Comprehensive diabetic foot care

New concepts for a complex disease

The Wound Care Unit at the Clinic Pasteur in Toulouse, France, was successfully set up to deliver a multidisciplinary approach to diabetic wound care.

This necessitated the formation of a team* of specialists from many fields. Here, Dr Philippe Leger, who will lecture on this subject at EuroPCR 2009, discusses the reasons why this is a necessary concept to deal with the vexing problem of diabetic foot care — and how it works.
“Diabetes can damage the nerves in the lower limbs, which can lead to loss of sensation in the feet. Diabetes causes arterial damage, particularly in arteries below the knee. Neurological and arterial disease induce ulcers, and infection increases the problem and can lead to amputation. Diabetes is the leading cause of non-traumatic amputations (eight out of 10). 50% of these could be prevented by improved screening, along with earlier and more coordinated treatment. Indeed, 85% of amputations in diabetic patients are preceded by a foot ulcer. People with diabetes are 15% more likely to have an amputation than those without. We can sum up the problem by saying that ‘someone, somewhere, loses a leg because of diabetes every 30 seconds of every day’. This complex and multifactorial disease requires a multidisciplinary approach, which is possible in a wound care unit or diabetic foot clinic. The international consensus on diabetic foot disease promotes the treatment of the diabetic patient by a multidisciplinary team.
Treatment must address all the factors involved in wound healing: We must off-load pressure. Many diabetic foot ulcers are neuropathic ulcers and an important part off the treatment is reducing external pressure with different devices or special shoes. With ischaemic ulcers we need to improve blood flow by endovascular revascularisation or by-pass. It is also necessary to treat any infection as soon as possible, because this stops, or delays, the normal wound healing process.
The aims of the multidisciplinary approach to the diabetic foot are numerous. They include diagnosis and treatment of the diabetic foot; obtaining optimum glycaemic control to reduce all complications; controlling other cardiovascular risk factors e.g. smoking, dyslipidaemia, hypertension; enabling patients’ education and coordinating surveillance of other complications.
The multidisciplinary approach to the diabetic foot is ambulatory care, with a care co-ordinator who is a diabetologist, angiologist or surgeon. In addition to the physician, team members are nurses, podiatrists, orthotist and educators. Access to different specialities is necessary to investigate and treat the disease. We need non-invasive vascular laboratory (duplex-sonography TcpO2), radiology with MRA/MRI, CT scan, biology, interventional radiology, vascular and orthopaedic surgery and cardiology. Sometimes it is necessary to hospitalise patient in a department that specialises in these diseases.
When we created the Wound Care Unit we had to address a variety of problems: We organised patient care with a wound care nurse specialist; we chose the care coordinators and recruited the staff: podiatrists, surgeon, orthotist, and organised their work; from international guidelines we created our own; we formalised multidisciplinary meetings to create the links between different staff involved in wound care, we organised therapeutic education,  we informed GPs, diabetologists, angiologists, cardiologists and surgeons of our area. After all this, communication was improved between the different specialist teams and a multidisciplinary clinic was created.
The activity increased very quickly. At present 12-15 patients per day are referred to the Wound Care Unit. The number of arteriographies and interventional endovascular revascularisation has increased by more than 6-fold.
We hope that by this approach we can save feet.
Review of the literature shows that efficient organisation of prevention and care by a multidisciplinary team reduces:
•    ulcers and amputations by 50–80%
•    significantly the occurrence of ulcers in risk patients 
•    the time for complete healing
•    the recurrence rate
•    the incidences of hospitalisations
•    length of hospital stays by allowing faster ambulatory care
And, it is cost-effective.
The main problem is that the administration cannot yet understand the importance of the coordinated wound care unit, both for a patient and society. In fact, there are not enough wound care units to give all patients equality of care. ”
* The Wound Care Unit team: Dr P Leger, Dr F Branet, Dr A Sauguet, Dr C Jordan, Mme S Zalateu and Mme F Creach.

01.05.2009

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