Diabetic Foot Ulcers

Recommendations

Identify and Treat the Cause
1 Take a careful history (general history, diabetic control and complications). Level of Evidence
1b
2 Conduct a foot inspection and examine for decreased sensation. Correct (if possible) risk factors for ulcer formation/amputation: - Vascular supply - Infection - Pressure (including bony deformity)) through pressure redistribution using accommodative footwear. Remember the mnemonic VIP Also, correct (if possible) co-factors that may affect healing. Level of Evidence
1a


Address Patient-Centered Concerns
3 Provide individualized education to enhance Glycemic control, Adherence to treatment, Plantar pressure redistribution/daily foot inspection. (GAP) Level of Evidence
1a


Provide Local Wound Care
4 Assess and document depth of trauma and extent of healing, with ulcer duration, location, size, and depth (probe to bone). Level of Evidence
2a
5 Optimize wound healing environment through Debridement, Infection (bacterial burden control) and Moisture balance. (DIM) Level of Evidence
1a
6 Consider the edge effect. For stalled wounds, consider the use of biological agents and adjunctive therapies (edge effect). DIM/E Level of Evidence
1a


Provide Organizational Support
7 Establish and empower an interprofessional team to work with Persons With Diabetes (PWD). Level of Evidence
4


Background

Foot ulcers are a major complication, occurring in approximately 15% of people with diabetes mellitus, and are a preceding factor in approximately 85% of lower limb amputations. Poor diabetes control may result in peripheral neuropathy and vascular disease. Peripheral neuropathy raises the likelihood of both trauma to the foot and inability to detect abnormal pressures that may predispose patients to develop foot ulcers.

Clinicians have the opportunity to positively influence client outcomes and quality of life by using effective strategies to try to prevent foot ulceration. Up to 85% of diabetic foot ulcers can be prevented. If ulceration has occurred, clinicians will improve outcomes by identifying and treating the cause, addressing patient-centered concerns, providing local wound care, and ensuring organizational support of evidence-based care through interdisciplinary intervention.

A systematic literature search for clinical practice guidelines on foot ulcer prevention and treatment was done using the Medline, CINAHL, and Embase databases and 46 guideline clearinghouses. A librarian was involved in helping identify the appropriate keywords and search strategies to ensure that all guidelines on the topic were found.

Thirty-two (32) foot ulcer prevention and treatment clinical practice guidelines were found in the English literature from 2002 until May 2007. Twenty-two (22) of these published articles were excluded because they were: recommendations or practical guide (3), an algorithm or protocol (4), individual studies (5), a summary of guidelines (2), an educational program (1), a consensus or position statement (3), unavailable (3), proceedings of a conference (1).

Of the identified papers, ten guidelines were appraised by a minimum of three reviewers using the AGREE instrument (http://www.agreecollaboration.org/instrument/). The AGREE instrument has six domains: scope and purpose, stakeholder involvement, rigour of development, clarity and presentation, applicability, and editorial independence. It is not recommended that the scores obtained for the domains be aggregated. Instead the guidelines that received the highest scores for most of the domains and particularly for rigour of development were ranked highest and their recommendations will be reported throughout this diabetic foot ulcer stream.

The most highly ranked guidelines were two that were developed by the Registered Nurses Association of Ontario (RNAO), one on assessment and management of foot ulcers for people with diabetes (2005), the other on reducing foot complications for people with diabetes (2004); one by the National Institute for Clinical Excellence (NICE) on the prevention and management of foot problems in people with type 2 diabetes (2004); one by Lipsky et al on the diagnosis and treatment of diabetic foot infections (2004).

References

High Ranking Guidelines
1 Quality Indicator
 Type: CPG (Clinical Practice Guideline)
Registered Nurses Association of Ontario (RNAO). Assessment and management of foot ulcers for people with diabetes. Toronto (ON): Registered Nurses Association of Ontario (RNAO); 2005 Mar. 112 p.
For clinicians or administrators who want to know the details, this comprehensive guideline provides the most recent systematically searched evidence and consensus reporting on the assessment and management of foot ulcers.
2 Quality Indicator
 Type: CPG (Clinical Practice Guideline)
Registered Nurses Association of Ontario (RNAO). Reducing foot complications for people with diabetes. Toronto (ON): Registered Nurses Association of Ontario (RNAO); 2004 Mar. 80 p.
This comprehensive guideline provides clinicians with the most recent systematically searched evidence and consensus reporting about the reduction of foot complications in prople with diabetes.
3 Quality Indicator
 Type: CPG (Clinical Practice Guideline)
National Collaborating Centre for Primary Care. Clinical guidelines for type 2 diabetes. Prevention and management of foot problems. London (UK): National Institute for Clinical Excellence (NICE); 2004 Jun. 104 p.
This comprehensive guideline provides clinicians with recent systematically searched evidence and consensus reporting about the prevention and management of diabetic foot problems. Its recommendations are made in additional areas to those addressed by the RNAO guidelines.
4 Quality Indicator
 Type: Concensus Statement
Lipsky BA, Berendt AR, Deery HG, Embil JM, Joseph WS, Karchmer AW, Lefrock JL, Lew DP, Mader JT, Norden C, Tan JS. Diagnosis and treatment of diabetic foot infections. Clin Infect Dis 2004 Oct 1;39(7):885-910.
This comprehensive systematically searched evidence and consensus guideline provides found that specifically addressed the diagnosis and treatment of diabetic foot infections.


Enablers for practice

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