Role of the podiatrist in diabetic limb salvage

Using Multidisciplinary Teams to Improve Outcomes for Treating Chronic-Limb Threatening Ischemia

Multidisciplinary teams are necessary to treat complex patients with chronic limb-threatening ischemia (CLTI). The need for adequate wound care and control of comorbid conditions cannot be accomplished by the vascular specialist alone. Numerous specialties have a role in this group to include surgical podiatrists, orthopedic surgery, plastic and reconstructive surgery endocrinology, and wound care. However, the vascular specialist must drive this team as the patients are usually referred to them and numerous studies have shown a direct correlation between major amputations and the lack of vascular involvement. Creating these teams is unique in each community and must consider practice patterns that are relevant in the local region. CLTI is a challenging disease to manage, and multidisciplinary teams have demonstrated an ability to improve outcomes and deliver superior care to this patient population.

Adjunctive topical oxygen therapy in the management of complex diabetes-related wounds: A South African case study series

Diabetic foot ulcers (DFUs) are a prevalent complication of diabetes mellitus and are associated with significant morbidity and mortality. The essential role of oxygen in the treatment of DFUs is documented. Indicated for use on a variety of wound types, topical haemoglobin therapy (Granulox®) is a novel therapeutic technology that binds atmospheric oxygen and improves the availability of oxygen at the wound site. When used as part of the wound management strategy, this therapy helps to reduce inflammation, exudate and slough, and promotes wound healing. In South Africa, health resources, coordinated foot care and podiatry, and data on diabetic foot complications are limited. Twelve patient case studies assessing the impact of adding topical haemoglobin therapy to the management regimes for DFUs and surgical (post-amputation) wounds were undertaken in South Africa. Patients were aged 50-71 years, and all had diabetes mellitus. At baseline, the area of the wounds ranged from 10.2 to 149.6 cm2 with depths ranging from 0.2 to 0.9 cm. Clinical signs of wound infection and high levels of viscous exudate were recorded in all cases. Wound dressings were changed twice weekly and sharp debridement of the wound performed as necessary. The wounds were cleansed and then completely coated with a thin film of Granulox® and dressings applied. Treatment was monitored over periods ranging from 57 to 276 days, during which dressings were changed and Granulox® administered to the wounds, ranging from 16 to 79 times. During the period of evaluation, wound size steadily reduced (by 87.1-100%), the condition of the wound bed tissue and peri-wound skin improved, and clinical signs of wound infection steadily resolved. Wounds significantly improved in two patients, almost healed in six patients, and healed in four patients. All patients reported a reduction in malodour and pain; seven patients were pain-free at the final followup assessment. The overall impression of Granulox® was rated as 'very good' by the clinicians, who considered that Granulox® facilitated an increase in tissue viability, with the promotion of granulation tissue, and stimulated epithelialisation.

The Opportunity for Impactful Integration of Vascular and Podiatric Care

BACKGROUND

The importance of collaboration between vascular and podiatric surgeons has been well-established. High-level partnerships are integral to the development of multidisciplinary programs and wound care centers, ultimately resulting in improved patient outcomes. This vascular-podiatric integration is not universal, however, and podiatric surgery may not be aligned within a vascular surgery division at many institutions. As one such institution, we reviewed our single-center experience in order to identify opportunities for the impactful integration of vascular-podiatric patient care.

METHODS

Institutional electronic medical records were retrospectively reviewed for all procedures performed by vascular surgeons at a high volume, safety-net academic medical center. Data were collected on all primary and additional procedures, current procedural terminology (CPT) codes, case type (elective, urgent, emergent), surgeon specialty, and date/time of the procedures performed. CPT codes were linked to the Centers for Medicare & Medicaid Services' Physician Fee Schedule to estimate the work relative value unit (wRVU) per procedure.

RESULTS

From 2018 to 2022, vascular surgeons performed a total of 12,206 operations, of which 1102 (9.9%) involved podiatric procedures. The most common vascular-performed podiatry procedures performed were toe amputations (38.1%, n = 420), transmetatarsal foot amputations (20.1%, n = 222), and ankle/foot debridement (16.2%, n = 178). Foot/ankle-specific procedures were identified as the primary procedure in 726 (65.9%) cases and as the adjunct procedure in 376 (34.1%) cases. A substantial proportion of podiatric procedures occurred on an urgent (n = 278, 25.2%) or emergent (n = 28, 2.5%) basis. A total of 163 (14.8%) cases occurred after hours (either before 0600 or after 1800), and 133 (12.1%) cases were performed on a holiday or weekend. Procedure-specific revenue included 4243.39 wRVU for primary procedures and 2108.08 wRVU for additional procedures performed.

