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Background


1. Objectives

2. Background

  1. Registered Nurses Association of Ontario (RNAO), Best Practices for Assessment, Prevention and Treatment of Diabetic Foot Ulcers 
  2. International Working Group Diabetic Foot (IWGDF), Consensus Guidelines on the management and prevention of the diabetic foot
  3. Registered Nurses Association of Ontario (RNAO), Clinical Best Practice Guidelines Strategies to Support Self-Management in Chronic Conditions: Collaboration with Clients
  4. Canadian Association of Wound Care (CAWC) Best Practice Enabler and Quick Reference Guide
  5. Wound Bed Preparation Paradigm

3. Address Patient Centered-Concerns

  1. Assess Psychosocial Needs /Pain and Quality of Life (QOL)
  2. Socioeconomic Determinates of Health
  3. Chronic Disease Self-management

4. Identify and Treat the Cause

4.1 Assessment

  1. Risk Factors, Effects and Etiology of Diabetic Foot Ulcers
  2. Pathogenesis of Ulceration
  3. General Inspection, Skin, Musculoskeletal and Neurological Assessments
  4. Factors and Predictors of Delayed Healing
  5. Symptoms of Peripheral Neuropathy

4.2 Obtain a Holistic Comprehensive Patient History and Perform a Physical Assessment

  1. Obtain a holistic comprehensive patient history 
  2. Complete a comprehensive physical examination
  3. Perform a bilateral lower leg assessment
  4. Assess Wound and Peri-wound
  5. Wound Measurement 
  6. Vascular Assessment
  7. Ankle Brachial Pressure Index  (ABPI) /and Toe Brachial Pressure Index (TBPI )
  8. Nutritional Assessment
  9. Assess Infection (NERDS AND STONEES)
  10. Relief of Pressure and Protection of Ulcer
  11. Determine if the wound is “Healable, Maintenance or Non-Healable”

5. Provide Local Wound Care

  1. Intervention Algorithm
  2. Signs and Symptoms of Infection
  3. Classification Systems
  4. Management of Infection
  5. Signs and Symptoms of Osteomyelitis
  6. Antiseptic Guidelines
  7. Antibiotic Guidelines
  8. Determine Goals for Treatment
  9. Utilize Product Picker from Canadian Association of Wound Care (CAWC) 
  10. South West Wound Care Program: Wound Cleansing Table and Dressing Selection & Cleansing Enablers
  11. Patient Education on Foot Care and Daily Assessment
  12. Adjunctive Therapies

6. Provide Organizational Support

  1. Multi-disciplinary Referral Criteria
  2. Steps to Avoid Amputation
  3. Patient/Caregiver and Health care provider Teaching and Learning Resources
  4. Discharge or Transfer Planning and Communications
  5. Waterloo Wellington Integrated Wound Care Program Evidence-Based Wound Care Diabetic Foot Ulcer Clinical Pathway

7. Diabetic Foot Ulcer Toolkit

The best practice recommendations provide clinicians with the best available evidence. The tables below show the levels of evidence from the Registered Nurses Association of Ontario Guidelines (RNAO):

Assessment and Management of Diabetic Foot Ulcers1

Levels of Evidence

A Evidence obtained from at least one randomized controlled trial or meta-analysis of randomized controlled trials
B Evidence from well-designed clinical studies but no randomized controlled trials
C Evidence from expert committee reports or opinion and/or clinical experience or respected authorities. Indicates absence of directly applicable studies of good quality
 

RNAO’s

Strategies to Support Self-Management in Chronic Conditions: Collaboration with Clients2

Levels of Evidence

Ia Evidence obtained from meta-analysis or systematic review of randomized controlled trial
Ib Evidence obtained from at least one randomized controlled trial
IIa Evidence obtained from at least one well-designed controlled study without randomization
IIb Evidence obtained from at least one other type of well-designed quasi- experimental study, without randomization
III Evidence obtained from well-designed non-experimental descriptive studies, such as comparative studies, correlation studies and case studies
IV Evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities

Background

In 2014, the World Health Organization (WHO) reported that globally the prevalence of diabetes was estimated to be 9% or 347 million people among adults aged 18+ years, creating a global epidemic 3 compelling healthcare organizations around the world to identify and acknowledge their own  challenges regarding the prevention and management of complications resulting from diabetes. Since 2014, healthcare organizational globally have been creating, modifying and researching methods and frameworks to identify and resolve these challenges.
 
