Complacency is not warranted:
Teamwork is needed
comment & analysis by Roger Greenhalgh
"The number of lower leg amputations is still too high" is a rarely disputed statement among medical professionals who treat leg/foot tissue loss. The debate over how many legs are lost in each country is a difficult one, as different countries rely on different approaches to record the number of lower limb amputations.
I have noticed over the last year that all involved medical disciplines are aware of the deficiencies in the care that patients with leg/foot tissue loss receive in Europe. Although statistics are reliable regarding the total number of amputations, they do not give information about the quality of medical treatment. Furthermore, information about the quality of medical treatment and about the underlying diseases is sparse.
The good news is that with well-organised, interdisciplinary care and education for patients to enable them to control their diabetes and encourage good self-management, more than 70% of amputations are preventable. However, there is no one single approach to improving patient outcomes as there are many aspects to consider - such as early referral, early intervention, infection control and removing healthcare system hurdles - when solving the puzzle of preventing amputations.
Early referral
Patients should be referred to an interdisciplinary team of specialists as soon as possible. The aetiologies of leg tissue loss are more complex and hence challenging than previously recognised, which may be a consequence of both increasing ulcer chronicity and age.
An interdisciplinary team of specialists needs to work together to establish an all-encompassing diagnosis, breaking down traditional silos of responsibility and attacking the challenge from a patient-centred view where all involved share responsibility for all aspects of patient care (see case study).
Early intervention and infection control
Early intervention can help save limbs both in securing flow and also in avoiding chronicity of wounds. When problems with wounds are identified early, appropriate interventions should avoid complications and facilitate healing.
Infection control is of course crucial to preventing amputation. However, it is not always identified early. As Michael Edmonds highlights in the article on page 2, "All healthcare professionals looking after diabetic patients should understand that the white blood count and body temperature may be normal even in severe infections. A normal white blood count or temperature does not rule out infection in diabetes."
Removing healthcare system hurdles is another part of the puzzle. A partnership between efficient professional networks and competent insurers has been able to eradicate the majority of the structural problems when treating the diabetic foot, as shown in the diabetic foot network Cologne (see case study).
Preventing amputations requires professionals to change the way they treat patients with leg/foot tissue loss and healthcare systems need to be changed to incentivise medical professionals to roll out the current best approach in their daily practice. Some centres of excellence are showing that it is possible to almost eradicate the number of leg amputations, but the word needs to be spread, professionals need to be educated to understand both the complexity of treating leg/foot tissue loss and ways to prevent amputation.
At this time of ageing populations and given the significant impact of leg/foot tissue loss on the lives of patients, the emphasis must now be on innovating to reach the objectives of the St Vincent Declaration agreed in October 1989, which set out general goals for people with diabetes. This should not be limited to diabetic patients, all patients with leg/foot tissue loss should benefit from optimal care.
One discipline alone cannot make a difference, only together can we eradicate the disease and improve patient outcomes.
The ilegx symposium, which will be held in Munich, Germany, on 13-14 October 2009, will focus on these issues. A diverse attendance from all specialties involved in foot and leg care will facilitate the sharing of knowledge and experience to keep an interdisciplinary approach at the heart of caring for patients with foot/leg tissue loss.
Early referral is needed to bridge community and hospital care
What have we learned from the second annual ilegx meeting in Germany? The ilegx initiative by definition includes all disciplines related to leg/foot tissue loss. Besides making the correct diagnosis, early referral is essential to ensure patients receive the best treatment. With the call for an interdisciplinary approach, establishing clear referral pathways came out as one of the most important messages from the meeting in Munich, on 13-14 October 2009.
Working together across medical disciplines is not as easy as communicating within a single medical discipline. The ilegx initiative recognises this and we note that a large number of members of the Deutsche Gesellschaft für Gefächirurgie (the German Vascular Society) attended their own diabetic foot syndrome and chronic wound sessions, while only a few crossed the road to meet with experts of other disciplines. This underscores the difficulty of the ilegx interdisciplinary collaboration.
It also highlights the achievements of the International Working Group on the Diabetic Foot, chaired by Karel Bakker, diabetic foot expert from The Netherlands. He stresses the importance of interdisciplinary diabetic foot care clinics, good diabetes control, education and well-informed self-care.
During his talk at ilegx 2009 he identified several barriers to best practice:
- Lack of foot education and foot services
- Lack of teamwork across medical staff
- Poor patient follow-up
- Delayed referral
Bakker insists that these barriers need to be lifted on a country-by-country basis, to allow the international consensus to be implemented successfully.
Kristien van Acker, diabetic foot expert, Willebroek, Belgium, spoke of implementation in that country and stressed the need for ongoing quality control and argued that centres of excellence have an obligation to educate smaller acute centres and the community.
Thus an advance in the ilegx initiative understanding is that where we accept difficulty in interdisciplinary working and lack of foot education we highlight an action step achievable by all: Earlier referral of foot ulceration into specialist care.
Prevalence of Leg Amputations is Still High!
The number of lower limb amputations from vascular causes is still increasing. The rise is due to increases in atherosclerosis and diabetes. In contrast, limb amputations caused by non-vascular causes remain level.
Despite the fact that the last 20 years have seen major developments in healing of foot/leg tissue loss driven by innovations in assessment and treatment, the development of modern wound care dressing materials and technological advances in high-compression bandaging where indicated, numbers of lower limb amputations are still high.
The relentless increase in lower limb amputations is likely to be due to changes in demography and increased risks of concurrent chronic illnesses like diabetes. Increasing numbers of the elderly in the population will lead to a corresponding increase in numbers of patients with leg/foot tissue loss, as the highest prevalence occurs in the most elderly. Already the number of leg amputations among 65+ years old patients has nearly doubled since 1997.
The WHO has recognised that there is a global 'epidemic of obesity' and the prevalence of type 2 diabetes is rising in parallel. US studies report a prevalence of 4% in 2000 which is projected to increase to more than 7% in 2050. Studies from the UK suggest a prevalence of diagnosed diabetes of about 7% for adult men and 5% for adult woman by the year 2010. This would equate to approximately 3 million. people with diagnosed diabetes.
Amputation is one of the most feared complications. The impact on the patient's life is immense and survival is bleak, with a 2-year mortality up to 50%. There is an urgent need to reduce amputation rates, which vary considerably globally and nationally.
The Challenge!
Clinicians and primary care services feel a need to unravel the aetiologies of leg/foot tissue loss in order to diagnose, prevent and manage leg/foot tissue loss more effectively. The aetiologies of leg/foot tissue loss are more complex and hence challenging than previously recognised, which may be a consequence of both increasing ulcer chronicity and age.
Patients can have leg/foot tissue loss with a single aetiology or with multiple causes. There are more than 40 reported causes of leg/foot tissue loss. Hence, day to day diagnosis is complex and challenging.
Only an interdisciplinary management approach which also spans the acute and community boundaries will step change prevalence.
A 11-year survey in diabetic amputation rates conducted between 1995 and 2005 at Ipswich Hospital showed a significant decrease in lower leg amputation rates following the introduction of an interdisciplinary foot team.
Over the survey period, the incidence of all amputations fell by 40%, among people with diabetes by 70%.
Disease Awareness among patients with concurrent chronic diseases is still low. There is very limited awareness regarding first indications of 'ileg/foot tissue loss' and severity and potential acute nature of 'leg/foot tissue loss among patients.