CONCLUSIONS

We report our single-center experience in which vascular surgeons provide a significant proportion of podiatric procedures. Our study underscores the potential for integrating podiatric surgeons within a vascular surgical division and presents opportunities for collaboration and enhanced patient care.

Research priority setting in UK podiatric surgery

Evidence-based practice provides the foundation for high quality patient care, and in the NHS, research is seen as vital to enable service transformation and improve outcomes. Research is one of the four pillars of enhanced and advanced clinical practice and is therefore a fundamental part of podiatric surgery services. In order to meet the UK health research strategies, the most recent being 'Saving and Improving Lives: The Future of UK Clinical Research Delivery' (2021), the Faculty of Podiatric Surgery in the UK agreed to support the development of research priorities in order to inform a future research strategy.The Podiatric Surgery Research Strategy Group was set up and embarked on a project with the aim of engaging its members in formulating and agreeing national research priorities. The initial stage included a national research scoping survey to identify key themes, topic, and research questions. The final stage consisted of developing and enabling a live consensus vote conducted at the 2022 national Faculty of Podiatric Surgery Conference. At the end of the vote, the top five research topics that met the agreement criteria were: 1. Surgical treatment - forefoot, 2. Patient reported outcome measures, 3. Post-operative management, 4. Surgical treatment - midfoot and 5. Service delivery. The top five research questions that met the criteria were1. How does quality of life improve following elective foot surgery? 2. How does podiatric surgery benefit the health of the population? 3. How does podiatric surgery benefit the health of the population in the at-risk foot? 4. What is the most effective Lapidus fixation option? and 5. What is the benefit of utilising PASCOM-10 to improve large scale outcome data? These will inform the initial UK podiatric surgery research priorities in the next three to five years.

Competency Framework for Podiatric Medicine Training in Canada: An Adapted Delphi Study

PURPOSE

Podiatrists are generally defined as professionals with high-level skills in the prevention and management of local foot conditions that are not systemic diseases. Across countries, different academic trainings are implemented due to the specific context and practice of podiatric medicine. It is thus essential to support country-specific podiatry education for the development of highly skilled podiatrists. Therefore, we report the development of a podiatric medicine competency framework to support training in Canada.

PARTICIPANTS AND METHODS

A Delphi process was conducted by 12 stakeholders (including 8 podiatry experts) from the University of Québec at Trois-Rivières which is the only university offering the degree of Doctor of Podiatric Medicine (DPM) in Canada. The developed framework is (1) based on the seven key roles of the Canadian medical education directives of specialists (CanMEDs) and, (2) closely aligned with the requirement of the College of Podiatrists of Québec which sets the standards of entry to practice in Québec.

RESULTS

The developed framework represents the state of the development process and the consensus of the podiatry experts. It reflects the expected profile of the institution's DPM graduates based on seven key roles (podiatry expert, communicator, collaborator, health advocate, leader and manager, scholar, and professional). This developed framework is an arborescence of complex skills defined in tangible indicators that characterize each expected part of a core competency. Twenty-four core competencies have been determined and divided into 84 enabling competencies and 288 observable indicators.

CONCLUSION

This competency framework has been designed to support high-quality education and to develop podiatry. Next steps include: (1) validation of this framework by external experts, (2) development of rigorous evaluation methods and, (3) concrete actions for its implementation and assessment. This framework would help to define the scope of practice and capabilities of podiatric medicine, both in Canada and internationally.

Early Diagnosis and Surgical Management of Necrotizing Fasciitis of the Lower Extremities: Risk Factors for Mortality and Amputation

Objective: In this study, we seek to identify patient characteristics associated with limb loss and mortality while exploring the potential impact a multidisciplinary care team may have. Approach: This was a 10-year retrospective review of patients presenting to our tertiary care center for limb salvage with a diagnosis of lower extremity (LE) necrotizing fasciitis (NF). Patient demographics, clinical history, and outcomes were compared between survivors and nonsurvivors and between those who underwent LE amputation and those who did not. The article adheres to the strengthening the reporting of observational studies in epidemiology statement. Results: Sixty-two patients presented to our tertiary care center for limb salvage with LE NF. Forty-two patients underwent LE amputation: 27 (43.5%) underwent below-knee amputation, 1 (1.6%) underwent above-knee amputation, 8 (12.9%) underwent transmetatarsal amputation and 2 (3.2%) underwent calcanectomy. The overall mortality rate was 16.1% (n = 10). Risk factors for mortality included increased age (p = 0.034), higher Charlson Comorbidity Index (p = 0.011), thrombocytopenia (p = 0.002), hypotension (p = 0.015), erythema (p = 0.010), pain (p = 0.027), diabetes mellitus (p = 0.012), and malignancy (p < 0.001). Risk factors for LE amputation included DM (p = 0.017), peripheral vascular disease (p = 0.033), and an elevated laboratory risk indicator for necrotizing fasciitis (LRINC) (p = 0.033). Innovation: To identify outcomes after admission to a tertiary hospital with a dedicated limb salvage team with LE NF and to analyze risk factors for mortality and amputation. Conclusions: This is a comprehensive analysis of risk factors for mortality and amputation after LE NF. Our institution's experience highlights the importance of a multidisciplinary approach in the care of these patients.

