Inpatient Management of Diabetic Foot Disorders
Guidelines, pathways, and checklists should be in place to evaluate patients with diabetes who are hospitalized for any reason. Patients should have their shoes, slippers, and socks removed and their feet examined for the presence of ulceration, ischemia, infection, neuropathy, and Charcot neuroarthropathy (CN). Urgent consultations should be obtained with an appropriate specialist for patients manifesting systemic signs of infection, critical limb ischemia, soft tissue crepitation, or deep tissue gas seen on radiographs, or fractures or dislocations of the foot and ankle. Timely (albeit less urgent) consultations should be obtained for less severe infection, noncritical ischemia, noninfected foot ulcers, or unexplained swelling in the foot or ankle. All biomechanical and dermatological conditions should be evaluated. Foot deformity can increase friction and cause pressure points, and simple paronychia and fungal skin infections can be a precursor to more significant infection.
A process should be in place to reduce pressure on the heels of all inpatients with diabetes in order to prevent iatrogenic pressure sores of the heel (Fig. 1). Fitzgerald et al. identified seven essential skills that might be required for an inpatient team caring for patients with diabetes. We have added an eighth essential skill (Table 1). These skills provide a comprehensive framework for the treatment of patients with diabetes independent of specific medical or nursing specialty, and include the ability to stage a wound; assess for peripheral vascular disease, peripheral neuropathy, wound infection; debride a wound; appropriately obtain wound cultures and select antibiotic therapy for infected wounds; plan for hospital discharge; and to prevent wound recurrence (Table 1).
(Enlarge Image)
Figure 1.
Photograph of a pressure-related heel ulcer in a hospitalized patient with diabetes. Friction against the bed in this neuropathic patient resulted in a full thickness ulcer.
Neurological evaluation at the bedside is aimed at detecting loss of protective sensation, using any of several validated techniques (the monofilament test, the neuropathy disability score, the Biothesiometer/vibration test, or the touch test). Because depression is associated with neuropathy and indeed predicts first foot ulcer development, careful assessment of the patient's affect should be made by the medical team caring for the patient. This is particularly important because psychological distress may also impact wound healing. The presence of ischemia should be assessed initially by history and physical examination, i.e., symptoms of claudication and palpation of the dorsalis pedis and posterior tibial pulses, and supplemented by evaluation with a handheld Doppler if pedal pulses are absent. When more objective evaluation is needed, assessment of lower extremity perfusion by means of Doppler waveform analysis, toe pressure measurement, transcutaneous oxygen measurement or arterial duplex ultrasound is recommended. Information based on this might prompt more invasive vascular assessment, e.g., angiography, which may lead to open or endovascular intervention.
Proper staging/grading of the wound using a validated classification system that documents depth, presence of infection and presence of ischemia may reduce ambiguity (Table 2). Diabetic foot ulcers (DFU) may be present in patients who are admitted for nonfoot problems, and these ulcers should also be evaluated by the diabetic foot team during the hospitalization. Noninfected foot ulcers should be debrided at the bedside, covered with a moist wound dressing, and protected by appropriate pressure offloading (redistribution). Offloading can be achieved by casting, removable boots, or postoperative sandals. Measurements should be obtained after debridement, and the characteristics of the wound (undermining, tunneling, and type of tissue at the base of the wound) should be recorded. Classification of wounds facilitates appropriate management (especially when different providers care for the patient over time) and has been shown to help predict wound outcomes.
Essential Skills of an Inpatient Diabetic Foot Service
Guidelines, pathways, and checklists should be in place to evaluate patients with diabetes who are hospitalized for any reason. Patients should have their shoes, slippers, and socks removed and their feet examined for the presence of ulceration, ischemia, infection, neuropathy, and Charcot neuroarthropathy (CN). Urgent consultations should be obtained with an appropriate specialist for patients manifesting systemic signs of infection, critical limb ischemia, soft tissue crepitation, or deep tissue gas seen on radiographs, or fractures or dislocations of the foot and ankle. Timely (albeit less urgent) consultations should be obtained for less severe infection, noncritical ischemia, noninfected foot ulcers, or unexplained swelling in the foot or ankle. All biomechanical and dermatological conditions should be evaluated. Foot deformity can increase friction and cause pressure points, and simple paronychia and fungal skin infections can be a precursor to more significant infection.
A process should be in place to reduce pressure on the heels of all inpatients with diabetes in order to prevent iatrogenic pressure sores of the heel (Fig. 1). Fitzgerald et al. identified seven essential skills that might be required for an inpatient team caring for patients with diabetes. We have added an eighth essential skill (Table 1). These skills provide a comprehensive framework for the treatment of patients with diabetes independent of specific medical or nursing specialty, and include the ability to stage a wound; assess for peripheral vascular disease, peripheral neuropathy, wound infection; debride a wound; appropriately obtain wound cultures and select antibiotic therapy for infected wounds; plan for hospital discharge; and to prevent wound recurrence (Table 1).
(Enlarge Image)
Figure 1.
Photograph of a pressure-related heel ulcer in a hospitalized patient with diabetes. Friction against the bed in this neuropathic patient resulted in a full thickness ulcer.
Neurological evaluation at the bedside is aimed at detecting loss of protective sensation, using any of several validated techniques (the monofilament test, the neuropathy disability score, the Biothesiometer/vibration test, or the touch test). Because depression is associated with neuropathy and indeed predicts first foot ulcer development, careful assessment of the patient's affect should be made by the medical team caring for the patient. This is particularly important because psychological distress may also impact wound healing. The presence of ischemia should be assessed initially by history and physical examination, i.e., symptoms of claudication and palpation of the dorsalis pedis and posterior tibial pulses, and supplemented by evaluation with a handheld Doppler if pedal pulses are absent. When more objective evaluation is needed, assessment of lower extremity perfusion by means of Doppler waveform analysis, toe pressure measurement, transcutaneous oxygen measurement or arterial duplex ultrasound is recommended. Information based on this might prompt more invasive vascular assessment, e.g., angiography, which may lead to open or endovascular intervention.
Proper staging/grading of the wound using a validated classification system that documents depth, presence of infection and presence of ischemia may reduce ambiguity (Table 2). Diabetic foot ulcers (DFU) may be present in patients who are admitted for nonfoot problems, and these ulcers should also be evaluated by the diabetic foot team during the hospitalization. Noninfected foot ulcers should be debrided at the bedside, covered with a moist wound dressing, and protected by appropriate pressure offloading (redistribution). Offloading can be achieved by casting, removable boots, or postoperative sandals. Measurements should be obtained after debridement, and the characteristics of the wound (undermining, tunneling, and type of tissue at the base of the wound) should be recorded. Classification of wounds facilitates appropriate management (especially when different providers care for the patient over time) and has been shown to help predict wound outcomes.
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