Diabetic Foot Ulcer - clinic treatment option

Diabetic Foot Ulcer Offloading Clinic

Linda Laakso B.Sc.C.O.(c) Custom Orthotic Design Group Ltd.http://www.customorthotic.ca

http://www.customorthotic.ca/conditions-treatments/conditions/diabetes-mellitus


http://www.customorthotic.ca/

85% of all lower extremity amputations are preceded by a diabetic foot ulcer (DFU)

(Orstead et al., 2006)

http://www.customorthotic.ca


“Pressure is a

factor in 90% of diabetic plantar ulcers, and the pressure must be modified or removed” (CAWC, 2006)



Evidence Based Diabetic Ulcer Care• Uncomplicated plantar ulcers can be healed in

6-8 weeks with pressure offloading– Cavanaugh and Bus (2010)

• There is evidence that offloading with a Total Contact Cast (TCC) is effective at healing ulcers – Spencer (2008)

• There is evidence that non-removable offloading treatments help healing– Bus et al. (2008)



Evidence Based Diabetic Ulcer Care

895 centres- 1.7% used the gold standard TCC- 15.2% used a removable cast walker (RCW) - 2.6% used other modalities (therapeutic shoes) - 41.2% used shoe modifications - 12.3% restricted weight bearing

(Wu et al., 2008)



Evidence Based Diabetic Ulcer Care

“there is a gap between evidence-based guidelines and current practice…”

(Cavanaugh and Bus, 2011, p.253S)



Evidence Based Diabetic Ulcer CareInformal needs survey

– 71.4% are using offloading

– 50% state that the treatment is effective

“I think it is effective when used properly” Survey respondent



Pressure• Sensory Neuropathy loss of sensation• Motor neuropathy deformity• Autonomic neuropathy deformity



Three Factors for Best Practice Treatment of Diabetic Foot Ulcers

•Vascular

•Infection

•Pressure




Improving outcomes for People with Diabetic Foot Ulcers

• Formal DFU offloading clinic• Clear and consistent referral pathway• Reduction of pressure to diabetic feet• Reduction in ulcer healing times• Reduction in lower extremity amputations• Reduction in cost of DFU



• Staff– 5 Certified Orthotists (C.O.c)– 2 Registered Technicians (R.T.O.c)– 2 Administration

• Best Practice Guidelines: RNAO, CAWC • Clinics– 5 private in GTA– 1 in Hospital

• Funding– ADP, DVA, NIHB, ODSP, SI, TPI



• Target Population: Persons with DFU• Assessment• Education• Treatment–Monitor, prophylactic footwear, cast boot,

custom made foot orthoses, RCW, CROW, AFO, TCC

• Follow-up



Activities



• Wound offloading• Patient education

Outputs



• Reduction in ulcer healing time• Reduction in amputations• Improved quality of life for patient

Outcomes



• Reduction in hospitalizations and length of stay• Reduction in cost of wound care• Reduction in amputations• Reduction in deaths

Impact



• Evidence based care• Experienced practitioners• Established practice• “Economic Tsunami”• Existing funding



• Reduction in ulcer healing time • Reduction in amputations• Reduction in deaths

Results in:

Cost savings to hospitals



And:

Improved Quality of Life for our Patients


References Bus, S.A., Valk, G.D., van Deursen, R.W., Armstrong, D.G., Caravaggi, C., Hlavecek, P., Bakker, K., Cavanaugh, P., R. (2008). The effectiveness of footwear and

offloading interventions to prevent and heal foot ulcers and reduce plantar pressure in diabetes: A systematic review. Diabetes Metabolism Research and Reviews. Vol. 24(Suppl 1):S162-S180.

Canadian Association of Wound Care Website (n.d.). Statistics: Diabetic Foot Ulcers. Retrieved from:

http://cawc.net/index.php/public/facts-stats-and-tools/statistics/ Accessed May 25, 2011.

Canadian Diabetes Association (2009). An economic tsunami, the cost of diabetes in Canada. Toronto, Canada. Cavanaugh, P.R., Bus, S.A. (2011). Offloading the diabetic foot for ulcer prevention and healing. Plastic and Reconstructive Surgery. January Supplement.

Volume 127, Number 1S. Goeree, R., Lim, M.E., Hopkins, R., Blackhouse, G., Tarride, J., Xie, F., O’Reilly, D. (2009). Prevalence, Total and Excess Costs of Diabetes and Related

Complication in Ontario, Canada. Canadian Journal of Diabetes. 33(1):33-45.

Hodges, B.C., Videto, D.M. (2011). Assessment and Planning in Health Programs (2nd ed.). Sudbury, MA: Jones and Bartlett Learning, LLC. Ministry of Health and Long Term Care (2005). Hyperbaric Oxygen Therapy for Non-Healing Ulcers in Diabetes Mellitus. Hyperbaric Oxygen Therapy - Ontario

Health Technology Assessment Series 2005; Vol. 5, No. 11. Retrieved from: http://www.health.gov.on.ca/english/providers/program/mas/tech/reviews/pdf/rev_hypox_081105.pdf.

National Diabetes Surveillance System (NDSS): Diabetes in Canada 2009. (2009). Report from the national diabetes surveillance system: Diabetes in Canada,

2009 No. HP32-2/1-2009) http://www.phac-aspc.gc.ca/publicat/2009/ndssdic-snsddac-09/2-2-eng.php. Her Majesty the Queen in Right of Canada. Orsted, H.L., Searles, G., Trowell H., Shapera, L., Miller, P., Rahman, J. (2006). Best Practice Recommendations for the Prevention, Diagnosis and Treatment of

Diabetic Foot Ulcers: Update 2006. Wound Care Canada. Vol. 4, No. 1. 57-71. Pope, M. Medical Doctor, Vascular Surgeon. The Credit Valley Hospital. Mississauga, Ontario. Registered Nurses’ Association of Ontario (RNAO) (2005). Assessment and Management of Foot Ulcers for People with Diabetes. Toronto, Canada: Registered

Nurses’ Association of Ontario.

Spencer, S. (2008). Pressure relieving interventions for preventing and treating diabetic foot ulcers (Review). The Cochrane Library. Issue 3. Witkowski, K. Registered Nurse. Skin and Wound Specialist. Trillium Health Centre. Mississauga, Ontario. Wu, S.C., Jensen, J.L., Weber, A.K., Robinson, D. E., Armstrong, D.G. (2008). Use of Pressure offloading devices in diabetic foot ulcers; Do we practice what we

preach? Diabetes Care Volume 31, Number 11.

The Wound Care Team needs our Certified Orthotists. Patients need access to care. Linda Laakso B.Sc.C.O(c)Custom Orthotic Design Group Ltd.This is part of a presentation originally completed by the author as a project for RS709 McMaster U.http://www.customorthotic.ca

Diabetic Foot Ulcer - clinic treatment option

Health & Medicine