One Center’s Experience With Team-Based Care for Diabetic Foot Ulcers

The authors of this column oversee an advanced wound center (AWC) team, a multidisciplinary, cohesive group with a variety of skills to become more than the sum of its members. Research has shown that a multidisciplinary approach to wound care can improve wound healing, reduce the number of amputations, and improve patient quality of life.^1-4 Thus, in this column, the authors aim to illustrate a working model of such an approach that they have found successful, especially for patients with diabetic foot ulcers (DFU). In this column, the authors share landmark studies and endeavors that today’s DPMs should know and evaluate for application in their practices.

As the word “team” suggests, each member contributes to the overall goal of improving patient care through improving wound healing, decreasing amputation rates, and improving quality of life. At our wound healing center, the assembled AWC team focuses on providing each patient with standardized, but custom-tailored, care during their visit. AWC patients present with a variety of wound types including burn wounds, venous leg ulcers, and DFUs.

Outpatients of our AWC tend to be a vulnerable population, are typically elderly, have smaller support networks than their younger counterparts, and have multiple comorbidities rendering them not sick enough to be hospitalized, but ill enough to require consistent and thorough medical care and follow-up. Our AWC team provides a support component for the outpatient wound healing patient by following up with them personally and organizing their clinic visits to be as efficient as possible, as well as keeping other specialists (ie, cardiologists, endocrinologists, etc.) updated and consulted as needed for streamlined care.

The AWC is located within the hospital, and the staff has hospital privileges so that continuity of care exists regardless of inpatient or outpatient status. The AWC is open Monday through Friday and 10 different doctors. We have podiatry, vascular, general surgery, plastics and infectious diseases amongst our panel physicians scheduled to a 4-hour block of patients once a week. These providers all communicate within the center, fostering a more comprehensive approach. Patient needs and DFU status dictate the scheduling of outpatient visits with the appropriate nurse or doctor for treatments or consultations. Consultations can be within the AWC team or from the different hospital departments. The AWC has 5 exam rooms and 4 hyperbaric oxygen chambers on site to minimize transit for patients who frequently have difficulty walking.

One Wound Center’s Clinical Pathway

Of note, the AWC follows a 7-step wound management paradigm sanctioned its the administrating organization (Figure 2). In the authors’ experience these guidelines help ensure that each wound patient is provided consistent care in line with good wound healing principles. These steps include determining the adequacy of patient blood flow and what treatment plan or procedures may be necessary. Likewise, determining if an infection is present and if so, using appropriate culture-guided antibiotic therapy. Step 3 is wound debridement, which is an essential tool and can positively impact wound healing when performed properly, especially for patients with DFUs.

For AWC patients with diabetes, the team works closely with the patient and caregivers to manage glucose control. This includes glucose level monitoring and proactively ensuring that hemoglobin A1c levels are measured every 3 to 6 months. When needed, nutritionist and endocrinologist consultations are added to the session schedule. Maintaining good glucose control and nutrition is essential for healing to occur. The body must have the nutrients it needs to heal, and the healing process requires a lot of calories.^5-6

The fifth step we follow is ensuring that the wound is properly offloaded. As the wound changes and offloading equipment is used, this step needs to be regularly reassessed. Any comorbidities or other factors impacting the patient should be examined and, if possible, resolved. These factors may play a role in dressing selection, thus considering the wound needs and the needs of the patient is paramount. Lastly, advanced modalities should be considered if healing is not progressing in spite of addressing the prior 6 steps. These dressings and therapies often will help boost a wound back into a healing phase. Because of their expense, these modalities are not considered until other factors that impair wound healing are addressed.

Notes on Clinical Trends During and After the COVID-19 Pandemic

Prior to the COVID-19 pandemic, the AWC saw approximately 200 patients per week. As with many practices, once the pandemic took hold, in-person visits halted. Unfortunately, patients with DFUs need regular evaluation to keep wound healing on track. Our team was large enough to provide multiple services, yet small enough to pivot nimbly to initiate virtual telehealth visits. Although the virtual visits could not completely replace in-person care, the communication provided vital follow-up and patient communication. Without such continuity, many patients with DFUs would may have gotten worse and delayed seeking care at the AWC or the hospital, as illustrated in recent publications.^7-9

As pandemic restrictions have lifted, the AWC has returned to many prepandemic routines. At Saint Vincent Hospital, we have noted an increase in DFU-related medical and surgical services. To determine what the AWC did well and what to improve, we plan to perform a retrospective review of patient chart data. As the literature expands with similar retrospective studies, this will be useful information for future growth. One recently published machine learning study compared pre- and post-lockdown DFU outcomes and showed prior DFU history, delay until hospitalization, and foot infection were significantly greater post-lockdown, and these increased the mortality rate.¹⁰ The mission of our AWC team is to provide compassionate care to improve the lives of our wound patients. For that reason, we are committed to learn continually what needs to be improved upon. We challenge all wound care clinicians to join us in striving for better patient outcomes. We are constantly trying to bridge the gap between healing patients and keeping those patients healed. One area of disparity in wound care is diabetic footwear. We have been working with outside facilities and doctors offices to make sure custom molded shoes, braces, Charcot restraint orthotic walkers (CROW) and other devices are proactively made in a timely fashion so theres no disruption in the continuity of care.

Dr. Tickner is the Medical Director of the of the Saint Vincent Hospital/RestorixHealth Wound Healing Center in Worcester, MA.

Ms. Gachimu is the Program Director of the Saint Vincent Hospital/RestorixHealth Wound Healing Center in Worcester, MA.

References
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8.    Atri A, Kocherlakota CM, Dasgupta R. Managing diabetic foot in times of COVID-19: time to put the best ‘foot’ forward. Int J Diabetes Dev Ctries. 2020 Sep;40(3):321-328. doi: 10.1007/s13410-020-00866-9. Epub 2020 Sep 1. PMID: 32904959; PMCID: PMC7461755.
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