Given that diabetes affects so many organs in the body, team-based care is particularly crucial for patients with diabetic foot ulcers. This author details how a multidisciplinary approach can save lives and limbs.
It’s human nature to pay more attention to acute, life-threatening events than to medical conditions that develop slowly and insidiously. That’s why diabetes is called the “silent killer.” It’s also human nature to pay more attention to painful conditions than non-painful ones. That’s a major reason that neuropathic diabetic foot ulcers so often end in amputation.
Unfortunately, teamwork does not come naturally to independent-minded clinicians. The disease of diabetes can affect nearly every organ system and is the perfect example of why team-based care is vital.
However, national statistics indicate we are not doing a very good job of managing this complex condition. The most recent analysis of the direct and indirect annual cost of diabetes was an astronomical $327 billion.1 In 2018, 10.5% of the U.S. population had diabetes (34.2 million people) and 1 in 5 diabetic foot ulcers (DFUs) ended in some level of amputation. In 2016, a total of 7.8 million hospital discharges in adults included diabetes among the diagnoses. The conditions for which they were hospitalized included major cardiovascular diseases (1.7 million), ischemic heart disease (438,000), stroke (313,000), lower extremity amputation (130,000), hyperglycemic crisis and hypoglycemia. When there is a foot infection, the risk of hospitalization is 55.7% greater and the risk of amputation is 154.5 times greater.2
We need to improve the delivery of all aspects of care. This includes improving diagnostic tests to better avoid mistakes in targeted treatments and creating better treatment protocols for different stages of disease. We need better communication among providers, particularly about the effectiveness of our interventions. When physicians are in sync with the care plan for a patient, it increases the patient’s sense of security, not to mention improving their outcomes. A product of this collaboration is often accountability. Multidisciplinary teams have been proven to improve outcomes in trauma, cancer, and limb salvage, to name just a few areas. The best possible outcomes don’t always necessarily mean returning to the initial state of function or anatomy; therefore, setting realistic expectations becomes an important component of care in patients with serious wounds.
Timing and knowledge are the two concepts that are integral to achieving the best possible patient outcomes. Interdisciplinary co-treatment maximizes applied knowledge. Clinicians can help each other find the best treatment options, but the communication has to be timely, particularly in the outpatient setting. There must be timely referral to specialists with a precise hand-off, which allows targeted treatments to be delivered before it’s too late. We must communicate about comorbid conditions to avoid adverse outcomes. Electronic medical records systems are still not able to facilitate communication when data remain in inaccessible silos.
Transitions from inpatient to outpatient and vice versa inevitably mean losing vital information. This is a huge problem when patients require hospital admission if the admission has to be handled through the emergency department. Bypassing the emergency department is cost effective for patients and payers but sadly, may be required for insurance reasons. Direct admissions with known team members enable faster and better care. Well-orchestrated inpatient care with optimization of systemic factors by medical specialists and collaboration with surgical specialists improves the odds of a successful outcome. Discharging patients from the hospital also requires appropriate follow-up with surgeons and/or the wound center but smooth transitions are challenging. Immediate access to care cannot be emphasized enough as delays in evaluation can have catastrophic consequences in this patient population.
Limb Preservation Teams Improve Outcomes
In 1998, Yale Medical Center created a center for limb preservation. Yale determined that early aggressive treatments including debridements and local foot amputations with liberal use of revascularization resulted in a cumulative limb salvage of 74% at 5 years in high risk groups.3
A study at Madigan Army Medical Center in Tacoma, WA demonstrated that implementation of a limb preservation service resulted in an 82% decrease in lower extremity amputation over 5 years (from 9.9 to 1.8 per 1,000 patients with diabetes), despite an increase in patients with diabetes by 48% within a period of five years from 1999–2003.4 A prospective study over 11 years in the United Kingdom evaluated the impact of multidisciplinary team work and improvements in the foot care services.5 Major amputations fell by 62%. Total amputations fell by 70%, from 53.2 to 16.0 per 10,000, and major amputations fell by 82%, from 36.4 to 6.7 per 10,000. An 11-year retrospective study in Sweden concluded that a multidisciplinary approach plays an important role in reducing and maintaining a low incidence of amputations in patients with diabetes.6 Major amputation at the level of the knee and above decreased by 78%. The poor prognosis associated with major amputations is well documented in literature.7,8
An Example of Team-Based Care
The patient in Figure 1 presented to the wound center with exposure of nearly the entire tibialis anterior tendon. His history of a rapidly enlarging, excruciatingly painful wound triggered by minor trauma was worrisome for pyoderma gangrenosum. This was confirmed by a biopsy and he was placed on high-dose steroids.
The patient’s nutritional status was immediately determined to be poor, and since some type of surgery was likely to be necessary, he was provided with samples of Impact Advanced Recovery® Drink (Nestle Health Sciences), an immuno-nutrition drink that can help patients prepare for major surgery.
Additionally, during his initial visit to the wound center, the patient had an arterial screening using skin perfusion pressure, which indicated that he had arterial disease. He wanted to avoid hospitalization as long as possible, so he was immediately referred to an interventional cardiologist and underwent endovascular revascularization as an outpatient within only a few days of his initial visit (Figure 2).