Team-Based Care in Patients with Chronic Limb-Threatening Ischemia

PURPOSE OF REVIEW

Team-based care has been proposed as a tool to improve health care delivery, especially for the treatment of complex medical conditions. Chronic limb-threatening ischemia (CLTI) is a complex disease associated with significant morbidity and mortality which often involves the care of multiple specialty providers. Coordination of efforts across the multiple physician specialists, nurses, wound care specialists, and administrators is essential to providing high-quality and efficient care. The aim of this review is to discuss the multiple facets of care of the CLTI patient and to describe components important for a team-based care approach.

RECENT FINDINGS

Observational studies have reported improved outcomes when using a team-based care approach in the care of the patients with CLTI, including reduction in mean wound healing times, decreasing rate of amputations, and readmissions. Team-based care can streamline care of CLTI patients by raising awareness, facilitating early recognition, and providing prompt vascular assessment, revascularization, and surveillance. This approach has the potential to improve patient outcomes and reduce downstream health care costs.

ECONOMIC VALUE OF PODIATRY SERVICE IN LIMB SALVAGE ALLIANCE

INTRODUCTION

Over the last decade, multidisciplinary "toe and flow" programs have gained great popularity with proven benefits in limb salvage. Many vascular surgeons have incorporated podiatrists into their practices. The viability of this practice model requires close partnership, hospital support, and financial sustainability. We intend to examine the economic values of podiatrists in a busy safety-net hospital in the Southwest United States.

METHODS

An administrative database that captured monthly OR cases, clinic encounters, in-patient volume, and total work relative value units (wRVU) in an established limb salvage program in a tertiary referral center were examined. The practice has a diverse patient population with >30% of minority patients. During a period of three years, there was a significant change in the number of podiatrists (n=1 to 4) within the program where the clinical full-time employees for vascular surgeons remained relatively stable.

RESULTS

The limb salvage program experienced >100% of growth in total OR volumes, clinic encounters, and total wRVUs over a period of four years. A total of 35,591 patients were evaluated in a multidisciplinary limb salvage clinic and 5535 procedures were performed. The initial growth of clinic volume and operative volume (P<0.01) were attributed by the addition of vascular surgeons in year one. However, recruitment of podiatrists to the program significantly increased clinic and OR volume by an additional 60% and >40% respectively (P<0.01) in the last three years. With equal number of surgeons, podiatry contributed 40% of total wRVUs generated by the entire program in 2019. Despite that most of the foot and ankle procedures that were regularly performed by vascular surgeons were shifted to the podiatrists, vascular surgeons continued to experience an incremental increase in operative volume and >10% of increase in wRVUs.

CONCLUSION

This study shows that the value of close collaboration between podiatry and vascular in a limb salvage program extends beyond a patient's clinical outcome. A financial advantage of including podiatrist in a vascular surgery practice is clearly demonstrated.

Establishing a multidisciplinary partnership integrating podiatric care into the Quebec public health-care system to improve diabetic foot outcomes: A retrospective cohort

Diabetic foot ulcers (DFUs) are one of the main complications of diabetes affecting many Canadians that need to be effectively managed. There is limited data concerning outcomes of Canadian patients with DFUs treated with a team approach in the public health system. Podiatrists are known to be key members of a multidisciplinary team approach to DFUs management, but in Quebec, Canada, they are only available in private practice. The aim of this study is to evaluate diabetic foot outcomes after integrating podiatric care into in-hospital wound care clinic settings. A 12-month retrospective cohort study was conducted into a new organization named the Pododiabetology University Center (PUC), which is described in this article. Healing rate and healing time were the outcomes measured. The analysis was performed by comparing data collected before and after the integration of the podiatrists. Preliminary results indicate that 73.2% of DFUs (n=52) healed in an average of 19.8 weeks (time to wound closure). Previous data collected on 15 individuals before the integration of podiatric care showed a 27.3% of DFUs resolved in 44.6 weeks. The findings suggest that a patient with DFUs who receives wound care from a multidisciplinary team that includes a podiatrist can improve both their healing rate and time. An integrated multidisciplinary approach including podiatrists for patients affected by acute DFU is highly suggested in the literature in order to reduce the number of hospitalizations, amputations and financial burden, which are variables that could be evaluated in further studies.

