The multidisciplinary approach to managing Diabetic Foot Ulcers

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The multi-disciplinary approach to managing Diabetic Foot Ulcers.

Rebecca will discuss the assessment, management and working as a team to manage DFU.

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VOICEOVER:
Welcome to Smith & Nephew's Closer to Zero podcast, bimonthly podcasts with leading experts in wound care, hosted by Smith & Nephew, helping healthcare professionals in reducing the human and economic cost of wounds.

00:00:03

RUTH TIMMINS:
Hello, I'm Ruth Timmins from Smith & Nephew, and we want to welcome you to today's podcast discussing the management of the patient with the diabetic foot ulcer with our very special guest Rebecca Aburn from New Zealand. Rebecca is the current vice president of the New Zealand Wound Care Society, and works as a nurse practitioner in vascular. Rebecca has a 25-year history of clinical experience in neurosciences, intensive care, vascular, diabetic foot, wound care, clinical education and district nursing. Rebecca is also involved at a national level in practice and guideline development, and one area of her many interests is the care of the complex vascular patient. So, thank you, Rebecca, for joining us today to share your expertise and knowledge.

00:00:18

REBECCA ABURN:
Thank you, Ruth, for having me. It's really quite a privilege to be able to share some of my experiences that I've had with managing complex diabetic foot ulcerations.

00:01:02

RUTH TIMMINS:
Yeah. We really appreciate you joining us today. So, perhaps to start off with, what are some of the you know, challenges in managing the diabetic foot ulcer?

00:01:13

REBECCA ABURN:
Oh thank you for asking that, Ruth, cause every day we see challenging patients in our clinics, and in particular, the complexities around managing a patient who has a diabetic foot ulcer. It's not just the hole in the foot that we're dealing with. It's the whole patient. And we have these amazing group of people that I work with in my multidisciplinary team that I wouldn't be able to manage these patients without their expertise. 

So, one of the challenges for us is being able to spend time getting together and actually discussing every case in detail to make sure that we're all able to provide the patients with the complex care that they need. And over the years, our diabetic foot clinic has evolved. And we now have a two-hour planning meeting prior to seeing these patients in clinic so that we can all get on board to be able to manage them in a, well, hopefully, seamless way. And the reason why we started this is that without managing the whole patient, which includes their psychological state that they are in when they come to our clinics, which is usually the end of the road for our clinic in particular, and their diabetes management, their diet, their home situation, their social situation or work situation, all of that is taken into account when we're doing our planning with them and the challenge is to be able to meet all of their and our expectations for their healing. And it's quite a complex situation that we find ourselves in with these patients, but it's quite challenging. And as a team, I think we do quite a good job.

00:01:22

RUTH TIMMINS:
So, could you give me some insights into how to identify the diabetic foot or assess the diabetic foot?

00:03:12

REBECCA ABURN:
The criteria for them to come into our clinic is that they need to have had a, they have an active ulceration. That's the first thing that will get them in. The second thing that is that they have an associated foot deformity, problems with their vascular. So, pulselessness or their vascular status is compromised. And poorly controlled diabetes is usually one of the issues that they come in with, and infection. And, yeah, that's the sort of major... We use a traffic light system. And so, once they've been identified as a high-risk foot, they come into our high-risk foot clinic for an assessment. And we have the wound care specialists there. We have podiatry, orthotics, vascular, orthopaedics, and the diabetic team as well. 

So, they get the full assessment and the things that we're looking for in their foot is that when you look at a normal foot, there's no areas of callus. In a diabetic foot, you'll find that they've got foot shapes changed and they've got areas that are loading when they're walking, they'll have poor foot or nails might be quite atrophic and indeed need some care. They may have an ulceration, they may not. The foot itself, if it's an acutely unwell foot, especially if it's infected, will look often quite not too bad on the top, but it's a little bit like a, what I always say, the iceberg. So, it looks not so bad on the top, but underneath if you probe it and look inside the ulcer and things it often probes to bone, which is a bit like the iceberg underneath. It's just the tip of what we can see.

00:03:20

RUTH TIMMINS:
And so, once you've done your assessments and so on, how do you manage the wound, I guess? Do you have protocols, or how do you manage that?

00:05:18

REBECCA ABURN:
So, management wise as a team, we want to stop the continued trauma that might be happening over that ulcer, wherever it is, cause it's usually on a bony prominence. So, a toe, a forefoot or heel. So, we want to control that trauma that's happening to that foot. We want to manage any infection, and especially in acutely infected diabetic foot ulcer may need to come in for surgical debridement in order to stop the sepsis from happening. 

