Saving Limbs and Lives: Knowledge Mobilization for Persons with Diabetes

Diabetes presents significant challenges globally, particularly in the context of lower extremity health. Persons with diabetes (PWD) face an alarming statistic: every 20 seconds, someone loses a lower limb, and more than 80% of these amputations begin with a foot ulcer. Preventing foot ulcers is possible through comprehensive, whole-person care, which includes regular screening and management of the high-risk foot, as well as optimal control of HbA1c and blood pressure. The 5-year survival rate following lower limb amputation is lower than that of patients with lymphoma, breast cancer in females, or prostate cancer in males.1 Regional Care and the VIP Model Regional diabetic foot care benefits from reframing the VIP acronym to focus on Vascular supply, Infection, and Plantar pressure redistribution. Utilizing the 8-megahertz Audible HandHeld Doppler (AHHD), clinicians can identify multiphasic sounds indicative of an ABPI ≥0.9.2 This approach allows for assessment without the need for leg compression and is not affected by arterial calcification. The patient can be seated in a chair, and the calf muscle does not need to be compressed with a blood pressure cuff. Audible waveforms can be recorded and verified through an audio file, and patients presenting with monophasic sound or impalpable pulses should be referred for further vascular evaluation. Every patient requires a clinical assessment for claudication, cold feet, and dependent rubor that blanches upon elevation. Infection Assessment and Management Assessing infection is critical in managing the high-risk diabetic foot. Covert and overt infections can be identified using the validated mnemonic NERDS and STONEES.3 A key indicator of overt infection is an increased local temperature, which can be detected using a non-contact infrared thermometer. A difference of 3 °F or more between mirror-image sites, combined with at least 2 other STONEES infection criteria, can help distinguish infection from other causes of temperature elevation, including deep inflammation or unequal vascular supply. The therapeutic index for common bacterial pathogens guides the optimization of wound cleansing.4 Hypochlorous acid demonstrates reduced host tissue damage in managing infections from Staphylococcus aureus, Pseudomonas, and E. coli. It is important to note that using saline before or after antiseptics can diminish their effectiveness by reducing contact time and raising the antibacterial acid pH to neutral. For MRSA (methicillin-resistant Staphylococcus aureus), PHMB (polyhexamethylene biguanide) is particularly effective.4 Surface compartment (covert) infections are managed with topical antibacterial dressings, whereas deep and surrounding infections (overt) are increasingly treated with oral antimicrobial agents at optimized doses, as supported by recent evidence.5 However, systemic or spreading infections may require intravenous approaches. Plantar Pressure Redistribution and Offloading The International Working Group of the Diabetic Foot 2023 update designates non-removable contact casting as the criterion standard for plantar pressure redistribution.6 Removable knee-high or ankle-high cast walkers, which can be rendered irremovable for improved adherence, are considered a close alternative. However, these devices pose significant challenges for patients, often interfering with activities of daily living. When other offloading devices are unavailable, appropriately fitting footwear combined with felted foam serves as a third-choice intervention. The use of total contact casting (TCC) is limited by the need for skilled application, cost, and time constraints. Only a small percentage of centers use TCC, and most patients rely on alternative, removable footwear solutions. Patient Factors in Offloading Device Use Patient-related considerations are pivotal in the selection and successful application of offloading devices for neuropathic diabetic foot ulcers (DFU). Tolerance and comfort issues with non-removable devices can impact adherence to prescribed therapies. Many patients prefer removable devices, perceiving them as less restrictive and more compatible with daily activities. However, this preference may lead to reduced adherence, as the ease of removal can compromise the effectiveness of offloading. Achieving optimal outcomes requires balancing patient comfort and flexibility with the clinical necessity for consistent pressure redistribution. Low-Cost Removable Footwear Solutions A systematic review in this issue examined the literature on low-cost removable footwear for DFU identifying 23 studies with 618 out of 1,644 participants presenting with foot ulcers. Seventy-one percent of these patients healed within an average of 68.4 days. The offloading modalities included therapeutic shoes (37.4%), padding or insoles (36%), boots (10%), sandals (6.3%), orthopedic shoes (5.9%), and other devices (4.3%). These options represent most patient interventions, underscoring the need for further research and implementation efforts to optimize the use of removable devices. Knowledge Transfer and Mobilization in Practice Knowledge transfer bridges the gap between research and practical application. In Guyana, South America, DFUs were a leading cause of hospital admissions. A Canadian International Development Agency-funded project introduced key interventions between 2008 and 2013, including HbA1c testing, blood pressure monitoring, a 60-second high-risk foot screen, and the use of the 8-megahertz Doppler.7 Among 1,266 PWD screened, 48% were identified as high risk for foot ulcers, with 9% already having undetected foot ulcers. Infection identification utilized NERDS and STONEES criteria, whereas plantar pressure redistribution was achieved through removable therapeutic footwear and insoles. Knowledge mobilization connects research with users, including policymakers, community groups, and the public. Education for key opinion leaders in Guyana was facilitated by the International Interprofessional Wound Care Course. This facilitated the establishment of the Diabetic and Foot Care Clinic at Georgetown Public Hospital Corporation and 7 regional satellite clinics. This initiative resulted in a 68% reduction in amputation rates over 43 months, as documented by operating room records. Since 2020, a fully trained vascular surgeon has provided required revascularization. Reverse Innovation and Virtual Education Reverse innovation brings effective, resource-adapted solutions from developing regions to developed countries. Since the onset of COVID-19, virtual wound care education has expanded. Project ECHO Ontario Skin and Wound, based on Wound Bed Preparation, has promoted limb preservation cycles and case discussions related to leg and foot ulcers. A toolkit, including the 8-megahertz Doppler, oral infection treatment enablers, and low-cost offloading strategies, has been developed to equip health care providers with the skills necessary for the prevention and treatment of DFUs (Figure). With increasing diabetic lower limb ulceration and amputation rates, this is the right time to equip low-resource communities with the tools to manage diabetic feet. It improves patient health and well-being with treatment in their own communities while reducing amputations. The Guyana model works; it is time to mobilize it into practice.FIGURE: ECHO SKIN AND WOUND CARE TOOL KITReproduced with permission from WoundPedia.