In the face of increasing pressure on healthcare systems, caused by the COVID-19 pandemic, the International Working Group on the Diabetic Foot (IWGDF)—in collaboration with D-Foot International and Diabetic Foot Australia—has set out to answer clinicians’ questions, particularly on how the speciality might provide evidence-based care with “increasingly limited physical resources”.
“These are unprecedented times, where a global pandemic disrupts all aspects of local clinical practice,” reads a statement published online by the IWGDF. “Yet, providing care for people with diabetic foot disease remains crucial: as clinicians caring for these patients, we can play our role in the Corona-crisis, by doing everything we can to keep our patients with diabetic foot disease free from hospital.”
Responding to the question, “What should be the priority recommendations for clinicians managing their patient with diabetic foot disease, to try and help them stay free of hospital and COVID?”, the IWGDF states, first and foremost, that most of these patients do not need to be hospitalised. “Hospitalisation should generally be reserved for those with severe infection (i.e., systemic manifestations, suggesting possible sepsis) who require urgent diagnostic tests and surgical assessment, as well as antibiotic and supportive treatment.”
Although the aim should be to implement non-hospital care for diabetic foot patients, the IWGDF also emphasises that a multidisciplinary foot clinic, or established clinician network, must function collaboratively in order to agree upon referral arrangements, either in person or, if possible, via telemedicine.
Answering this question further, the IWGDF calls upon clinicians to triage as soon as possible, meaning that patients who are at a high risk of limb loss—due to severe infection or ischaemia—are discharged into hospital immediately, while those at a more moderate risk are treated as outpatients if this is viable. For diabetic foot patients at a lower risk, it is suggested that telemedicine follow-up or home-visits, if necessary, are arranged.
Commenting further on the potential of alternative services, and answering the question, “Should we be shifting most of our services to telehealth? And if yes, how?”, the IWGDF state: “The most frequently used method by our clinicians are photos in combination with instant messaging, as these are accessible for many patients or their carers. But, be aware that diagnosing based on a photo is not very reliable, and even triaging for treatment urgency differs between clinicians.”
On the subject of self-care and what should be discussed with patients, the group affirm the need to focus on hygiene and protection in relation to COVID-19. Glycaemic control has also been underlined as an important area of attention, as this may become more difficult during a lockdown. Moreover, it is necessary, say the IWGDF, to “discuss [with patients] the need to wear their prescribed offloading device or footwear at home as much as possible. This is very important at this time of limited physical resource or treatment options, and try and check your patient is doing this by telemedicine.”
Another key aspect for these patients is daily exercise: “Try to motivate your patient to create an exercise routine compatible with their conditions, and with limited day-to-day variations,” the IWGDF writes.
Looking closer at the issue of infection, and how patients can help to diagnose this without a clinician present, the IWGDF offer examples of questions that can be asked, including:
- How long have you had the ulcer? The longer the duration, the more likely it will be infected.
- Do you have pain or tenderness in the ulcer or surrounding tissues? Presence, especially in a patient with known peripheral neuropathy, increases the risk of infection.
- Has there been any drainage from the ulcer? If so, please describe it? If it is white/yellow/ greenish, non-translucent and thick, it is likely pus, which strongly suggests infection.
It is also stated by the IWGDF that many cases of diabetic foot osteomyelitis “can be treated in the outpatient setting”, though there are a number of requirements. Making an initial accurate diagnosis, obtaining material for culture, and prescribing an initial empiric antibiotic regimen, that can be modified along the way, are all key steps, as well as bone debridement or resection if required. “This can sometimes be done by a qualified surgeon in the outpatient setting,” say the IWGDF.
Finally, with respect to offloading, the group reflect that in light of a problem which has emerged in Italy, it is now being decided by clinicians there that in cases of ulcers at a high risk of worsening, a cast (or non-removable walker) should be applied in the outpatient setting. “For other plantar ulcers, we mainly use [a] removable cast (or removable walker) with offloading insole and appropriate dressing, and ask patients and nurses to email us every week [with] a picture of the dressing and ulcer, organising, where it is possible, an outpatient appointment…every two weeks,” they add.
More information and responses, to questions on topics such as wound healing interventions, peripheral arterial disease (PAD) and wound prevention, is said to be coming soon.
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