Dieter Mayer:
The team leader should be a motivator
In an interdisciplinary approach the best consensus can be reached through communicating our passion for feet. At ilegx, a key message was that management of chronic wounds needs an interdisciplinary approach.
In 2006, after two years of working towards our goal, we started to implement a hospital-wide interdisciplinary wound healing concept at the University Hospital of Zurich. It was a difficult task but finally we got there and every day we are improving.
To run an interdisciplinary wound clinic you must first establish a common language based on a mission statement. Ideally, we would all like to provide round-the-clock care for patients - patient care does not stop at the end of the working day or before the start of the weekends. Furthermore, before we can establish good treatment we need to establish a correct diagnosis. We all have different silos and areas of responsibility but we have to be transparent to other disciplines so that the patient can be driven into the right silo. General practitioners, podiatrists, community nurses all need to be involved to contribute to the diagnosis.
There are many people involved when you work in an interdisciplinary way.
This means that good communication is essential. For this we decided that a team leader is needed. The role of the team leader, or the head of wound care, is one of coordination: of the wound centre itself, of the team, of medication, of standards, and of activities. The head of wound care must communicate with the patients, with external partners, and with the media. He or she should deal with politics within and without the hospital, and above all should be a motivator, not only for the patient but also for the other team members.
In our clinic we are all equal partners. We all go in and talk to the patient; far from confusing the patient as we feared, we have received feedback that the patients are happy even when we discuss things controversially, because they can see how we find the best consensus for them. We are not only working in an interdisciplinary fashion but also in an interprofessional fashion and it is often the nurses that help us a lot with our communication. It is the responsibility of the head of wound care, as a motivator, to be passionate about wounds and to impart this passion into the other team members, including the nurses who have the most contact with the patient. If every member of the team shares the same vision the best outcome for the patient can be reached.
There are many challenges to overcome in establishing an interdisciplinary and interprofessional wound care clinic, from overcoming remuneration issues and healthcare system hurdles.
There is a lot to do, and to implement it you must be insistent and very patient and above all you must share your visions without fear.
Gunnar Tepe:
A shared vision is needed to save legs
A single healthcare professional can rarely develop a successful service single-handed. Ensuring the collaboration of colleagues and patients is vital to create a shared vision that should underpin a new or expanded leg/foot tissue service.
Eighteen months ago, the ilegx team decided that we needed to do something to tackle the issue of the unacceptably high number of amputations in Europe, and throughout the world.
Our first ilegx meeting took place in 2008 and was attended by approximately 250 attendees. This year again, around 250 delegates attended the ilegx 2009 meeting. Most were from Germany and UK but we also welcomed several colleagues from South Africa, Australia, and USA, among others.
Representatives from all the specialties involved in foot and leg tissue loss treatment attended, including vascular surgeons, diabetologists, dermatologists, wound care specialists, podiatrists, interventional radiologists, and angiologists. There was not one discipline which showed significantly more participation than the others, reflecting the message of ilegx, that one specialty alone cannot solve the problem: All specialties need to work together and learn from each other to save legs.
Without adequate diagnosis and treatment leg/foot tissue loss can have a major impact on patients' lives, causing disability, inability to work, emotional problems, and in the worst cases, amputation. Many patients are not properly diagnosed due to the large number of underlying causes and the increasing number of mixed aetiologies. Wounds often fail to heal swiftly and, in some cases, healing can take years. In Munich we focussed on day one on diagnosis and management of leg/foot tissue loss. From the inauguration of ilegx it has been our ambition to change daily practice and to implement the current best approach into clinical reality. To identify barriers to successful implementation we included in 2009, for the first time, a review of European centres of excellence to learn from the experts. Included in the programme on the second day was an analysis of systematic barriers, particularly reimbursement issues in the German healthcare system, to enable ilegx to remove these barriers in the coming years.
In a roundtable discussion on day one we discussed the ilegx wheel algorithm with the delegates. The ilegx wheel is a powerful visual tool which simplifies the complexity of leg/foot tissue loss based on the current best approaches developed by professional societies, consensus groups and experts in leg/foot tissue loss. When diagnosing leg/foot tissue loss, nine distinct entities need to be considered. Specifically, there are three arterial causes: ischaemic, renal and diabetic. These are followed by inflammatory, venous and lymphatic causes, and the non-vascular causes: diabetic (neuropathy), pressure and other, like malignant, causes.