Current trends in diet, population growth, aging, urbanization, a reduction in physical activity and consequent increase of obesity and other societal changes4 across the developed world has substantially increased the prevalence of diabetes. The increase in diabetes has been reported across socioeconomic status, age and geography and growing statistics of diabetes across Ontario Canada is no exception.  The Canadian Diabetes Association (CDA) (2014) reported that 1.4  million Ontarians (9.8%) were diabetic at a cost of $5.8 billion dollars in 2014 with estimations into the year 2024 increasing the prevalence to 2.2 million (13.1%) at a cost $7.6 billion across Ontario5 
 
For healthcare organizations with a high population of diabetic patients, prevention and management of complications associated with diabetes is at the forefront – and for good reason. The effects and consequences of a high population of diabetic patients across health care organizations are well documented. People with diabetes are “over three times more likely to be hospitalized with cardiovascular disease, 12 times more likely to be hospitalized with end-stage renal disease and over 20 times more likely to be hospitalized for a non-traumatic lower limb amputation compared to the general population,”6. The costs of amputations have been found to be 10 to 40 times greater than the cost of effective initiatives to prevent amputation7. The Canadian Institute for Health Information (CIHI) reports alarming statistics regarding foot ulceration, a common complication for patients on service at Community Care Access Centre's (CCAC): “foot ulceration affects an estimated 15 - 25% of people with diabetes at some time in their lives. One third of amputations in 2011- 2012 were performed on people reporting a diabetic foot wound. In addition, statistics across acute care organizations have confirmed that the number one complication for admission in acute care hospitals in Canada is the diabetic foot ulcer8.  
 
In addition to the high percentage of diabetic patients in health care organizations, interventions in the prevention and management of complications associated with the disease must include other areas of concern. In its 2014 report, the Canadian Diabetes Association (CDA) estimated that the number of Canadians living with diabetes emphasized that diabetes is the leading cause of ‘‘blindness, end stage renal disease, foot ulceration and non-traumatic amputation in Canadian adults,”9 . Capes and Sherifali (2010) stated that of the Canadians living with diabetes, an estimated ‘‘325,000 (approximately 16%) will develop a foot ulcer.’’ 
 
Given the high percentage of patients living with diabetes in Ontario, healthcare organizations need to ensure an enhanced focused care model for patients with diabetes; to include promotion of healthy behaviours in the prevention of diabetic complications, to reduce health risk for complications associated in the diabetic patient, and to decrease in fiscal resources used to provide care for diabetic complications10 11
 
  The following document summarizes research, best practice guidelines, literature, expert interprofessional opinions and ongoing changes to the care received by patients with diabetes across the sectors of care. This work was completed by a collaborative group of interdisciplinary wound care professionals from Acute Care, Complex Continuing Care/Rehabilitation, Long-Term Care (public and private), Primary Care, Specialized Ambulatory Clinics and Home Care (including Service Provider Organizations).  This document focuses on the prevention and management of diabetic foot ulcers and should be utilized by clinicians and policy makers in the endeavor to create enhanced care for these patients.   

