WHASA consensus document on the management of the diabetic foot

No abstract available.


Introduction
The management of the diabetic foot is often a costly endeavour due to the magnitude of foot complications that can arise when not managed within the multi-disciplinary team.The International Working Group on the Diabetic Foot (IWGDF 2011) states that: "A strategy that includes prevention, patient and staff education, multidisciplinary treatment of foot ulcers, and close monitoring can reduce amputation rates by 49-85%". 1 This document is based on the work done by the IWGDF and fully endorses International Consensus Document on the Management and Prevention of the Diabetic foot (2011). 1 Other Guidelines that play a predominant role in adapting the International Guidelines to the South African and also African context are comprehensively detailed in the SEMDSA guidelines (2012), 2 NICE guidelines (2008), 2 Wound Bed Preparation Guidelines (2011), 3 SIGN guidelines (2010) 4 and the International Best Practice Guidelines: Wound Management in Diabetic Foot Ulcers (2103). 5Wound Care for the Diabetic Foot poses unique challenges due to the predisposing risk factors as well as the psychological impact on both the patient, family and care givers.It is also noted that a Diabetic Foot Ulcer (DFU) is a pivotal event in the life of a person with diabetes and is seen as a clear marker of serious under lying disease.Rapid wound deterioration is inevitable if wound care interventions are not done early to avoid ultimate amputation. 3,5The purpose of this document is to describe the basic principles in managing the diabetic foot by focussing on both prevention and ulcer treatment within the African context.

Method
An expert collaboration group from all walks of clinical care assembled for two day in Gauteng, South Africa to discuss and formulate a consensus document on the Management of the Diabetic Foot.Teams were selected for clinical expertise and background in Vascular surgery, Vascular assessment & management, Orthopaedic management, Wound management, Reconstructive Surgery, Product application and Managed Health Care.Societies who brought their expertise to this endeavour to create collaboration and unified approach are As verification of this, an online-based modified Delphi method was used where each team member voted independently to verify the initially reached recommendation strength.Thereafter it was verified by an independent second panel consisting of national and international experts who were not part of the panel.A 4-point Likert scale (strongly agree, partially agree, partially disagree, strongly disagree) was used with space for individual comments.Each item to be included in this document has achieved eighty percent agreement (either strongly agree or partially agree) by all panels.This process took 24 months to complete.

Assess patient ability to heal and treat the cause
All patients with diabetes should be examined at least once a year for potential foot problems.If any risk factors are demonstrated during first examination, a follow up assessment should proceed every 1-6 months depending on the severity.Risk factors are summarized in Table 1.The stratification system described in Table 3 according to SIGN (2010) supports and the use of the 60 second risk screen tool (Addendum A).

Do a thorough clinical assessment
Clinical assessment is key in enabling the practitioner to make the correct diagnosis and implement an appropriate individualized treatment plan.A holistic patient assessment should include:

Presence of femoral bruit
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Vascular
• Vascular supply assessment according to the PEDIS grading (Table 4):

Recommendation 3 Agreement: 100%
Ankle-brachial-pressure indices may be falsely elevated in people with diabetes due to incompressibility of arteries and severity of PAD

Recommendation 4 Agreement: 100%
Both feet should be investigated in a diabetic foot assessment even if one foot has no problems verbalized by the patient.The patient with diabetic neuropathy may experience moderate to severe pain.

Smoking
• Offering patients strategies that may be either psychosocial and/or pharmacological to aid in cessation of smoking and improve tissue oxygenation and healing

Develop an individualized plan of care
Develop an individualised plan of care according to your patient assessment

Interdisciplinary team
• Inter-professional, individualized patient-centred care with the patient involved in the care has to be part of the process.• The patient needs to be the centre of the Interdisciplinary team • Team member may differ depending on resources and skills available.
• Communication amongst all team members is crucial for positive

Optimize blood glucose (HbA1c)
Recommendation 6 Agreement: 100% HbA1c in a patient with a diabetic foot ulcer is often elevated above 10%.Once treatment is started with an interdisciplinary approach, a 3 month period should be given by managed healthcare for the team involved with the management of the patient to reach an optimal HbA1c of <8%.

Identify and address the cause related to specific wound aetiology and diagnosis
Recommendation 7 Agreement: 100% In diabetic foot management the underlying cause is either related to vascular supply problems, infection, pressure or a combination of the above With diabetic foot ulcers (DFU) it is important to address the cause by utilising the acronym vip. 3 Table 5 shows the typical features of DFUs according to their aetiology and should be used as a clinical guide to identify and treat the cause. 5In patients without clinical signs of ischemia or with perfusion measurements suggesting adequate blood flow, the effect of optimal wound care should be evaluated after 4-6 weeks.
Revascularisation should always be considered whenever a major amputation in patients with persistent ischemic rest pain or in patients with a low probability of wound healing.

