Evaluating the Initial Management and Referral Process for Patients with Diabetic Foot Ulcers

Abstract

Approximately 10% of the U.S. population is living with diabetes. Diabetic foot ulcers (DFU) are one of the most prevalent and debilitating complications. One in four people with diabetes will develop a DFU at some point in their lifetime. The consequences of non-healing DFUs include risk of amputation, further disease complications, increased risk of mortality, and more frequent and extended hospital stays. Adhering to evidence-based guidelines, which include recommendations for DFU prevention, assessment, and management, is crucial for achieving complete healing and reducing risks for poor outcomes. However, research has consistently shown a significant gap in the use of these guidelines in primary care, where DFU prevention should occur and DFU assessment and management most often begins. Objective: The purpose of this quality improvement project was to evaluate the initial management and current referral process for DFU patients and make recommendations for improvements based on current evidence-based practice guidelines for DFU management. Methods: A retrospective chart review was performed at the University of Kansas Hospital’s Outpatient Burn and Wound Care Center to evaluate for adherence to evidence-based practice guidelines for initial management and referral for DFU care by referring providers. Factors associated with lack of adherence to guidelines were identified via the collection of variables from 70 randomly selected patient charts, including specific data points related to DFU prevention, assessment, and management. Descriptive statistics were utilized to analyze the data collected using means for continuous variables and frequencies and percentages for categorical variables. Results: Retrospective data indicates that evidence-based guidelines were poorly implemented for DFU assessment and management in the primary care setting. In a sample of 70 patients, neuropathy assessments were done 21.4% of the time, ischemia assessments 45.7%, and infection assessments 87.1% in the primary care setting. In contrast, all three of these assessments were performed 100% of the time at the specialty wound clinic. Making a referral was the most common management strategy utilized by primary care providers for treating a DFU and was applied 75.7% of the time, although only 23% of these referrals were made to a wound care clinic. Debridement and offloading were infrequently seen in primary care with the former being utilized in 10% of cases and the latter 18.6%. Most often, referrals to wound care were made by a specialist, which was the case 49% of the time. Sixty-one percent of patients required more than one referral before being evaluated by a wound care specialist. Average total duration of a DFU from onset to resolution was 104 days (range 13-248). Conclusion: The results of this study indicate that the initial management and referral process of DFU’s is currently inadequate and not in line with current evidence-based practice guidelines for DFU management. Further research is needed to explore the reasons for provider noncompliance in order to determine appropriate interventions to facilitate improvements in adherence to guidelines.