Best Practices for Assessment, Prevention, and Treatment of Diabetic Foot Ulcers

The Registered Nurses’ Association of Ontario (RNAO) embarked on a multi-year program of nursing best practice guideline development, pilot implementation, testing, evaluation and dissemination. In 2005, during the fifth cycle of the program, one of the areas of importance was on the assessment and management of diabetic foot ulcers. This guideline was developed by a panel of interdisciplinary team members convened by the RNAO12.  
In 2006, The Canadian Association of Wound Care (CAWC) developed best practice recommendations for the prevention and treatment of diabetic foot ulcers for clinical practice13
 
Every 5 years, since 1992, the Clinical & Scientiļ¬c Section (C&SS) of the Canadian Diabetes Association (CDA) has published comprehensive, evidence-based recommendations for healthcare professionals to consider in the prevention and management of diabetes in Canada 14. They have served as a helpful resource and aid for anyone caring for people with diabetes and are recognized, not only in Canada but also internationally, as high-quality, evidence-based clinical practice guidelines. In 2013, the Canadian Diabetes Association (CDA) created a Clinical Practice Guidelines Expert Committee to review existing literature and best practices. The committee created updated Clinical Practice Guidelines for patients with a Diabetic Foot Ulcer15.  
 
All clinicians are expected to use best practices to assess, prevent, and treat diabetic ulcers to improve patient outcomes. The framework used in this guideline was applied from the Registered Nurses Association of Ontario (RNAO) “Clinical Best Practice Guidelines of Assessment and Management of Diabetic Foot Ulcers (2005) and its supplement (2013)16. The RNAO Clinical Best Practice Guidelines “Strategies to Support Self-Management in Chronic Conditions: Collaboration with Clients” (2010)17was also used for self-management section. A complete list of references can be found in the appendices.
 
The International Working Group on the Diabetic Foot (IWGDF) was founded in 1996. The aim of the IWGDF is to create awareness of the disease and to improve the management and prevention of the diabetic foot. Since 1999 the IWGDF produces quadrennial Practical, Specific and Consensus guidelines on the management and prevention of the diabetic foot. Guidelines designed by the IWGDF (2015) include Prevention and management of foot problems in diabetes 18 ; IWGDF Guidance on the prevention of foot ulcers in at-risk patients with diabetes; IWGDF Guidance on footwear and offloading interventions to prevent and heal foot ulcers in patients with diabetes 19; IWGDF Guidance on the diagnosis, prognosis and management of peripheral artery disease in patients with foot ulcers in diabetes 20; IWGDF Guidance on the diagnosis and management of foot infections in persons with diabetes 21
 
In the year 2013, it brought together another international-interdisciplinary expert group to review and submit best practice guidelines for wound management in the diabetic foot ulcer. This group formed in recognition of literature gaps in not only assessment, debridement, infection management but an appropriate dressing selection to optimize healing in patients with diabetic foot ulcers 22 . These guidelines have been published and referenced in the document
 

Wound Bed Preparation Paradigm

The Wound Bed Preparation (WBP) 23 paradigm is used to assess, diagnosis, and treat wounds while considering patient concerns. It links evidence-based literature, expert opinion, and clinical experiences of respected wound care specialists.  The framework is beneficial because the components are interrelated and can be re-evaluated if the wound deviates from the care plan. Furthermore, the interprofessional team is able to collaborate together through shared discussion to classify a healable, maintenance, and non-healable wound. 
 
Figure 1 Adapted from:
Sibbald R.G, Orstead H.L, Coutts P.M, Keats D.H. Best Practice Recommendations for Preparing the Wound Bed: Update 2006. Wound Care Canada. Volume 4  Number 1. 2006

Address Patient-Centred Concerns

 