High plantar pressures -offloading to prevent and heal foot ulcers
Recommendation 8 Agreement: 100% Footwear and off-loading techniques to prevent and heal DFU are recommended and the choice of technique depends on the presence and severity of co-factors (PAD, infection, mobility, ability, age, diabetes control, quality of life and should be applied with the patient's consent.Non adherence to treatment will affect the effectiveness of all devices.

Recommendation 9 Agreement: 100%
Early detection of Charcot foot is essential in preventing further damage, it is recommended to evaluate the surface temperature on both feet to determine inflammatory changes.

Use appropriate risk, ulcer and charcot classfications available
This panel recommends the use of the adapted PEDIS categorisation in table 4 to determine the level of risk as well as the University of Texas ulcer classification system to classify the depth and amount of tissue damage 5 (addendum C).Early detection of Charcot foot is essential in preventing further damage, it is recommended to evaluate the surface temperature on both feet to determine inflammatory changes.

Recommendation 10 Agreement: 100%
Total contact casting is the gold standard for stabilization in the acute phase of Charcot foot management.

Local wound care Recommendation 11 Agreement: 100%
The first step in local wound management is determination of healability (healable, non-healable or maintenance) depending on the correctability of the underlying cause.

Assess wound(s) location and description
• Location of the wound(s) • Measure mnemonic 3 (Addendum C) • Classify wounds as healable, non-healable or maintenance wounds (table 5)

Recommendation 12 Agreement: 100%
The local wound care for healable diabetic foot ulcers is determined by best evidence, patient preference and clinician recommendation and may include moist interactive dressings.

Crutches, walkers and wheelchairs
• Proved complete offloading of the foot • Patients need good upper body strength for crutches • Patients need to understand the purpose of using the device and be motivated to use the devices • Wheelchairs can be difficult in unmodified homes.

Felt & foams
• Customised use for specific offloading points by a trained health professional

Surgery
• Orthopaedic intervention in stabilising the foot or redistributing pressure points.

University of texas (Armstrong)
Assesses ulcer depth, presence of infection and presence of signs of lower-extremity ischaemia using a matrix of four grades combined with four stages Well established Describes the presence of infection and ischaemia better than wagner and may help in predicting the outcome of the DFU.
Lavery et al 1996 11 Armstrong et al 1998
Lipsky et al 2012 11 The page number in the footer is not for bibliographic referencing www.tandfonline.com/ojfp45

Cleanse wounds with low toxicity solutions
Cleansing solution used should be chosen according to the clinical appearance of the wound and cytotoxic solutions should be avoided. 3Wounds should be cleansed/irrigated with drinkable potable tap water/sterile water/saline.
• Do not irrigate wounds where you cannot see where the solution is going or cannot retrieve for aspirate or irrigation solution.

Recommendation 13
Agreement: 95.6% In wound cleansing, the use of foot soaks should be avoided due to the increase of spread of bacteria to other possible wound sites.

Recommendation 14
Agreement: 82.6% For healable diabetic foot ulcers the gold standard technique for tissue management include regular, local, sharp debridement using scalpel, scissors and or forceps by a suitably trained clinician.
Clinical findings from the assessment will determine the best method of debridement.Healthy tissue should be debrided sparingly by a trained health care professional in a healable wound. 1,3,5,13Gold standard technique for tissue management in diabetic foot ulcers is regular, local, sharp debridement using scalpel, scissors and or forceps. 1,3,5,6,13thods of debridement available include: Sharp debridement should be carried out by experienced practitioners (podiatrist or specialised nurse) with specialist training.

Assess and treat infection
The normal pathway of infection differs in the diabetic foot due to the underlying pathophysiology.Around 56% of diabetic foot ulcers become infected and overall about 20% of patients with an infected foot wound will undergo an amputation. 5,14sk factors for infection

Methods to determine infection
Diagnosis of infection depends on using clinical signs and symptoms, not only microbiological results. 5,12,15Wound swab using the Levine technique • Tissue biopsy • Probe to bone -all deep wounds should be probed to bone with a blunt sterile metal instrument • X-ray of the affected foot Table 6 provides a description of the different categories of inflammation and infection as well as the confirmation test to substantiate the diagnosis.

Recommendation 15 Agreement: 100%
Aggressive referral to an all-inclusive interprofessional team should be done in diabetic foot conditions with deep tissue infection or osteomyelitis.