Multidisciplinary Approach to PAD: Who's on Your Team?

The complexity of peripheral arterial disease (PAD) and its multiorgan involvement requires the utilization of a multispecialty team approach. Members of this team include a vascular specialty (interventional radiology, cardiology, and vascular surgery), podiatry, orthopedic surgery, primary care, infectious disease, endocrinology, plastic surgery, wound care nursing, and dietetics. A team approach has been proven to significantly improve patient outcomes as well as decreasing amputation rates. In order to promote collaboration and avoid duplication of care, the team can be broken down into three main pillars: medical management, wound care, and revascularization. A complete team approach is vital for this population, with an overall goal to treat all manifestations of the disease and prevent further progression and risk of major sequelae of the disease.

Diabetic foot ulcer care: a concept analysis of the term integrated into nursing practice

BACKGROUND

Diabetic foot ulcer care demonstrates a beneficial approach to overcoming problems in patients with diabetes. This approach is frequently given but is not always successfully implemented due to its fragmentation amid healthcare providers. What's more, there are a number of different understandings, interchangeable languages and an absence of uniformity overlapping terminologies of meaning for diabetic foot ulcer care. Therefore, analysing the concept of diabetic foot ulcer care is important to provide a wider nursing knowledge, synthesise a greater theoretical model and drive more effective care of diabetic foot ulcer.

OBJECTIVE

This article aimed to analyse how the concept of diabetic foot ulcer care is clearly defined in the relevant evidence as it has several implications in nursing practice.

METHOD

Walker and Avant's (1995) method of concept analysis was systematically used in this study.

FINDINGS

Three critical attributes of diabetic foot ulcer care were determined consisting of assessment, intervention and evaluation. Constructed cases are also presented to differentiate the concept of diabetic foot ulcer care from other concepts. This concept analysis results in the critical attributes of diabetic foot ulcer care, defines an operational definition and describes common goals that improve clarity, consistency and understanding of the concept amid healthcare professionals along with researchers.

CONCLUSION

Effective implementation of the concept of DFU care into clinical nursing practice may undoubtedly improve patient outcomes and prevent the complexities of DFU in the years to come. Future research needs to be developed for evaluating the current use of this concept.

Promoting Limb Salvage through Multi-Disciplinary Care of the Diabetic Patient

OPINION STATEMENT

Despite an explosion in the number of options available for helping diabetic patients heal wounds, major amputation remains a critical issue for these persons. Since diabetes prematurely ages tissues and no organ system is immune to its presence, it makes inherent sense that multi-disciplinary team approaches to these patients is necessary to make significant strides forward. Here, we present literature from the fields of podiatric surgery/medicine, vascular and plastic surgery and introduce the successes that a multi-disciplinary limb salvage center can have on the lives and limbs of patients with diabetes.

Application of the five stages of grief to diabetic limb loss and amputation

A potentially underappreciated member of the multidisciplinary approach to diabetic limb salvage is that of psychiatry. Diabetic patients are more likely to experience depression, and diabetic patients with depression are more likely to undergo an amputation. Also, both diabetes and depression independently increase the healthcare costs in the United States. The objective of the present investigation was to increase knowledge among diabetic foot practitioners with respect to psychiatric and other mental health patient-care issues, specifically the potential application of the 5 stages of grief to diabetic limb loss and amputation. We enlisted the assistance of a clinical professor from the psychiatry department at our institution to review the 5 stages of grief, provide context specific for application to diabetic limb loss, and offer clinically relevant guidelines for surgeons to better understand and communicate with their patients at each stage. The 5 stages reviewed were denial, anger, bargaining, depression, and acceptance. We hope that the present review will increase the body of knowledge with respect to relevant psychiatric issues and the diabetic foot and provide a starting point for increased awareness with respect to this important, yet underappreciated, aspect of patient care.

Where art thou diabetic foot disease literature? A bibliometric inquiry into publication patterns

The objective of the present investigation was to evaluate the published scientific data with respect to the diabetic foot. We specifically aimed to assess the quantity published and the specific location of the published reports. A standard PubMed(®) search was performed, and the returned abstracts were evaluated by a 2-person panel for their relevance to medical professionals working within the field of diabetic foot disease. We identified 1286 relevant studies published in 659 different journals in 2012. We also found a 6.94-fold increase in returned abstracts meeting our search criteria from January 1988 to December 2012. The results of our investigation provide unique information regarding the high volume and variety of published information pertaining to diabetic foot disease and perhaps highlights a need for multidisciplinary thinking with respect to publishing and data organization, in addition to patient care.