Improving clinical outcomes for patients with diabetes related foot complications

© 2005 Dr. Paul Robert WraightBackground: Individuals with diabetes have a 15% lifetime risk of developing a foot ulcer, which are ultimately responsible for over 100,000 amputations being performed each year in the United States. Although it has been well documented that we currently have the available knowledge to successfully heal approximately 90% of such ulcers, amputation and admission rates for these conditions continue to increase. Aim: To determine if management approaches and clinical outcomes (length of stay, amputation rate), for individuals with diabetes related foot complications, can be improved with the introduction of a novel evidence-based clinical guideline by a multidisciplinary team of health professionals. Theories regarding guideline dissemination and implementation will be explored in an attempt to identify strategies that are more effective in achieving sustained clinical change. Methods: A novel evidence-based clinical guideline was created, by reviewing 266 articles specific to the area. The guideline was specifically designed to encourage a systematic and global approach to the clinical assessment, investigation and management of individuals with diabetes related foot complications. The clinical guideline was initially introduced into the pre-existing environment of the hospital, drawing upon published dissemination and implementation strategies / theories. Two-month prospective studies were undertaken both prior and post guideline implementation, evaluating the extent of guideline uptake and the corresponding changes to clinical care. In response to these findings, efforts were made to further improve guideline utilisation by specifically addressing identified barriers to implementation in a second launch of the guideline. A further two-month prospective study was undertaken, 1-year post the initial launch. As sustained changes to health care provision were not achieved at this time, a final strategy to be employed was to use a multidisciplinary team of health professionals, including representatives from endocrinology, podiatry, vascular surgery, infectious diseases, diabetes educators, dietician, clinical psychology, rehabilitation and radiology, to implement the clinical guideline as a part of a newly created, centralised Diabetic Foot Unit (DFU). Results: The evidence-based clinical guideline was insufficient, in itself; to encourage health professionals to change their clinical approach when managing someone with a diabetes related foot complication. Despite identifying many barriers preventing the more widespread uptake of the guideline and multidisciplinary team (professional autonomy, knowledge deficits, environmental and patient barriers) the only approach that achieved significant change was the creation of a centralised, multidisciplinary, diabetic foot unit. With the introduction of the DFU, a complete clinical examination of the foot was undertaken in all patients, investigations were tailored to the specific condition, mean length of stay was reduced by 5 days per admission and there was a significant reduction in the amputation rate. Conclusion: Implementation of (i) an evidence-based clinical guideline, (ii) a multidisciplinary team, and (iii) centralised DFU, can improve all aspects of health provision, with corresponding reductions in length of stay and amputation rates. The development of this complete package for health provision suggests that similar results should be achievable with the introduction of this approach to other health institutions