The patient was also urgently referred as an outpatient to a podiatrist trained in limb salvage and a few days after revascularization, was admitted to the hospital for surgical management, which included a staged approach to his lower extremity wound. The index procedure was an excisional debridement with deep cultures and a repeat biopsy followed by application of negative pressure wound therapy and definitive procedure split thickness skin grafting harvested from his ipsilateral leg and bolstered with negative pressure wound therapy (Figures 3A-C). His hospitalization was uncomplicated and additional consulting multidisciplinary services included general internal medicine, cardiology (same team that performed the endovascular procedure as an outpatient), and infectious disease. His outcome was complete healing of this limb-threatening and highly complex lesion (Figure 4).
Caring for these patients can be a humbling experience because they are often faced with secondary bacterial infections, which can have devastating consequences. The skin envelope is the primary barrier against infection and its destruction, combined with immunocompromise, makes these patients highly vulnerable to bacterial infection. Compromised arterial inflow further complicates the picture.
However, in a patient with systemic problems including malnutrition, the local wound should not be the focus. The focus of all interventions must be on the patient. Within two months of his definitive procedure, he had a non-ST elevated myocardial infraction (NSTEMI) that required a coronary artery endovascular intervention and stent placement.
This is a great example of the way that a diverse but well-identified team can collaborate for a positive outcome. Arterial screening and biopsy were performed on his initial visit. Additional diagnostic studies and revascularization were completed within a few days of his initial visit to the wound center so that the focus of hospitalization was on surgical wound management in a patient who was already prepared for surgery. The vital, but often overlooked, need for nutritional supplementation was addressed immediately and almost certainly contributed to his good outcome.
This kind of efficient care does not require a major medical center—our hospital is in a suburban area. It does require team members to be identified beforehand, to know each other’s skill set, to be committed to same-day responsiveness in communication, to have some flexibility in patient scheduling, and to understand when a situation is limb threatening and respond accordingly. The wound center practitioner was able to identify the major barriers to healing on the first visit, so no time was wasted in creating a cohesive plan or getting the involvement of an interventionalist and surgeon with the right skill sets. Teams like this can be created by committed individuals in any community.
Yes, how we handle patients in the operating room or the endovascular suite matters. But it’s just as important to manage their concurrent medical problems well and to close the gaps in surveillance with appropriate follow-up.
A multidisciplinary approach is advantageous for patients. It has the potential to deliver care in a controlled fashion, precisely and timely. The burden to care for patients with complex diseases is too heavy to be carried by one person. Multidisciplinary team members often include wound care physicians and nurses, pedorthists, physical therapists, primary care providers, interventional cardiologists, infectious disease specialists, endocrinologists, nephrologists, and multiple surgical specialists (e.g., podiatrists, orthopedic surgeons, reconstructive foot and ankle surgeons, vascular surgeons, plastic surgeons), and social workers.
We can measure team success in terms of limbs saved and hospital admissions avoided. Sadly, the way we deliver care is driven more by payer policies than processes demonstrated to create a healthier society. Coordinated, team-based care benefits the patients and the practitioners, but it requires an investment in time and commitment and the determination to overcome some aspects of human nature.
Efthymios Gkotsoulias, DPM, is a foot and ankle surgeon at Baylor St. Luke’s Medical Group/Baylor College of Medicine practicing in the North Houston area. His main focus is diabetic foot infections, limb salvage/preservation, reconstructive surgery of the foot and ankle and revision surgery.
1. Centers for Disease Control and Prevention. National Diabetes Statistics Report 2020. Available at https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf. Accessed March 29, 2021.
2. Lavery LA, Armstrong DG, Wunderlich RP, Mohler MJ, Wendel CS, Lipsky BA. Risk factors for foot infections in individuals with diabetes. Diabetes Care. 2006 Jun;29(6):1288–93. doi: 10.2337/dc05-2425. PMID: 16732010.
3. Sumpio BE, Aruny J, Blume PA. The multidisciplinary approach to limb salvage. Acta Chir Belg. 2004 Nov-Dec;104(6):647–53. doi: 10.1080/00015458.2004.11679637. PMID: 15663269.
4. Driver VR, Madsen J, Goodman RA. Reducing amputation rates in patients with diabetes at a military medical center: the limb preservation service model. Diabetes Care. 2005 Feb;28(2):248–53. doi: 10.2337/diacare.28.2.248. PMID: 15677774.
5. Krishnan S, Nash F, Baker N, Fowler D, Rayman G. Reduction in diabetic amputations over 11 years in a defined U.K. population: benefits of multidisciplinary team work and continuous prospective audit. Diabetes Care. 2008 Jan;31(1):99–101. doi: 10.2337/dc07-1178. Epub 2007 Oct 12. PMID: 17934144.
6. Larsson J, Apelqvist J, Agardh CD, Stenström A. Decreasing incidence of major amputation in diabetic patients: a consequence of a multidisciplinary foot care team approach? Diabet Med. 1995 Sep;12(9):770–6. doi: 10.1111/j.1464-5491.1995.tb02078.x. PMID: 8542736.
7. Fortington LV, Geertzen JH, van Netten JJ, Postema K, Rommers GM, Dijkstra PU. Short and long term mortality rates after a lower limb amputation. Eur J Vasc Endovasc Surg. 2013 Jul;46(1):124–31. doi: 10.1016/j.ejvs.2013.03.024. Epub 2013 Apr 28. PMID: 23628328.
8. Thorud JC, Plemmons B, Buckley CJ, Shibuya N, Jupiter DC. Mortality after nontraumatic major amputation among patients with diabetes and peripheral vascular disease: a systematic review. J Foot Ankle Surg. 2016 May–Jun;55(3):591–9. doi: 10.1053/j.jfas.2016.01.012. Epub 2016 Feb 19. PMID: 26898398.