  1. Registered Nurses Association of Ontario, "Assessment and Management of Diabetic Foot Ulcers," Registered Nurses Association of Ontario, Toronto, 2013.
  2. Registered Nurses Association of Ontario, " Nursing Best Practice Guideline: Strategies to Support Self-Management in Chronic Conditions: Collaboration with Clients," Registered Nurses Association of Ontario, Toronto, 2010.
  3. World Health Organization, "Global status report on noncommunicable diseases 2014," World Health Organization, Geneva, 2014.
  4. Wild, S; Rogklic, G; Green, A; Sicree, R; King, H, "Global Prevalence of Diabetes," Diabetes Care, pp. 1047-1053, 2004.
  5. Canadian Diabetes Association, "Canadian Diabetes Association," 2014. [Online]. Available: http://www.diabetes.ca/getmedia/5941b1c2-8b03-45bf-8db0-e18b969d9aa6/diabetes-charter-backgrounder-ontario-english.pdf.aspx. [Accessed 19 05 2015].
  6. Canadian Diabetes Association Clinical Practice Guidelines Expert Committee, "Canadian Diabetes Association 2013 Clininical Practice Guidelines Expert Committee for the Prevention & Management of Diabetes in Canada," Canadian Journal of Diabetes, p. 37 (supl. 1), 2013.
  7. Canadian Institute for Health Information, "Canadian Institute for Health Information: Comprised Wounds in Canada," AiB, Toronto , 2013.
  8. Canadian Institute for Health Information, "Canadian Institute for Health Information: Comprised Wounds in Canada," AiB, Toronto , 2013.
  9. Canadian Diabetes Association, "Canadian Diabetes Association," 2014. [Online]. Available: http://www.diabetes.ca/getmedia/5941b1c2-8b03-45bf-8db0-e18b969d9aa6/diabetes-charter-backgrounder-ontario-english.pdf.aspx. [Accessed 19 05 2015].
  10. D. Lau, " The cost of diabetes: A game changer.," Canadian Journal of Diabetes, vol. 34, no. 1, pp. 16-18., 2010.
  11. G. &. B. M. Doucet, "The Cost of Diabetes in Canada: The Economic Tsunami.," Canadian Journal of Diabetes, vol. 31, no. 1, pp. 27-29., 2010.
  12. Registered Nurses Association of Ontario, "Assessment and Management of Diabetic Foot Ulcers," Registered Nurses Association of Ontario, Toronto, 2013.
  13. Canadian Association of Wound Care, "Recommendations for the Prevention and Treatment of Diabetic Foot Ulcers," CAWC, Toronto, 2006.
  14. International Diabetes Federation , "IDF Diabetes Atlas," in Internation Diabetes Federation , Brussels, 2012.
  15. Canadian Journal of Diabetes, "Clinical Practice Guidelines for Patients with a DIabetic Foot Ulcer," Canadian Journal of Diabetes, Toronto, 2013.
  16. Registered Nurses Association of Ontario, "Assessment and Management of Diabetic Foot Ulcers," Registered Nurses Association of Ontario, Toronto, 2013.
  17. Registered Nurses Association of Ontario, " Nursing Best Practice Guideline: Strategies to Support Self-Management in Chronic Conditions: Collaboration with Clients," Registered Nurses Association of Ontario, Toronto, 2010.
  18. International Working Group on the Diabetic Foot, "Prevention and management of foot problems in diabetes," International Working Group on the Diabetic Foot, Brussels, 2015.
  19. International Working Group on the Diabetic Foot, "Guidance on the Prevention of Foot Ulcer in At Risk Patients with Diabetes," International Working Group on the Diabetic Foot, Brussels, 2015.
  20. International Working Group on the Diabetic Foot, "Guidance on the diagnosis, prognosis and management of peripheral artery disease in patients with foot ulcers in diabetes," International Working Group on the Diabetic Foot, Brussels, 2015.
  21. International Working Group on the Diabetic Foot, "Guidance on the diagnosis and management of foot infection in persons with diabetes," International Working Group on the Diabetic Foot, Brussels, 2015.
  22. International Best Practice Wounds International Available from: www.woundsinternational.com, "Best Practice Guidelines: Wound Management in the Diabetic Foot Ulcer," Wounds International A division of Schofield Healthcare Media Limited, London SE1 9PG, UK, 2013.
  23. Sibbald, G; Orstead, H; Coutts, D; Keast, D., "Best Practice Recommendations for Preparing the Wound Bed," Wound Care Canada, vol. 4, no. 1, pp. 15-29, 2006.

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