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Survey of hospital admissions related to diabetic foot disease - Survey

Diabetic Foot, The, Spring, 2004 by D.R. Coles, D.V. Coppini

Introduction

Diabetic foot ulceration is one of the most common and devastating complications of diabetes. Patients admitted with diabetic foot disease or complications of neuropathy tend to have a longer than average hospital stay. The related human and medical costs are huge and adequate resourcing is necessary to enable a sound and cost-effective management strategy. The results of our survey revealed a high hospital bed occupancy related to diabetic foot complications.

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The National Service Framework for Diabetes (Department of Health, 2002) has drawn up standards for the inpatient care of patients with diabetic foot disease. Strategies have been developed in an attempt to reduce the substantial co-morbidity and mortality related to this disease. Figure 1 shows an hospital inpatient receiving vacuum suction treatment for a foot ulcer. Detailed information systems are also being designed to help improve the quality of service delivery. The main aim of our survey was to try to determine the impact of foot complications on hospital bed occupancy, patient outcome and current specialist service resources.

Methods

Poole Hospital is a district general hospital serving a population of 250 000. The diabetic foot clinic is a multidisciplinary twice-weekly clinic with an average of 12 patients per clinic. The survey period was from November 1, 2000, to October 31, 2001, and included patients admitted electively from the foot clinic and those admitted to the hospital in whom foot complications or associated problems were the main reason for hospital admission or stay. Inclusion and exclusion criteria are shown in Figure 2.

[FIGURE 1 OMITTED]

Inpatient diabetes care is provided by the medical team, an orthopaedic specialist with an interest in the diabetic foot, a vascular surgeon, a podiatrist (for the weekly inpatient session), a DSN, dietitian and ward nurses.

Information on patient demographics, length of hospital stay and outcome at the time of discharge was recorded on an Excel spreadsheet.

Patient outcome was classified as:

1) Conservative management with significant wound improvement (incorporating strict bed rest, intravenous antibiotics and inpatient podiatric assessment and treatment).

[FIGURE 3 OMITTED]

[FIGURE 4 OMITTED]

2) Angioplasty or bypass procedure

3) Operative procedure

a) Surgical debridement

b) Toe amputation

c) Forefoot amputation

d) Below knee amputation (BKA)

e) Above knee amputation (AKA)

4) Death

Patients were discharged on the basis of good clinical evidence of wound healing, with the elimination of sepsis and necrotic tissue. Post-discharge care ensured adequate off-loading and domiciliary support with regular foot clinic attendance. Elderly or infirm patients may have also received temporary placement in rehabilitation centres with regular review in the diabetic foot clinic. Patients who had had major amputations were subsequently also reviewed in the limb fitting centre.

Results

In total, 29 patients met the inclusion criteria and were admitted over the study period; there were 32 admissions (three re-admissions). The mean patient age was 70.2 years (35-89 years) and 69% were male. There was a notable peak during the winter period in the pattern of admissions throughout the year (Figure 3).

Patients (n=29) were admitted with the following foot complications: 20 (70%) with infected foot ulceration, 3 (10%) with unresolving foot ulceration, 3 (10%) with severe complications of neuropathy, 2 (7%) with gangrene and 1 (3%) with severe lymphoedema.

A total of 14 patients (48%) were managed conservatively and four patients (14%) required vascular intervention (angioplasty or bypass procedure) to enhance healing. Surgical wound debridement was performed on one patient (3%), and seven patients (24%) had amputations (three toe amputations, one forefoot amputation, one BKA and one AKA). Three patients (10%) with severe infected foot ulceration died from concomitant cardiovascular causes (Figure 4).

The average length of stay of patients with diabetic foot disease was 22.2 (range 3-56) days. Of patients admitted with infected foot ulceration that was managed conservatively (n=12), the average length of stay was 19.1 days compared with 29.8 days for those (n=9) who had an operative procedure (e.g. amputation) or vascular intervention.

Discussion

There is a substantial hospital bed occupancy for diabetes related to admission for diabetic foot complications. Foot complications tend to represent the main inpatient clinical workload for UK hospital diabetes teams (Waugh, 1998). Although we have not quantified patient bed occupancy as a proportion of total medical admissions, diabetic foot complications represent our main 'specialist' workload. The estimated total bed occupancy for 1 year is 711 patient bed days, and the observed pattern of increased admissions during the winter months tends to aggravate 'bed pressures' at the time.

Infected foot ulceration represents the main cause for hospital admission for diabetic foot complications (23 out of 32 admissions, 72%), and although we did not detail the exact source of referral, most cases were admitted from the diabetic foot clinic. Patients may also have been referred by medical or surgical (including orthopaedic) colleagues, and others were admitted under our care directly from the accident and emergency department. It is also likely that some patients with foot complications may have bypassed our care and would have not been included in this audit. The multispeciality involvement in diabetic foot complications may lead to exclusion of cases during the audit period. Our team is, however, generally renowned in the hospital for its interest in the diabetic foot, and 'initial treatment guidelines for treatment and referral' are present on all hospital wards and on the hospital intranet. We believe that such factors would help minimise bias on our reported patient outcomes.

Health Care Industry

Survey of hospital admissions related to diabetic foot disease - Survey

Diabetic Foot, The, Spring, 2004 by D.R. Coles, D.V. Coppini

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