Inpatient Management of Diabetic Foot Disorders

A Clinical Guide

Dane K. Wukich, Md; David G. Armstrong, Dpm, Phd, Md; Christopher E. Attinger, Md; Andrew J.M. Boulton, Md; Patrick R. Burns, Dpm; Robert G. Frykberg, Dpm, Mph; Richard Hellman, Md; Paul J. Kim, Dpm; Benjamin A. Lipsky, Md; James C. Pile, Md; Michael S. Pinzur, Md; Linda Siminerio, Rn, Phd

Disclosures

Diabetes Care. 2013;36(9):2862-2871. 

In This Article

Abstract and Introduction

Abstract

The implementation of an inpatient diabetic foot service should be the goal of all institutions that care for patients with diabetes. The objectives of this team are to prevent problems in patients while hospitalized, provide curative measures for patients admitted with diabetic foot disorders, and optimize the transition from inpatient to outpatient care. Essential skills that are required for an inpatient team include the ability to stage a foot wound, assess for peripheral vascular disease, neuropathy, wound infection, and the need for debridement; appropriately culture a wound and select antibiotic therapy; provide, directly or indirectly, for optimal metabolic control; and implement effective discharge planning to prevent a recurrence. Diabetic foot ulcers may be present in patients who are admitted for nonfoot problems, and these ulcers should be evaluated by the diabetic foot team during the hospitalization. Pathways should be in place for urgent or emergent treatment of diabetic foot infections and neuropathic fractures/dislocations. Surgeons involved with these patients should have knowledge and interest in limb preservation techniques. Prevention of iatrogenic foot complications, such as pressure sores of the heel, should be a priority in patients with diabetes who are admitted for any reason: all hospitalized diabetic patients require a clinical foot exam on admission to identify risk factors such as loss of sensation or ischemia. Appropriate posthospitalization monitoring to reduce the risk of reulceration and infection should be available, which should include optimal glycemic control and correction of any fluid and electrolyte disturbances.

Introduction

The implementation of an inpatient diabetic foot service should be the goal of all institutions that care for patients with diabetes. The objectives of this team are to prevent problems in patients while hospitalized, provide curative measures for patients admitted with diabetic foot disorders and to optimize the transition from inpatient to outpatient care. Pathways for the outpatient management of diabetic foot disorders are available; however, little has been written on the inpatient management of these disorders while patients are hospitalized. A multidisciplinary group was assembled on the basis of their experience in treating patients with diabetic foot disorders and tasked with preparing a guideline to assist practitioners who care for hospitalized patients. Medical specialists (infectious disease, hospital medicine, and endocrinology), surgical specialists (podiatry, plastic surgery, and orthopedic surgery), diabetes educators, and nursing staff contributed to this article. Members were assigned to research and write on their areas of expertise using an evidence-based approach and incorporating their own expert opinions when a lack of evidence existed.

The lower extremity manifestations of diabetes are multifactorial, and the approach to treatment and prevention of complications should take each of the key factors into consideration. Physicians, surgeons, nurses and other staff play a central role in the management and screening of the inpatient with diabetes.[1] Although the staffing of this team might vary from region to region, or even over time, the skill sets required remain constant. For patients with diabetes whose primary admission is not for a lower extremity wound, provisions should be made during the hospitalization to screen for diabetic foot complications and implement preventative care practices. Nondiabetic patients presenting with foot lesions, particularly if neuropathic and/or ischemic, should be screened for diabetes: foot ulcers and infection may be the presenting sign of diabetes.

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