by Susan M. Cleveland, BSN, RN, WCC, CDP, NADONA Board Secretary
by the WoundSource Editors
Comprehensive treatment of diabetic foot ulcers (DFUs) includes moist local or topical wound care, serial sharp debridement, treatment of infection, mechanical offloading, glycemic control, nutritional management, and overall chronic disease management. These facets of therapy are best addressed by an interdisciplinary approach.
If we understand the principles of healing, what can we do to prevent the pathologic process of DFUs? Instituting measures to prevent development of DFUs can decrease morbidity and mortality. There are several organizations with guidelines for prevention of DFU and subsequent complications including amputation, infection, and loss of independence. This article will review the highlights of some of the most recent guidelines for DFU prevention.
Helpful Guidelines for the Prevention of Diabetic Foot Ulcers
National Institute for Health and Care Excellence (NICE) Guideline for Prevention and Management of Diabetic Foot Problems. This document provides a validated tool for risk stratification of diabetic patients.1 It details a number of risk factors contributing to the development of diabetes-related foot complications (DRFC) including neuropathy, limb ischemia, ulceration, callus, infection and/or inflammation, deformity, gangrene, and Charcot arthropathy. Low-risk factors include those patients with a current diagnosis of diabetes; moderate risk factors include low-risk criteria plus one risk factor; and high-risk individuals are those with more than one risk factor present, currently require renal replacement therapy, or have a history of ulceration or amputation. The guidelines suggest that patients be counseled with clear expectations on a comprehensive diabetes management and education program, both oral and written. The importance of appropriate glucose management, regular foot care and examinations, and targeted, customized patient education is discussed as paramount to prevention of diabetic foot problems. In addition, according to risk stratification, low-risk individuals may have foot examinations as infrequently as annually, moderate-risk patients may have examinations every three to six months, and high-risk patients may be examined every one to two months and as needed.1
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International Best Practice Guidelines: Wound Management in Diabetic Foot Ulcers.These guidelines dictate that prevention requires an integrated approach, including regular foot care by an interprofessional team versed in diabetes and related complications, focused patient education, and a diabetes disease management plan.2 Of equal importance, control of disease state and complications in diabetes is imperative as part of prevention of diabetes-related foot complications such as DFUs, gangrene, infection, and amputation. Patient education regarding diabetes and prevention of foot problems should be provided in several appointments utilizing a variety of delivery methods, and effectiveness of teaching should be evaluated. Education is integral because patients’ outcomes are directly related to patients’ knowledge of their disease process and self-care ability.2
Preventive Foot Care in People with Diabetes: A Technical Review. This review recognizes risk identification as the first step in prevention of DRFC.3 It details that the foot examination should include skin integrity, testing of protective sensation with a 10g monofilament, biomechanical or weight-bearing status of the foot, and noting of any unusual or uneven wear on footgear. In addition to the examination, patients should receive education and reinforcement of important concepts at each visit. For best assimilation of information, a thorough assessment of readiness to learn, current level of knowledge, and physical capacity for self-care should be made.3
Prevention and Early Intervention for Diabetes Foot Problems: A Research Review. This review states that deployment of an interprofessional team can produce significant cost savings compared with the cost of treating a DFU.4 In addition, screening and repeat foot examinations are critical to a preventive plan of care for DRFC and can alert providers to patients who have loss of protective sensation sooner. A positive correlation between tobacco use and amputation rate has been found; therefore, smoking cessation should be a prominent part of patient education. Relating to overall disease management, normalization of glucose levels delays onset of microvascular and macrovascular complications secondary to diabetes and lessens risk factors such as sensory neuropathy and peripheral vascular disease that can contribute to diabetes-related foot problems.4
Cochrane Review: Patient Education for Preventing Diabetic Foot Ulceration. A Cochrane review revealed that diabetic foot care education can improve short-term outcomes, but that education alone, in absence of other interventions such as screening examinations and comprehensive disease management, does not demonstrate a reduction in diabetes-related foot ulcer incidence or amputation.5
Consensus shows that one of the most prominent mechanisms for achieving the goal of reduction in development of DFUs and subsequent amputations is the increase in screening examinations. This idea is based largely on the hypothesis that screening examinations and proper foot care can prevent the majority of ulcerations and complications that lead to amputations. Surgical amputations prove costlier than treatment of DFUs and result in disability, loss of independence, and decreased quality of life in this patient population.2
1. National Institute for Health and Care Excellence. Diabetic foot problems: prevention and management. NICE clinical guideline NG 19. London, United Kingdom: National Institute for Health and Care Excellence; 2015. https://www.nice.org.uk/guidance/ng28. Accessed August 6, 2018.
2. Chadwick P, Edmonds M, McCardle J, Armstrong D International best practice guidelines (IBPG): wound management in diabetic foot ulcers. Wounds International. 2013. http://www.woundsinternational.com/best-practices/view/best-practice-gui.... Accessed August 6, 2018.
3. Mayfield J, Reiber G, Sanders L, Janisse D, Pogach L. Preventive foot care in people with diabetes. Diabetes Care. 2003;26:S78–9.
4. National Diabetes Education Program (NDEP). Feet can last a lifetime: a health care provider’s guide to preventing diabetes foot problems. National Diabetes Education Program. 2000. http://www.algadam.net/images2/Guide-PDF%20%282%29.pdf. Accessed August 6, 2018.
5. Dorresteijn J, Kriegsman D, Assendelft W, et al. Patient education for preventing diabetic foot ulceration. Cochrane Database Syst Rev. 2012;(10):CD001488.
The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.