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2011-08-23
1
Dr. R. Gary Sibbald MD, FRCPC (Med, Derm), MACP, FAAD, M.Ed.
Professor Of Medicine / Public Health U. Of Toronto Director Of The International Interprofessional Wound Care Course
President Of The World Union Of Wound Healing Societies
Dr. Sibbald is:Company/ Agency Paid
Lecturers Advisory Board Members
ResearchParticipants
3M √ √ √
CIDA √
Coloplast √ √ √
Convatec √ √
Covidien √ √
Govt Ontario √
KCI √ √ √
J&J (Systagenix) √ √ √
Mölnlycke √ √ √
RNAO √ √
Stryker √ √
Objectives Participants will:
Focus on screening and prevention
Introduce the simplified 60 second screen to identify the person at high risk of a diabetic foot ulcer
Highlight appropriate foot care/ footwear to prevent skin complications
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The Problem- Diabetic Foot Ulcers
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Global pandemic of Diabetes Developing countries on the frontline Person With Diabetes (PWD) has a
15-25% lifetime risk- Diabetic Foot Ulcer (DFU)
50-70% recurrence rate (5yrs)
Every 30 seconds a lower limbis lost to diabetes
The Problem- Diabetic Foot Ulcers
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Precedes amputation in 85% cases Average healing rates 11-14 weeks 14-24% proceed to amputation 1 yr amputation rate- 15% Cost to the health system - profound
The Problem- DFUs
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Issue Statistics
Person with diabetes 20x risk of a lower limb amputation
World wide lower extremity amputations
25-90% diabetic related
5 years after the first amputation •50% dead•50% second amputation
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The Financial Cost Diabetes & Foot complications
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Issue Cost Diabetes •10.9 billion US dollars
•3 billion UK pounds Diabetes related foot complications
252 Million UK pounds
Cost per Amputation •16.488 US dollars •66,215 US dollars
The Problem: Lower extremity amputation (LEA)
Region Country Data Used Incidence per 100,000 diabetic population
Europe Denmark Holstein et al, 2000
430
UK Rayman et al, 2004
285
North America USA Lavery et al, 2003 590
Africa NA NA
Asia NA NA
South America Brazil Spichler et al, 2001
181
Caribbean Barbados Hennis et al, 2004 936
Guyana Newark et al, 2007
478
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Ulcer Risk Factors : Person with Diabetes
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Ulceration
Potential Amputation
Neuropathy
Oxygen*Medication delivery
impaired
*Poor healing*Infection
Sensory loss of protective sensation
Autonomic skin, joints
Motor foot deformity, limited mobility joints
*Self care deficit *Poor glucose control*Improper footwear*Obesity
Peripheral Arterial Disease
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Who should be involved in the care of the person with
Diabetes ?
PATIENT Medical Internist –Endocrinologist
Surgeons/Family MD
Occupational Therapist
Dermatologist
Diabetic Educator/ Dietitian
Physiotherapist/Occupational Therapist
RehabAssistant/Foot Specialist
Clinic Nurses
VascularSurgeon
Plastic Surgeon
OrthopedicSurgeon
Radiologist
SocialWorker
Reception-Secretary
Neurologist
OrthotistPedorthist
Pharmacist
Prosthetist
FamilyDoctor
DIABETIC FOOT- AN INTERPROFESSIONAL TEAM APPROACH
Foot specialist
Clinical & Education Program
Best Practice Recommendations of the Canadian Association of Wound Care (CAWC)
Development of a comprehensive interprofessional diabetic foot program gram
Primary and secondary educational strategies
Best practice seminars
Skills: Doppler ABPI, skin temperature, conservative debridement
Prevention 60 sec. screen
IIWCC key opinion leader training
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Person with Diabetic Foot Ulcer
Treat Cause
Local Wound Care
Patient-Centered Concerns
Superficial Infection /
Chronic Inflammation
Tissue-Debridement of
Devitalized tissueMoistureBalance
Edge-Non-healing WoundBiological Agents-
Growth FactorsSkin substitutes Acellular matrix
Skin Grafts-Full / Partial ThicknessAdjunctive Therapies (VAC)
Sibbald et al2006,20072011-08-23
Sibbald et al WBP, 2007,WHO 2010
Advances Sept 2011
Treat the Cause: Whole Patient
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A HbA1c: Target for Diabetes in Control is 7.0% and should be checked every 90 days
B Blood pressure: Target for PWD is 120 mm Hg systolic and 80 mm Hg diastolic
C Cholesterol: Cholesterol < 200mg/dL, LDL < 100 mg/dL, Triglycerides <150 mg/dL.
D Diet: > 5 daily servings of fruit and vegetables, > 6 daily servings of grain products, including whole grains, > 2 servings of oily fish per week, 25-30 grams of fiber per day, < 1 tsp salt.
E Exercise: Minimum of 30 minutes most (if not all) days
F Foot Care and Foot Wear: and Ulcer: VIPs
S No Smoking! One cigarette will decrease local circulation 30-50% for one hour!
Diabetes Control Priorities in Developing Countries1
Highest level priority: o Cost saving AND Highly feasible
Diabetes
o Foot care
o Glycemic control to HbA1c < 9%
o Blood pressure control to BP < 160/90
1) Narayan V, et al. Diabetes: The Pandemic and Potential Solutions. In: Jamison D, et al., editors. Disease Control Priorities in Developing Countries. 2nd ed. Washington, DC: World Bank; 2006. p. 591-603.
