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More Specialties, Fewer Problems: Using Collaborative Competency Between Infectious Diseases, Podiatry, and Pathology to Improve the Care of Patients with Diabetic Foot Osteomyelitis

Vimal V. JhaveriDivision of Infectious Diseases, Department of Medicine, Boston, MA.
Harvard Medical School, Boston, MA.

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Christopher SullivanDivision of Podiatry, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA.

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Ashley WardDepartment of Pathology, Beth Israel Deaconess Medical Center, Boston, MA.
Harvard Medical School, Boston, MA.

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John M. GiuriniDivision of Podiatry, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA.

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Adolf W. KarchmerDivision of Infectious Diseases, Department of Medicine, Boston, MA.
Harvard Medical School, Boston, MA.

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Isaac E. StillmanDepartment of Pathology, Beth Israel Deaconess Medical Center, Boston, MA.
Harvard Medical School, Boston, MA.

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Roger B. DavisDivision of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA.
Harvard Medical School, Boston, MA.

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Jason A. FreedDivision of Hematology and Hematologic Malignancies, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA.
Harvard Medical School, Boston, MA.

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Mary T. LaSalviaDivision of Infectious Diseases, Department of Medicine, Boston, MA.
Harvard Medical School, Boston, MA.
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Wendy SteadDivision of Infectious Diseases, Department of Medicine, Boston, MA.
Harvard Medical School, Boston, MA.
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Background: Diabetic foot osteomyelitis is a common infection where treatment involves multiple services, including infectious diseases, podiatry, and pathology. Despite its ubiquity in the hospital, consensus on much of its management is lacking.

Methods: Representatives from infectious diseases, podiatry, and pathology interested in quality improvement developed multidisciplinary institutional recommendations culminating in an educational intervention describing optimal diagnostic and therapeutic approaches to diabetic foot osteomyelitis (DFO). Knowledge acquisition was assessed by preintervention and postintervention surveys. Inpatients with forefoot DFO were retrospectively reviewed before and after intervention to assess frequency of recommended diagnostic and therapeutic maneuvers, including appropriate definition of surgical bone margins, definitive histopathology reports, and unnecessary intravenous antibiotics or prolonged antibiotic courses.

Results: A postintervention survey revealed significant improvements in knowledge of antibiotic treatment duration and the role of oral antibiotics in managing DFO. There were 104 consecutive patients in the preintervention cohort (April 1, 2018, to April 1, 2019) and 32 patients in the postintervention cohort (November 5, 2019, to March 1, 2020), the latter truncated by changes in hospital practice during the coronavirus disease 2019 pandemic. Noncategorizable or equivocal disease reports decreased from before intervention to after intervention (27.0% versus 3.3%, respectively; P = .006). We observed nonsignificant improvement in correct bone margin definition (74.0% versus 87.5%; P = .11), unnecessary peripherally inserted central catheter line placement (18.3% versus 9.4%; P = .23), and unnecessary prolonged antibiotics (21.9% versus 5.0%; P = .10). In addition, by working as an interdisciplinary group, many solvable misunderstandings were identified, and processes were adjusted to improve the quality of care provided to these patients.

Conclusions: This quality improvement initiative regarding management of DFO led to improved provider knowledge and collaborative competency between these three departments, improvements in definitive pathology reports, and nonsignificant improvement in several other clinical endpoints. Creating collaborative competency may be an effective local strategy to improve knowledge of diabetic foot infection and may generalize to other common multidisciplinary conditions.

Corresponding author: Vimal Jhaveri, MD, Beth Israel Deaconess Medical Center, 110 Francis St, Ste GB, Boston, MA 02215. (E-mail: vjhaveri@idcdenver.com)