So, we want to make sure that they've got good blood supply, so assess their peripheral arterial disease. Do they have pulses? What is their ankle-brachial index? We want to assess for any neuropathy. So, that's the monofilament testing to see what sort of neuropathy they have, and if they do have neuropathy give them some footwear that will be appropriate for them to wear in the future.

00:05:29

We want to assess their diabetes control because any altered function of their blood cells at a cellular level alters their healing. So, we always got a really good slide that says there's sugar being here in a very messy looking diabetic foot ulcer. And any wounds that we have, we want to assess for any bacterial loading or presence of bacteria. And then there's obviously all the patient-related factors, which is managing their diabetes better and managing themselves better. So, that's sort of the management process. 

And as a group, we do that through podiatry, we'll help with all the offloading and orthotics, we'll provide them with appropriate footwear. Wound care specialists will manage the wounds. If we need to do any arterial work, we'll do the arterial testing and subsequent angioplasties if they need it to get better blood supply. We'll bring the renal team on board if we need to bring them on board because they've often got poor renal function as well. So, that's why we work as a team and a lot of our patients cross lots of services, but the one service they come to continuously is ours.

00:06:27

RUTH TIMMINS:
And you mentioned, you know, managing infection there and obviously that can be very challenging in the high-risk foot. So, what would your advice be specifically around the infection management aspect?

00:07:41

REBECCA ABURN:
So, if a patient has a wound that probes to bone we can assume that that bone is an osteomyelitis and that's not an oral antibiotic that can fix it. They would need to be admitted to hospital. So, I always say to any nurses that work with me, or anyone who works with me, when you're assessing the patient and they've got a new wound, you need to be able to make sure, see if it probes to bone. And we would do a set of foot x-rays just to see where they're at because, obviously, continued infection in a diabetic foot can lead to Charcot foot, which is very, very complex to manage. And as an ongoing issue can be quite debilitating for patients, especially if they're still working or still needing to work. 

So, if you suspect an infection in a diabetic foot ulcer or in a diabetic foot, they need to come to a tertiary. Well, for us in New Zealand, they need to come to one of the nearest vascular centres, the centre that would deal with high risk diabetic foot, so that they could get IV antibiotics appropriately. And that they're managed appropriately and in a timely manner. So, I always tell people out in our peripheral areas, if in doubt, I'd rather you send them in. And if it was a red herring, than you send them in and it's too late.

00:07:55

The biggest thing is that you can't treat them with your standard antibiotics, say, Flucox, for a diabetic foot. The studies have shown that diabetic foot ulcers have every single anaerobes and aerobes in them. And that means you need to make sure you've got a broad spectrum antibiotic to cover them. And I'm not sure how antibiotic use in Australia is looking, but in New Zealand, we're trying to be more conservative with our antibiotic use, which is perfectly reasonable with standard skin infections, but with a diabetic foot infection that's not a standard foot infection. It's probably been there for months. And by the time the patient's actually noticed it, it's usually down to bone, which is why we always say, it's just the tip of what you see on the skin is the tip of the iceberg of what's actually been going on inside the patient's foot for this length of time.

00:09:18

RUTH TIMMINS:
And so, do you have a different approach if you think there's biofilm present?

00:10:07

REBECCA ABURN:
So, with diabetic foot obviously comes neuropathy. So, what we tend to do is the biofilm in a diabetic foot is much easier to manage than, say, a venous leg ulcer. And that's because they don't have the feeling that we would, that people have in sort of venous leg ulcers or other types of ulcerations. And so you're able to use sharp debridement, and we use sharp debridement a lot in the diabetic foot, and we are able to sharp debride back to good tissue. If they've got good blood supply, then we've got bleeding and then we're able to offload and treat their diabetes and then treat the diabetic foot ulcer. 

So, biofilm in diabetic foot is much easier to manage. And we would then put an anti-microbial type dressing on such as the ACTICOAT(TM) Flex and a secondary foam or offloading felt depending on what we're doing. Sometimes we do total contact casting depending on the patient. So, yeah, for us it's, we do get the opportunity to do a lot more sharp debridement in diabetic foot because of the neuropathy.

00:10:13

RUTH TIMMINS:
So, Rebecca, you mentioned the use of anti-microbials in the management of the diabetic foot ulcer, and you mentioned ACTICOAT(TM) Flex. Is there any other sort of anti-microbials that you use?

