, around 15% of patients with diabetes will develop a foot ulcer during their lifetime. Other research puts that figure closer to 25%.

“The longer a person has the disease, the more prone they are to complications such as foot ulcers,” says Laura Dahl Popkes, RN, CWOCN, clinical services manager at McKesson Medical-Surgical.

In addition to pain, diabetic foot ulcers are expensive, notes Mary Madison, RN, RAC-CT, CDP, of Briggs Healthcare. Citing research from a 2006 study in the journal Clinical Diabetes, she notes that the average cost of healing just one ulcer is $8,000; it jumps to $17,000 if the ulcer is infected.  In addition, more than 80,000 lower extremity amputations are performed each year on diabetic patients — at an average cost of $45,000 apiece.

“Add to that the three-year mortality rate after an initial amputation, which is as high as 50 percent, and you can see why increasing awareness around diabetic foot ulcers is so important,” Madison says. “In addition, these numbers remain unchanged over the past three decades, despite advances in diabetes care and management.”

Especially in long-term care, prevention and early intervention of diabetic foot ulcers is critical, she and other experts agree.

Newest treatments

When a foot ulcer is first detected in a diabetic patient, treatment must begin with a neurological and vascular assessment as well as an overall evaluation of the foot ulcer itself, Madison says.  During the evaluation, providers should check for signs of infection, as well as the patient's circulation status, says Katherine Raspovic, DPM, spokeswoman for the American Diabetes Association and a podiatric surgeon at MedStar Georgetown University Hospital and MedStar Washington Hospital Center.

“If there's any concern about abnormal arterial circulation, you'd want to get that patient in to see a vascular specialist right away,” says Raspovic. 

After these assessments and evaluation, treatment of a diabetic foot ulcer involves several key processes, Madison says. First, debriding the wound may be necessary in order to remove necrotic tissue, decrease the risk of infection and reduce pressure around the edges of the foot ulcer. Autolytic debridement — the process by which the body uses moisture to shed dead tissue — can be encouraged by using dressings that promote a moist environment, says Margaret Falconio-West, BSN, RN, APN/CNS, CWOCN, DAPWCA, senior vice president of clinical services at Medline. Available dressings include hydrogels, calcium alginates, foams and absorbent polymers, as well as some newer products such as non-antimicrobial PluroGel, a biomaterial surfactant, or cleaning agent, for wound care developed by researchers at the University of Virginia.

It's also important that providers make sure the dressing is changed, keeping the wound bed moist but not wet, and protected from bacterial invasion, says Betsy Meyers, MBA, LNHA, ACHE, vice president of the Midwest Region at Gentell.

Offloading or pressure relief is another essential element of diabetic foot ulcer treatment, and can often be the biggest challenge in healing an ulcer, Madison says. Wheelchairs or crutches are the simplest and easiest appliances for offloading. Some physicians use total contact casts while others use removable cast walkers. One 2014 study in Advances in Skin & Wound Care found there were significantly more amputations within a year for those with diabetic foot ulcers who did not have total contact casting when compared with those who did. Special shoes also can be used but they have to be large enough for bulky dressings.  

“The key — and the challenge — is to get the patient to use such devices all the time,” Madison says.

Infection control is also critical to the treatment and healing of a diabetic foot ulcer, she adds. If such a wound is severe or a life-threatening infection is present, the patient should be hospitalized and treated with IV antibiotics. Mild infections can be treated with oral antibiotics after initial cultures are obtained, and can often be managed successfully without hospitalization. Appropriate use of antimicrobials, such as controlled release silver dressings, also can make a world of difference in a person that has a diabetic foot ulcer, says Falconio-West.

“There are many antimicrobial products available, and no one product is going to be right for all patients,” she says. “Clinicians need to match up appropriate product features and clinical characteristics of the wound bed.”

Acting decisively

If a wound edge is not migrating after appropriate treatment, advanced therapies may be considered, says Raspovic. These include bioengineered skin substitutes such as Apligraf, a bilayered living cell therapy to help stimulate healing, and collagen products such as Integra, which act as a scaffold for cellular invasion and growth, facilitating reconstruction of the dermal tissue, she says.

“In general, if we apply the basic wound principles — offloading and making sure there's good circulation and no infection — foot ulcers should heal on their own,” Raspovic says. “But if the wound really isn't responding after a few weeks, we'll often head in the direction of these bioengineered products.”

The bottom line is that prevention of diabetic foot ulcers is paramount, says Falconio-West.

“In long-term care environments where residents are typically older, have limited mobility and activity levels, and have issues testing their glucose levels and adjusting insulin, the management of diabetes can be challenging,” she says. “Nursing staff must be their advocates.”

Brooke Milton, RN, MSN, with Nurse Rosie Products/Life Systems Inc., agrees, noting there needs to be an increasing focus on nurses' knowledge and skills.

“The more they know about diabetic foot care, the more they can prevent ulcers and effectively treat wounds that do appear,” she notes.