Collaborative Care Vital for Patients with Feet at Risk
By Terrence P. Sheehan, MD
Chief Medical Officer, Adventist Rehabilitation Hospital of Maryland;
Medical Director, Amputee Coaltion;
Scientific Advisory Board Member, Institute for Preventive Foot Health
“I had no idea this could happen to me. No one ever told me I could lose a foot because of diabetes. It happened so quickly. My life has turned upside down.” It’s a story I hear over and over again in my practice. I work with patients who have already had an amputation and are at risk for further limb loss. Our team members do everything they can to keep these patients from losing the contralateral limb, something that happens to more than half of those who have a limb amputated because of diabetes and vascular disease. But what pains me most is that many of these patients might have avoided the first amputation had they received collaborative care in a timely way. According to the Amputee Coalition, upwards of 400-500 amputations occur daily in the United States—and the majority of those are in people with diabetes who didn’t know they were at risk.
“My foot didn’t really hurt; it just got red and smelly”
Most individuals who experience limb loss at one point had feet at risk. Within that risk period, their care most likely was fragmented—a primary care doctor may have diagnosed diabetes but not mentioned risk to the feet. A nurse educator might have mentioned risk to the feet, but no one actually looked at the feet in follow-up visits because the patient didn’t report symptoms. If someone did look, he or she might not have realized that once a callus forms, for example, alarms should be going off because that person’s foot needs to be protected immediately.
As a patient goes down the “at-risk” road, not getting their feet checked, not getting foot care or doing daily foot inspections, the callus—which is dead tissue—persists. Bacteria grows under the dead tissue, which leads to infection. Once an infection starts, untreated, it spreads quickly, often right to the bone. The person ends up in the emergency room often because sensation has been impaired by diabetes so the body’s sensory alarm did not switch on in the presence of severe injury. Asked why he or she waited to be treated, the patient says, “Oh, my foot didn’t really hurt, it just got red and smelly and stuff like that.” But by that time, it’s too late. We doctors know this; the literature is clear. The answer: we need to come together and collaborate to prevent the needless loss of a limb.
As my colleagues and I wrote in the June 2015 issue of the AMA Journal of Ethics, losing a leg or foot puts a person at risk for multiple health issues, including osteoarthritis, back pain, joint pain, osteoporosis/osteopenia. Amputation also negatively impacts body image, self-esteem and quality of life. The key to improving outcomes for those who have lost limbs is to ensure that they receive appropriate and comprehensive collaborative care that addresses both their physical and psychosocial needs.
At Adventist, our post-amputation collaborative rehabilitation team is made up of a podiatrist, physical therapist, nurse, prosthetist/orthotist and peer visitor. As a physiatrist, I coordinate the team and also work directly with patients. We hold wound care clinics every other week, during which patients are evaluated, managed and educated by the team members sequentially—all with a view toward preventing further amputations and allowing people to continue participating fully in their lives. While helping a person get fitted and properly use a prosthesis, I’m also educating him or her on how to protect the other foot, ensuring followup by other team members, and making sure patients know there is a place to go if they have even the smallest skin breakdown or trauma, in which case, they have to see me quickly.
Imagine if, instead of waiting until after a person has lost a limb to galvanize a collaborative care team, we were able to provide such care the moment someone is diagnosed with diabetes or another condition that puts the feet at risk. We have ample evidence from the literature that collaborative foot care is both effective and efficient: with the introduction of a multidisciplinary foot team in Ipswich, UK, the incidence of total amputations among patients with diabetes decreased 70% over 11 years, while a four-year retrospective study in a military center showed an 82% decrease in lower-limb amputations among diabetics in a military center thanks to a “focused limb preservation team.” An article in the Journal of Vascular Surgery states:
A team of dedicated specialists is required to prevent lower extremity amputation in persons with diabetes, because it would be exceedingly rare to find one practitioner capable of managing all aspects of care for the complicated diabetic foot…Individual team members should focus on one or more of the ‘steps’ in the pathway to amputation, but certainly, screening and prevention, wound healing, infection management and revascularization are paramount.
Why don’t we have collaborative care teams working with people with diabetes in the United States? For the same reason the wound care center at Adventist depends on a grant from the Amputee Coalition: Currently, hospital wound centers are reimbursed for treating wounds, not for preventing them. An exception is the Veterans Administration system, which does provide collaborative care. In the civilian sector, if no one pays for it, it doesn’t happen.
But we remain hopeful. The Amputee Coalition’s Limb Loss Task Force is striving to develop model systems that will both take care of people with limb loss and prevent limb loss in those at risk. We are working with the National Institutes of Disability and Rehabilitation Research, which funds model systems of care for spinal cord injury, brain injury and burn care, to see if we can create a fourth center for limb loss and limb preservation. From there, we could grow the standard of care at the community level. Meanwhile we are trying to raise awareness one practitioner at a time.