Recommendation 16
Agreement: 91.3% All deep wounds should be probed to bone with a blunt sterile metal instrument to determine the presence of underlying osteomyelitis.
Treatment for deep tissue infection (moderate to severe) 4,5,12 • Start patients quickly on broad-spectrum antibiotics • Take deep tissue specimens or aspirates of purulent secretions for cultures at the start of treatment to identify specific

Ideal multidisciplinary team in managing the diabetic foot ulcer
Communication between the team members is crucial to ensure best treatment options and outcomes • All health care professionals should provide education be it individual or structured education programs (13).
• Utilize enablers available to promote foot care etc.
• Patients involvement is essential in treatment plan • Education should be reinforced and repeated • Identify the barriers to changing of behaviour • Educators should ensure that active learning is taking place • This consensus panel supports the views with regards to education of the NICE guidelines 6

Conclusion
The aim of this document is to form a global wound care guideline adapted for the south african context.This document should not be used in isolation but together with the international guidelines that it supports.
WHASA, Case Manager Association of South Africa, South African Stomaltherapy Association, Pan African Diabetic Foot Study Group and the Society of Private Nurse Practitioners of South Africa.The Diabetic Foot team consisted of members of whom 73.9% had more than 15 years of experience and 50% of them specialists (medicine, nursing and podiatry).They have reviewed the current literature pertaining to their area of expertise and present their findings during the meeting in a structure based on the Wound Bed Preparation Paradigm 3 .The purpose was not to reinvent the wheel but rather to put forward the South African voice and experience by means of recommendations.On day 2 to the full audience took part in a Modified Delphi method to generate an eighty percent immediate consensus for each recommendation.

•
Oedema of the lower leg (distinguish between bilateral or unilateral oedema) Oedema of the lower leg No diagnosis or final clinical decision should be made until oedema has subsided, unxless frank gangrene and systemic sepsis is present.Assesss and support individualized patient centred concerns according to the following: Pain • Diagnose and treat according to the cause: -Neuropathic pain -Neuro-ischemic pain -Wound related pain Nociceptive pain -Inflammatory pain (arthropathy, connective tissue disorders) Recommendation 5 Agreement: 91.3% systemic and co factors that may impair healing peripheral arterial disease (PAD)

60 4 .Neuropathy 11 .
Second screen for the high risk diabetic foot Name _________________________________________________________________ Phone # ____________________________ Dob (dd/mm/yr) _______/_______/______ Years with diabetes ______________________________________________________ Gender: M ___ F ____ Date of exam (dd/mm/yr) ________/_________/________ If all responses circled no: re-screen in 1 Pedal pulses are absent (dorsalis pedis or posterior tibial) No Yes 5. Fixed joint (no movement) check 4th and 5th web spaces and nails for fungal infection) Monofilament exam (record negative reaction) least 1 yes response refer to foot clinic (Increased risk of foot ulcer, infection, or amputation).Foot clinic appointment time: ________________________ B. All responses were no: re-screen in 1 year.Date for re-exam (dd/mm/yr) ________/_________/________.Risk screening tool adapted from rg sibbald 2010 recommended by whasa

Table 1 :
Risk factors for ulceration

Table 2 :
Stratification of risk for utilising the 60 second screening tool

Table 3 :
Test Methods for risk screening

Grading of the diabetic foot adapted from PEDIS GRADE
1No symptoms or signs of PAD in the infected foot in combination with: • Palpable dorsalis pedis and posterior tibial arteries or • Ankle brachial index 0.9 to 1.

VASCULAR CLINICAL EXAMINATION OF BOTH FEET UTILISING THE PEDIS CLASSIFICATION SYSTEM Patient with acute limb ischaemia is characterised by the six P's: Pulselessness, Pain, Pallor, Perishing cold, Paraesthesia and Paralyses 5,26 Access to care & financial limitations
1sing local resources and do the most with what is available.Health care professionals should advocate for required patient resources.Most appropriate for health care worker and patient according to the resources they have.1 •

Table 5 :
5ypical feature of DFUs according to aetiology adapted from best practice guideline 20135 Foot temperature and pulsesWarm with bounding pulses Cool with absent pulses Cool with absent pulsesOtherDry skin and fissuring Delayed healing High risk of infectionTypical locationWeight-bearing areas of the foot such as metatarsal heads the heel and over the dorsum of clawed toes Tips of toes, nails edges and between the toes an lateral borders of the footMargins of the foot and toesPrevalence based on (10) 35% 15% 50%

Table 6 :
5lcer prevention adapted from best practice guidelines5

Table 7 :
5lcer treatment adapted from best practice guidelines5

Table 8 :
Key features of the recommended classification systems adapted from international best practice

Table 9 :
3ealable, maintenance or non-healing wounds3Cause of the wound is corrected • Existing cofactors, conditions, or medications that could potentially delay healing are optimized or ideally correctedMaintenance• A wound that is healable but is being prevented from healing by healthcare system factors or patient related issues.These proposed levels have been adapted within the south african and african context where there are often only one health care practitioner present.It is therefore the recommendation of the panel that the minimum team should comprise of a trained health care practitioner, with prevention and basic curative cost effective care as the aim.

Table 12 :
1roposed levels of care adapted from Bakker et al 20121 Diabetic foot prevention programs should not be limited to education only but should consist of multiple continued and combined interventions to promote patient self-management.