By considering the patient's history, carrying out physical examination and using special investigation techniques, the medical professional arrives at an all-encompassing differential diagnosis. Based on this thorough diagnosis, the ilegx algorithm suggests appropriate treatment. Specific healthcare professionals are then suggested as appropriate members of the interdisciplinary team treating the patient in question.
The ilegx wheel was developed during the inaugural ilegx event and is currently being evaluated in all Lindsay Leg Clubs in the UK. Feedback from the audience was positive overall and the simplicity of the algorithm was praised. We learned that we could further improve the ilegx wheel by giving suggestions with regard to infection control and rehabilitation management.
Beyond the algorithm's unique simplicity the delegates commented on the patient as the centre of the wheel. The patient needs to be in the centre of all clinical decisions to achieve compliance and successful outcomes.
The ilegx algorithm can be ordered by contacting info@ilegx.com.
Michael Edmonds:
Early diagnosis and intervention is key to saving the diabetic leg
The critical factor in saving limbs is making the right diagnosis promptly and administering the appropriate treatment early. In this way, rapid healing can be achieved in the diabetic foot/leg, thus preventing patients from needing amputations, according to Michael E Edmonds, consultant in diabetes, King's College Hospital, London, and one of the three ilegx programme directors.
The two risk factors for foot/leg ulceration are neuropathy and vascular disease. The great quartet of factors that predispose the patient to neuropathy and peripheral vascular disease are hyperglycaemia, hypertension, hyperlipidaemia, and smoking. Thus, the first step should be good control of blood glucose, blood pressure and blood lipids, as well as refraining from smoking to preserve critical neurological and vascular function.
"If we could only keep neuropathy and peripheral vascular disease at bay, then we would prevent patients with diabetes from getting ulcers. But since there is just a partial understanding of neuropathy and ischaemia of the lower limb, we cannot do this very well at present," Edmonds said.
Thus, ulcer prevention has to be the second goal. Patients who develop neuropathy or peripheral vascular disease and thus become at risk of ulceration should be detected early and entered into a foot protection programme. This should consist of foot care education to encourage them to look after their feet well, advice on appropriate footwear, and preventative podiatry to remove calluses and care for the nails.
Once the diabetic patient has an ulcer, quick healing is of utmost importance to prevent infection and gangrene. These patients need emergency referrals to interdisciplinary teams with clear treatment pathways. Infection is responsible for considerable tissue necrosis in the diabetic foot and is the main reason for major amputation.
It is important to understand that there are two distinct clinical syndromes in which diabetic foot ulceration presents. These are: the neuropathic diabetic foot, and the neuro-ischaemic diabetic foot.
Ulceration in the neuropathic foot most often occurs on the plantar aspect of the foot and requires debridement and specially designed in-soles or footwear.
Neuro-ischaemic foot ulcers mainly occur on the margins of the foot and the apices of the toes, that is, on sites that are vulnerable to trauma and pressure from poorly fitting shoes. They also require debridement and wide-fitting footwear but, most importantly, an immediate vascular assessment to evaluate the necessity of revascularisation.
It is important to note that the neuro-ischaemic foot is not just an ischaemic foot in a diabetic patient who happens to have neuropathy. Edmonds says, "The diabetic neuro-ischaemic foot is a clinical syndrome distinct from the ischaemic foot in the non-diabetic patient, with neuropathy contributing a crucial role. Claudication and rest pain are often absent because of the neuropathy and the patient will often initially present with ulceration. If this is not healed promptly, infection will supervene and spread rapidly due to the reduced blood supply, so vascular input is paramount."
Ischaemia and infection is "double trouble" in the diabetic foot (see Benjamin Lipsky's article on page 6 for more on the relationship between ischaemia and infection). Infection in the neuro-ischaemic foot needs to be diagnosed early but, because of the neuropathy, local and systemic signs of infection may be diminished or absent. Edmonds urges professionals to be aware that, "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." This is not widely appreciated and leads to delays in diagnosis.
Furthermore infection, once diagnosed, needs aggressive treatment with appropriate antibiotics, surgical debridement if necessary, and revascularisation. Edmonds concludes, "Interdisciplinary co-operation has been demonstrated as the most successful approach to the management of foot lesions in patients with diabetes. I believe that when an interdisciplinary approach is incorporated into daily practice to facilitate early diagnosis and intervention, it can significantly reduce the incidence and morbidity of foot disease in diabetes."
