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Toe and Flow
Essential Components and Structure of the Amputation Prevention Team
At the end of an anatomical peninsula, the foot in diabetes is prone to short- and long-term complications involving neuropathy, vasculopathy, and infection. Effective management requires an interdisciplinary effort focusing on this triad. Herein, we describe the key factors leading to foot complications and the critical skill sets required to assemble a team to care for them. Although specific attention is given to a conjoined model involving podiatric medicine and vascular surgery, the so-called toe and flow model, we further outline three separate programmatic models of care—basic, intermediate, and center of excellence—that can be implemented in the developed and developing world. (J Am Podiatr Med Assoc 100(5): 342–348, 2010)
Background
Diabetes-related lower limb amputations (LLAs) are a major complication that can be reduced by employing multidisciplinary center frameworks such as the Toe and Flow model (TFM). In this study, we investigate the LLAs reduction efficacy of the TFM compared to the standard of care (SOC) in the Canadian health-care system.
Methods
We retrospectively reviewed the anonymized diabetes-related LLA reports (2007-2017) in Calgary and Edmonton metropolitan health zones in Alberta, Canada. Both zones have the same provincial health-care coverage and similar demographics; however, Calgary operates based on the TFM while Edmonton with the provincial SOC. LLAs were divided into minor and major amputation cohorts and evaluated using the chi-square test, linear regression. A lower major LLAs rate was denoted as a sign for higher efficacy of the system.
Results
Although LLAs numbers remained relatively comparable (Calgary: 2238 and Edmonton: 2410), the Calgary zone had both significantly lower major (45%) and higher minor (42%) amputation incidence rates compared to the Edmonton zone. The increasing trend in minor LLAs and decreasing major LLAs in the Calgary zone were negatively and significantly correlated (r = -0.730, p = 0.011), with no significant correlation in the Edmonton zone.
Conclusions
Calgary's decreasing diabetes-related major LLAs and negative correlation in the minor-major LLAs rates compared to its sister zone Edmonton, provides support for the positive impact of the TFM. This investigation includes support for a modernization of the diabetes-related limb preservation practice in Canada by implementing TFMs across the country to combat major LLAs.
Toward a Change in Syntax in Diabetic Foot Care
Prevention Equals Remission
Because neuroischemic complications are associated with a high rate of recurrence, we propose a slight shift in the mechanism by which we counsel and communicate risk daily with our patients. If the epidemiology of this problem is comparable with that of cancer, and recurrences are common, then perhaps language commensurate with such risks should follow. After initial healing of an index wound, our unit now refers to patients not as being cured but rather as being “in remission.” This concept is easy for the patient and the rest of the team to understand. We believe that it powerfully connotes the necessity for frequent follow-up and rapid intervention for inevitable minor and sometimes major complications. (J Am Podiatr Med Assoc 103(2): 161–162, 2013)
Diabetic foot infections are a common and often serious problem, accounting for more hospital bed days than any other complication of diabetes. Despite advances in antibiotic drug therapy and surgical management, these infections continue to be a major risk factor for amputations of the lower extremity. Although a variety of wound size and depth classification systems have been adapted for use in codifying diabetic foot ulcerations, none are specific to infection. In 2003, the International Working Group on the Diabetic Foot developed guidelines for managing diabetic foot infections, including the first severity scale specific to these infections. The following year, the Infectious Diseases Society of America published their diabetic foot infection guidelines. Herein, we review some of the critical points from the Executive Summary of the Infectious Diseases Society of America document and provide a commentary following each issue to update the reader on any pertinent changes that have occurred since publication of the original document in 2004.
The importance of a multidisciplinary limb salvage team, apropos of this special issue jointly published by the American Podiatric Medical Association and the Society for Vascular Surgery, cannot be overstated. (J Am Podiatr Med Assoc 100(5): 395–400, 2010)
Both vascular surgeons and podiatric physicians care for patients with diabetic foot ulcerations (DFUs), one of today's most challenging health-care populations in the United States. The prevalence of DFUs has steadily increased, along with the rising costs associated with care. Because of the numerous comorbidities affecting these patients, it is necessary to take a multidisciplinary approach in the management of these patients. Such efforts, primarily led by podiatric physicians and vascular surgeons, have been shown to effectively decrease major limb loss. Establishing an interprofessional partnership between vascular surgery and podiatric medicine can lead to an improvement in the delivery of care and outcomes of this vulnerable patient population.
Emergency department visits for lower extremity complications of diabetes are extremely common throughout the world. Surprisingly, recent data suggest that such visits generate an 81.2% hospital admission rate with an annual bill of at least $1.2 billion in the United States alone. The likelihood of amputation and other subsequent adverse outcomes is strongly associated with three factors: 1) wound severity (degree of tissue loss), 2) ischemia, and 3) foot infection. Using these factors, this article outlines the basic principles needed to create an evidence-based, rapid foot assessment for diabetic foot ulcers presenting to the emergency department, and suggests the establishment of a “hot foot line” for an organized, expeditious response from limb salvage team members. We present a nearly immediate assessment and referral system for patients with atraumatic tissue loss below the knee that has the potential to vastly expedite lower extremity triage in the emergency room setting through greater collaboration and organization.
History of the Team Approach to Amputation Prevention
Pioneers and Milestones
This historical perspective highlights some of the pioneers, milestones, teams, and system changes that have had a major impact on management of the diabetic foot during the past 100 years. In 1934, American diabetologist Elliott P. Joslin noted that mortality from diabetic coma had fallen from 60% to 5% after the introduction of insulin, yet deaths from diabetic gangrene of the lower extremity had risen significantly. He believed that diabetic gangrene was preventable. His remedy was a team approach that included foot care, diet, exercise, prompt treatment of foot infections, and specialized surgical care.
The history of the team approach to management of the diabetic foot chronicles the rise of a new health profession—podiatric medicine and surgery—and emergence of the specialty of vascular surgery. The partnership among the diabetologist, vascular surgeon, and podiatric surgeon is a natural one. The complementary skills and knowledge of each can improve limb salvage and functional outcomes. Comprehensive multidisciplinary foot-care programs have been shown to increase quality of care and reduce amputation rates by 36% to 86%. Development of distal revascularization techniques to restore pulsatile blood flow to the foot has also been a major advancement.
Patients with diabetic foot complications are among the most complex and vulnerable of all patient populations. Specialized diabetic foot clinics of the 21st century should be multidisciplinary and equipped to coordinate diagnosis, off-loading, and preventive care; to perform revascularization procedures; to aggressively treat infections; and to manage medical comorbidities. (J Am Podiatr Med Assoc 100(5): 317–334, 2010)