00:11:28

REBECCA ABURN:
So, we use topical anti-microbials in the management of the diabetic foot and we have good success with managing them using things like IODOSORB(TM), which is often very good for cleaning the wound bed up. We also, after debridement, like to use the RENASYS(TM) in order to improve wound healing as well. So, that's another option once we've especially done the surgical debridement, we use either the gauze or the black sponge in order to do some accelerated healing. 

The only thing when we use that is that we need to monitor the surrounding skin and just make sure that as long as there's good blood supply, the standard negative wound pressure therapy can be quite an effective way of accelerating healing in the diabetic foot. The biggest thing is to manage the offloading, that's what we are quite aware of. And it also means patients can go home. 

So, we do use a multitude of approaches. It all depends on the wound bed, the size of the wound bed and where it is and so, and how mucky it might be, but we definitely use anti-microbials and all sorts of treatments to be able to manage the diabetic foot. The particularly sloughy foot that, say, negative wound pressure therapy wouldn't be appropriate, IODOSORB(TM) has been really quite revolutionary in regards to how we manage it because it can be... Once it's been left on for its time, it turns white. And so, we know we're done, we can take it off and it can last up for three days, which is fantastic for these patients. So, we do have good success with our anti-microbial choice that we have here in New Zealand, which is great.

00:11:43

RUTH TIMMINS:
OK. Thank you. And so, you've mentioned that you have a very large team and you have the planning, so, you know, do you want to expand a little bit how you approach this as a multidisciplinary team? Because that seems to be very key to your management.

00:13:53

REBECCA ABURN:
It is, it is key. And so, what we do is we have a one-stop-shop referral system that comes through our team here in Dunedin, and we're now across Dunedin and Invercargill. And so we link up with the Invercargill team and we go through all the referrals and put them to the appropriate clinics. 

So, if they are high-risk foot and fit into our clinic where they've got an active ulceration and the symptoms that we need, they'll come into our clinic for a full review. If it's a podiatry issue, which is a lot of podiatry problems that come alongside patients with diabetes, they would go just straight to the diabetic high-risk podiatry clinic. And the majority will come through our clinic. And then once we've done our full assessments on the patients, we then work out what their plan might be. And most of the time it's debridement, offloading, good wound care and follow up with district nursing, and then with ourselves on a regular basis once we've established blood supply. 

So, generally, our patients will have, especially as they're getting younger and younger, pretty good blood supply, and we are able to work with the team to be able to get them back on track. And so once the wounds are healed, say, for instance, they did have a deformity that meant that they were getting re-ulceration. We would send them to the orthopaedic surgeon for a review of any options that could be done surgically to prevent them having any further ulcerations. And that would then be followed up by our orthotics team who'd be able to fit them with appropriate footwear. And so both the orthotics team in the orthopaedic team and the podiatry team have all been part of that process from when they first came, and so they know their history, they know what works for these patients, and they know how to prevent further ulcerations.

00:14:08

RUTH TIMMINS:
That's really interesting how, you know, that whole team approach, you know, it can be so effective working together.

00:16:11

REBECCA ABURN:
One of the reasons why having the multidisciplinary team approach has been so successful is it was first started in London by Dr Edmonds and Alphina Foster, who's actually a podiatrist who set up their first multidisciplinary diabetic foot clinic. And they found that they had a success of improving and healing ulcers by 80% if they approached them as a team. And the consultant that I work with has gone over subsequently to London and worked with the team and brought that concept back to New Zealand so that we have now for the last 13 years been working as a multidisciplinary team to identify high risk feet and be able to manage them appropriately. 

The other thing that we set up within our team in order to streamline the process for managing the patients is early identification. So, out in primary health care, if you're a general practitioner and a patient comes in to see you, you're able to identify where they need to be according to the risk that they have for their diabetic foot. And we use a screening tool that uses a traffic light system. When it's green it's low risk, and there's no risk factors present and no loss of sensation or absent or diminished pulses. And they would go onto a yearly review within their GP practice. And then the next group of patients are a moderate risk group where they may have one risk factor, which might be, for example, they may just have decreased sensation, or they may have absent or diminished pulses, and they have no other symptoms. So, no callus, no deformity or ulcerations or any other changes to their feet. They would then be put under a community podiatrist where they would be assessed on an annual basis just to manage them in a conservative way to make sure that they don't have any further ulcerations, or problems, sorry. 