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Break:Prevention: 1266 screenings GuyanaSouth America
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•History•Inspection abnormalities •Palpate pulse •Monofilament testing (4 out 10 negative)
Results of 60 second screeningITEM NO% YES%
Previous Ulcer 86.5 13.5
Previous Amp 95 5
Absent pulse 91.5 8.5
Stiffness ankle/toe 98.7 1.3
Active DFU 92.3 7.7
Ingrown toenail 81.7 18.3
Callus 77.7 22.3
Fissure 89.5 10.5
Neuropathy 76.6 23.4
REFERRED DFC 59.1 40.92011-08-23
Screening – high risk statusRisk factor Ulcer yearly
incidence/ rate %Odds ratio
(95%CI)
Group 0 (no PN, no PVD) 2%
Group 1
(PN, no PVD or deformity)
4.5% 2.4 (1.1.-5)
Group 2B (PVD) 13.8% 9.3 (5.7-15.2)
Group 3 PN/ PVD (history of ulcer or amputation)
32.2% 52.7(27.2-109.8)
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Lavery LA, et al. … classification system of the International Working Groupon the Diabetic Foot. Diabetes Care 31(1):154-6, 2008.
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60 Second Screen - History
1. Previous Ulceration 2. Previous Amputation
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60 Second Screen –Physical Examination
3. Deformity
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60 Second Screen –Physical Examination
4. Pulses absent Dorsalis Pedis and /or Posterior Tibial
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60 Second Screen – Physical Examination- fixed joints
5.No movement large toe joint Limited Ankle joint dorsiflexon
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60 Second Screen –Foot Lesions6. Active Ulcer 7. Ingrown toenail
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60 Second Screen – Foot Lesions
8. Calluses= increased pressure
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60 Second Screen –Foot Lesions9. Blisters
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10. Fissure
60 Second Screen –Foot Lesions 4th – 5th Toe Web Space Nails
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60 Second Screen – Neuropathy
11.Mono filament ExamX all negative= 4/ 10
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X
X
X X
60 second screen video
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60 Second Screen – PlanPOSITIVE SCREENNeuropathy only
See in 6 monthsAll other +ve screens
Refer to next level facility
NEGATIVE SCREEN No referral See in 1 year
SCREENING KIT Sixty Second tool Monofilament Patients Practice Documentation Referral
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Physical Activity:How Does Exercise Help?
Improves insulin sensitivity
Increases sense of well-being
Increases flexibility and muscle strength
Prevent weight gain
Improves cardiovascular function
If hypertensive, helps to control high blood pressure
Improves cholesterol and other lipids
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No Smoking: Double indemnity Every cigarette will decrease the circulation in the leg or
foot up to 30% for an hour or increase sympathetic tone for 8 hours
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Foot ailment is the most common complication of diabetes that requires hospitalization.
High blood sugar can damage the nerves of your feet resulting in loss of sensation (numbness), tingling or burning to the feet, so there is no pain when there is an injury.
High blood sugar can also cause poor blood supply to the feet and so small injuries take a very long time to heal
Taking care of your feet can make a big difference in preventing foot problems and ultimately amputation. Your feet can last a life time.
How Does Diabetes Affect Your Feet
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Pat dry between your toes each day
with a soft cloth, warm
water and mild soap.
Put some powder after
you wash them. Use powder that is mild and has
no scent
Use lotion for dry skin. Do not
put any lotion between your toes, or used
perfume lotion
Never walk barefooted
How to Care for Your Feet
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Look for colour changes such as blue, bright red or white (pale)
spots Keep your eyes
on your feet
Check your feet each day
for cuts, blisters or
sores.
Use a mirror, if necessary,
to see the bottom of your feet
You should look and touch to
ensure that there is no swelling nor tenderness
Check Your Feet Everyday
See your health care provider if you have a foot problem do not treat them yourself.
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Change your socks every day
Look inside your shoes
before you put them on (make sure nothing is
in them and make sure the lining in them are not torn)
Do not wear pointed or open –toed
shoes. Sandals or thongs may
cause problems.
Shoes should fit
well. There should be
enough room for
your toes to move
Footwear
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How to Care for Your Feet
When infection is bad, part of the foot or leg may need to be amputated.
If you take good care of your feet, this does not have to
happen to you.
Shoes for Persons with Diabetes
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Good Shoe Featureslook for comfort & support
Extra depth Ventilation (natural material) Stretching material Seamless, lightweight
construction Arch support Room For Your Toes A Perfect fitting heel Thick sole
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Tips on socks, too!
Light coloured, absorbent seamless Clean Loose fitting elastic but firm Increased length
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Get moving
Appropriate??
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1 2
3
4
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Person with Diabetic Foot Ulcer
Treat Cause
Local Wound Care
Patient-Centered Concerns
Superficial Infection /
Chronic Inflammation
Tissue-Debridement of
Devitalized tissueMoistureBalance
Edge-Non-healing WoundBiological Agents-
Growth FactorsSkin substitutes Acellular matrix
Skin Grafts-Full / Partial ThicknessAdjunctive Therapies (VAC)
Sibbald et al2006,20072011-08-23
Sibbald et al WBP, 2007,2010WHO 2010
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15
Objectives Participants have:
Focused on screening and prevention
Introduced the simplified 60 second screen to identify the person at high risk of a diabetic foot ulcer
Highlighted appropriate foot care/ footwear to prevent skin complications
2011-08-23
Thank you!Together we can
make a difference!
2011-08-23