Inpatient Management of Diabetic Foot Disorders
Inpatient Management of Diabetic Foot Disorders
The inpatient team should aim to seamlessly perform appropriate postoperative monitoring to reduce risk of reulceration and infection after hospital discharge to home, a rehabilitation unit, or a skilled nursing facility. This begins with having nursing professionals integrally involved on the diabetic foot team. Ideally, elements of the same team that manages the inpatient care should oversee transition to outpatient care for preventative measures as the foot moves into "remission". In addition, to nurses familiar with diabetes education, the inpatient team should include a dietitian who can provide nutritional assessments and further education on the importance of ideal body weight and diabetes management. Continued optimal glycemic control will improve the probability of successful wound healing. As with the foot care service, care coordination for glycemic control is also necessary.
Optimal outcomes in patients with diabetes require patients to be knowledgeable about their disease and its complications and able to provide appropriate self-care to achieve treatment goals. Most patients will be responsible for self-management after a hospital stay, making it critically important for nurses to provide education on diabetes self-management concepts, including foot care during the patient's hospitalization. The Joint Commission and American Diabetes Association recommend that inpatient programs specifically include patient education because this provides the foundation for self-care. Patients who do not receive education are more likely to develop a major complication and incur higher diabetes-related hospital costs, while those who do can improve HbA1C levels, reducing risk for DM-related foot problems. Foot care education is strongly associated with various improved outcomes, including reduced foot complications and amputation rates. Although hospitalization offers an opportunity to educate diabetic patients, teaching during a hospital stay can be challenging given that inpatients are ill and have competing demands, such as scheduled diagnostic and therapeutic procedures. Nevertheless, a hospital admission for a diabetes-related foot problem provides a unique "teachable moment" because patients may be motivated to prevent further problems.
Even though staff nurses have competing demands and limited time for education, it is essential that they address key diabetes content areas, i.e., nutrition, activity, medication taking and monitoring, and risk reduction. During the assessment, nurses gather information about a patient's experiences, knowledge, technical skills, beliefs, and support systems. Nurses can identify educational gaps (e.g., nutrition understanding) and use hospital team resources for educational support (e.g., the dietitian). By careful observation and teaching, nurses can also play a pivotal role in reducing the risks of in hospital complications such as decubitus heel ulcers.
The primary focus of the education should be to address what the patient perceives to be the most critical area needing attention and to help the patient to prioritize self-care plans. In the case of a patient hospitalized for foot problems, the information and skills necessary to assure proper attention to foot care have high priority. The nurse should strategically seek opportunities to educate patients throughout the hospital stay. Skills can be evaluated and reinforced with routine procedures, including blood glucose testing and injections. Nursing tasks offer an opportunity for demonstration of skills by the patient and/or caregiver. Return demonstration during wound care procedures and dressing changes, provide teachable moments for the patient and caregiver.
It is unrealistic to expect that comprehensive diabetes education beyond the delivery of basic skills can be provided during a stressful hospital admission. Therefore, the nurse needs to assist in the coordination of a discharge transition plan that includes appropriate follow-up with an outpatient education program visit, preferably at an outpatient site staffed by members familiar with the inpatient diabetic foot team.
We recognize that assembling an interdisciplinary team of specialists may be difficult in certain hospital environments (Table 4). The leader of the team can be from any specialty, with the major asset being a passion for this type of work. Strategies for success include incorporating both the administrative and professional components of the hospital (Table 5). Hospital administrators will become enthusiastic supporters if the team can demonstrate a reduction in hospital length of stay. Even a modest one-day shorter hospital stay can translate into a reduction in hospital costs. Professional staff members will support this concept if improved outcomes can be demonstrated such as a reduction in major amputations. Major amputations may be associated with increased mortality, decreased function, and increased cardiac demands. One of the most effective ways to promote the inpatient management of the diabetic foot disorders is through medical education. Hospitals with large departments may provide an opportunity to speak at subspecialty conferences such as infectious disease, endocrinology, plastic surgery, vascular surgery, orthopedic surgery, and podiatry. Both clinicians and administrators need to understand the epidemiology and profoundly negative impact that diabetic foot disorders have on patient outcomes. The mortality of patients presenting with an acute CN event or DFU is surprisingly high. In fact, the 5-year mortality of patients with newly diagnosed DFUs is nearly 50% and carries a worse prognosis than breast cancer, prostate cancer, or Hodgkins lymphoma. A paradigm shift in our thinking is necessary to improve outcomes of patients with diabetic foot disorders, and we should strive to emulate the contributions made in centers that specialize in trauma, burns, stroke, and cardiology. Time equates to tissue loss, and prompt intervention in patients with diabetic foot disorders may preserve limbs and restore function.
In conclusion, hospital admission in patients with diabetes is unfortunately commonplace. Foot complications in this already impaired population constitute a major danger to the overall well-being of the patient and to the fiscal capacity of a health system. Consideration for development of effective, systematic, interdisciplinary teams that focus on skills for inpatient management should be a priority in these complex patients. The goals of this interdisciplinary team should be to provide comprehensive evaluation, thorough risk assessment, definitive treatment, and coordination of discharge planning in patients with diabetes who are hospitalized for foot problems. Prevention of foot problems in patients with diabetes who are hospitalized for unrelated causes should also be a priority.
