Implementation of a clinical pathway for diabetes-related foot ulcers reduced the number of amputations and shortened hospital stay.

Abstract

Introduction: Diabetes-related foot ulcer (DFU) is the leading cause for lower extremity amputations (LEAs) in western countries, and may cause social isolation, depression, and death. However, people with DFU are not offered the same prioritized care as cancer patients, despite comparable mortality rates. We therefore decided to create a clinical pathway for patients with DFU. The purpose of this study is to evaluate the efficacy of implementing a new clinical pathway on rates of LEA, length of hospital stays, and cost reduction.

Methods: On January 1, 2019, a new clinical pathway ensured that all patients with a DFU were evaluated in a designated clinic run by a foot and ankle orthopedic surgeon in collaboration with the vascular surgeons, supported by a specialized wound nurse and a certified prosthetist/orthotist (CPO). We designed an algorithm for the first consultation to identify patients in need for further investigation by other specialties such as endocrinology, infectious diseases, cardiology, or vascular surgery. All patients underwent a surgical wound debridement of DFU. Negative pressure wound therapy (NPWT) was not applied. After surgery, the dressings were changed daily on the ward, until the wound was deemed viable and clean. The patients were followed for two years and compared to a historic cohort of patients with DFU admitted to the institution in 2017.

Results: The number of major amputations was reduced from 65% (13/20) to 7.4% (2/27) (p < 0.001) after the introduction of the clinical pathway. Both the mean number of surgical revisions (5.5 vs. 1.2) and the median length of stay (46 vs. 9 days) were statistically significantly reduced. The median cost per patient was reduced by 76% (from €538 000 to €129 000, p < 0.001).

Conclusion: The clinical pathway for managing DFUs resulted in a reduction in major amputations and shorter hospital stays. Discontinuing NPWT after surgical debridement did not adversely affect clinical outcomes. The new pathway also contributed to lower healthcare costs.