The next group would be high risk. And these are the group that would come to us. They have had a previous amputation or ulceration and their risk factors are two or more. So, that means they've got a loss of sensation, absent or diminished pulses, known peripheral vascular disease, foot deformity with callus and pre-ulcerative lesions, end-stage renal failure, or in New Zealand if they have a Maori ethnicity they automatically get a point for that. So, if they have two or more risk factors, they would come to be seen by a specialist podiatrist under the umbrella of the diabetic foot clinic, which is our MDT clinic. And then there's the active group, which would be a presence of active ulceration. They have an unexplained hot red or swollen foot with or without pain, severe spreading infection or critical limb ischemia, where they've got no arterial flow. They would be an urgent referral to the MDT team or hospital high-risk clinic for suspected infection and/or Charcot foot. And if you thought they were critically unwell, they'd come straight through ED. 

So, that's our screening tool that we use and our podiatrists use that as well out in the community so that we're putting patients into early care. And that's the key for us, is being able to identify well before it becomes an issue, these patients, and get them in the system and appropriate wound care, offloading, footwear and restoring any blood supply that we need to.

00:16:19

RUTH TIMMINS:
So, what would be your top three take-home messages today, Rebecca?

00:20:22

REBECCA ABURN:
I think the take-home message that I was thinking about as you were talking about it the other day, Ruth, it's try not to ever manage a diabetic foot in isolation because they are really complex. Refer early if you're feeling that this is out of your depth and I would refer early, that would be my first take home message. And the other one is that patients re-ulcerate, and it can be quite disheartening, but don't get disheartened. I had a situation today where a patient had been part of the health service for many years, but no one has ever just sat down and chatted about what the real problem was for this person. And afterwards he said to me, I just want to say, thank you for actually discussing the fact that I need help and I need to actually help myself as well. And so sometimes with the whole re-ulceration you need to then get the patients on board to actually take control of their own health because that's really gonna be the key. 

So, empowering the patient would be the second take home message for me, is that if they get on board with actively managing themselves, then they're going to be less likely to re-ulcer. And the infection would be my third take-home message. If it looks like there's pus in there, and there's more than you can see. So, always make sure they get IV antibiotics and support because I've been to theatre with patients and we've debrided a diabetic foot that looked pretty innocuous from where I was sitting, but once we opened them up the pus just literally poured out and they could have died from that. And it is a fine line. So, if you suspect infection, my suggestion would be to seek support. So, that would be my third take home message.

00:20:27

RUTH TIMMINS:
Well, thank you so much, Rebecca. Some really important information there, and I'm sure that's been really valuable. So, we really appreciate you sharing your insights today, and don't forget to tune in for our next podcast and there will be some resources available for this podcast as well that you can have a look at. So, thanks again, Rebecca.

00:22:33

REBECCA ABURN:
Thank you, Ruth. Thank you so much for having me. I really appreciate it.

00:22:53

RUTH TIMMINS:
Thank you. We appreciate your time. Bye for now.

00:22:58

VOICEOVER:
Know when to use silver on chronic wounds, effective against free moving bacteria and prevent biofilm reformation, but cannot disrupt initial biofilms. Find out how Iodosorb 0.9% cadexomer iodine performs against biofilm.(1) Contact your local Smith & Nephew representative, or email us at profed.anz@smith-nephew.com.

00:23:03

VOICEOVER:
Helping you get closer to zero complications from wound infection. The information presented in this podcast is for educational purposes only. It is not intended to serve as medical advice. Products listed outlined with care are examples only. Product selection and management should always be based on comprehensive clinical assessment. For detailed product information, including indications for use, contraindications, precautions and warnings, please consult the products' applicable instructions for use prior to use.

00:23:29

1. Malone M et al. J Antimicrobial Chemotherapy, 2017; 72(7): 2093-101


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Speakers

Rebecca Aburn

Nurse Practitioner, Vascular

Vice-President New Zealand Wound Care Society

Rebecca has a 25 year history of clinical experience in neurosciences, intensive care, vascular, diabetic foot, wound care, clinical education and district nursing. She completed her Masters of Nursing in 2006 and has a great passion for nursing practice development. As past treasurer and now Vice president, for the New Zealand Wound Care Society Rebecca is involved at a national level in practice and guideline developments.

In 2010 Rebecca completed an advanced post graduate certificate in clinical nursing. In 2017 she completed Nurse Practitioner training and works as the Nurse Practitioner for vascular. Rebecca has presented at both National and international conferences. Her areas of professional interest are innovation to improve patient’s journey, Lymphoedema, Pyoderma Gangrenosum, Surgical site infection prevention and care of the complex vascular patient.

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