Diabetes Education and Discharge Planning
The inpatient team should aim to seamlessly perform appropriate postoperative monitoring to reduce risk of reulceration and infection after hospital discharge to home, a rehabilitation unit, or a skilled nursing facility. This begins with having nursing professionals integrally involved on the diabetic foot team. Ideally, elements of the same team that manages the inpatient care should oversee transition to outpatient care for preventative measures as the foot moves into "remission". In addition, to nurses familiar with diabetes education, the inpatient team should include a dietitian who can provide nutritional assessments and further education on the importance of ideal body weight and diabetes management. Continued optimal glycemic control will improve the probability of successful wound healing. As with the foot care service, care coordination for glycemic control is also necessary.
Optimal outcomes in patients with diabetes require patients to be knowledgeable about their disease and its complications and able to provide appropriate self-care to achieve treatment goals. Most patients will be responsible for self-management after a hospital stay, making it critically important for nurses to provide education on diabetes self-management concepts, including foot care during the patient's hospitalization. The Joint Commission and American Diabetes Association recommend that inpatient programs specifically include patient education because this provides the foundation for self-care. Patients who do not receive education are more likely to develop a major complication and incur higher diabetes-related hospital costs, while those who do can improve HbA1C levels, reducing risk for DM-related foot problems. Foot care education is strongly associated with various improved outcomes, including reduced foot complications and amputation rates. Although hospitalization offers an opportunity to educate diabetic patients, teaching during a hospital stay can be challenging given that inpatients are ill and have competing demands, such as scheduled diagnostic and therapeutic procedures. Nevertheless, a hospital admission for a diabetes-related foot problem provides a unique "teachable moment" because patients may be motivated to prevent further problems.
Even though staff nurses have competing demands and limited time for education, it is essential that they address key diabetes content areas, i.e., nutrition, activity, medication taking and monitoring, and risk reduction. During the assessment, nurses gather information about a patient's experiences, knowledge, technical skills, beliefs, and support systems. Nurses can identify educational gaps (e.g., nutrition understanding) and use hospital team resources for educational support (e.g., the dietitian). By careful observation and teaching, nurses can also play a pivotal role in reducing the risks of in hospital complications such as decubitus heel ulcers.
The primary focus of the education should be to address what the patient perceives to be the most critical area needing attention and to help the patient to prioritize self-care plans. In the case of a patient hospitalized for foot problems, the information and skills necessary to assure proper attention to foot care have high priority. The nurse should strategically seek opportunities to educate patients throughout the hospital stay. Skills can be evaluated and reinforced with routine procedures, including blood glucose testing and injections. Nursing tasks offer an opportunity for demonstration of skills by the patient and/or caregiver. Return demonstration during wound care procedures and dressing changes, provide teachable moments for the patient and caregiver.
It is unrealistic to expect that comprehensive diabetes education beyond the delivery of basic skills can be provided during a stressful hospital admission. Therefore, the nurse needs to assist in the coordination of a discharge transition plan that includes appropriate follow-up with an outpatient education program visit, preferably at an outpatient site staffed by members familiar with the inpatient diabetic foot team.
We recognize that assembling an interdisciplinary team of specialists may be difficult in certain hospital environments (Table 4). The leader of the team can be from any specialty, with the major asset being a passion for this type of work. Strategies for success include incorporating both the administrative and professional components of the hospital (Table 5). Hospital administrators will become enthusiastic supporters if the team can demonstrate a reduction in hospital length of stay. Even a modest one-day shorter hospital stay can translate into a reduction in hospital costs. Professional staff members will support this concept if improved outcomes can be demonstrated such as a reduction in major amputations. Major amputations may be associated with increased mortality, decreased function, and increased cardiac demands. One of the most effective ways to promote the inpatient management of the diabetic foot disorders is through medical education. Hospitals with large departments may provide an opportunity to speak at subspecialty conferences such as infectious disease, endocrinology, plastic surgery, vascular surgery, orthopedic surgery, and podiatry. Both clinicians and administrators need to understand the epidemiology and profoundly negative impact that diabetic foot disorders have on patient outcomes. The mortality of patients presenting with an acute CN event or DFU is surprisingly high. In fact, the 5-year mortality of patients with newly diagnosed DFUs is nearly 50% and carries a worse prognosis than breast cancer, prostate cancer, or Hodgkins lymphoma. A paradigm shift in our thinking is necessary to improve outcomes of patients with diabetic foot disorders, and we should strive to emulate the contributions made in centers that specialize in trauma, burns, stroke, and cardiology. Time equates to tissue loss, and prompt intervention in patients with diabetic foot disorders may preserve limbs and restore function.
In conclusion, hospital admission in patients with diabetes is unfortunately commonplace. Foot complications in this already impaired population constitute a major danger to the overall well-being of the patient and to the fiscal capacity of a health system. Consideration for development of effective, systematic, interdisciplinary teams that focus on skills for inpatient management should be a priority in these complex patients. The goals of this interdisciplinary team should be to provide comprehensive evaluation, thorough risk assessment, definitive treatment, and coordination of discharge planning in patients with diabetes who are hospitalized for foot problems. Prevention of foot problems in patients with diabetes who are hospitalized for unrelated causes should also be a priority.
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