Meeting the Challenges of Diabetic Foot Ulcer Care: One Institution’s Mission

Ronald Sherman, DPM, MBA:

I'm an Assistant Professor here at Johns Hopkins Hospital in the Department of Surgery, specifically in a division of vascular and endovascular therapy. I'm also the program director of our Limb Preservation and Wound Care fellowship. I am the principal podiatric surgeon in our multidisciplinary practice. I've been associated with Dr. Abularrage now over 10 years in developing our multidisciplinary diabetic foot and wound care service. And to that end, we've been able to develop a variety of paradigms based on his insight and experiences.

Christopher Abularrage, MD:

So my name is Chris Abularrage. I am a professor of surgery here at Johns Hopkins in the division of vascular surgery and endovascular therapy. I'm a peripheral vascular surgeon specializing in both open and endovascular surgery and I'm director of our multidisciplinary diabetic and limb preservation service.

Ronald Sherman, DPM, MBA:

I think that one of the biggest challenges we face is a communication amongst the various disciplines who take care of diabetes. We found that not one physician is an expert in all the comorbidities that a diabetic has, and hence that we have found that care is non-continuous in treating the diabetic between vascular, podiatry, endocrinology, and the associated other disciplines, orthopedics and plastic surgery, as well as physical therapy. And what we found is that these patients are treated in the community for months and months with these now chronic wounds. And then they actually come to our multidisciplinary care for a second opinion in hopes of saving their leg.

And that takes us to the next challenge that we have is that oftentimes we're referred patients too late. The community just refers the patient too late to our service and the amount of options we have are either Hail Mary options or heroic options to save the leg. So I think those are two of the challenges that come to my mind. The other thing is is using proven paradigms as the standard of care in the community. I think that one thing that we've tried to do is to develop paradigms and publish on those paradigms so that the care of these diabetics and that the reduction of limb amputations actually occurs. Dr. Abularrage.

Christopher Abularrage, MD:

Yeah. I think there's really no standard paradigm for the care of these patients in the community. I think in general it's been our experience to see that a patient develops a problem with their foot, they end up going to their primary care physician. If they have a podiatrist, maybe they're lucky and they go there first. Otherwise they get referred to a podiatrist. Then they see the podiatrist, they undergo some wound care. If they're lucky, things heal. If they don't, then they're referred out elsewhere. And as Dr. Sherman was referring to, the problem is is that diabetic foot disease is multifactorial. There are so many things that lead into it that unless you try to address everything in general, it's very hard to get someone to heal and to keep them healed. So I think this idea of multidisciplinary care becoming the standard of care is exceedingly important in saving limbs. Delays in referrals, delays in specialty care are what lead to these amputations and that's been our experience over and over again.

Ronald Sherman, DPM, MBA:

I think the way that our service is set up, so we have an outpatient and an inpatient service, and I'm just going to talk about the outpatient service at this point. When a patient comes in to see us, they'll see three physicians, they'll see Dr. Abularrage from vascular, they'll see me from podiatry, and they'll see an endocrinologist as well. So in one visit, a patient's going to be reviewed on the essence of probably the problems that they have that have contributed to the symptom of developing a diabetic foot ulceration. So at that point, we have a seamless communication system amongst three physicians to be able to discuss exactly what the problem is and what needs to be done. I think that we also have a variety of testing that we do that is standard of care and that would be obvious radiographs are taken at the first visit and non-invasive vascular studies are also done so that we have a very good understanding of the baseline of the pathology that the patient has.

I think to that end, we then formulate a treatment plan, and if they require inpatient stay, then we have a variety of paradigms that we go through at that point. One of the things that we have come to understand is, and this is what Dr. Abularrage says all the times, not all wounds are the same and not all patients are the same. And therefore we have to be able to understand each one of those patients to really understand if they are a limb preservation or limb salvage patient. So I think that's important. The other thing that we understand is that we see patients who haven't been seen for quite a long time and they develop now chronic wounds. And the reason it becomes chronic in our opinion is that these wounds are being treated for months and months and months.

And we know that from the literature from Dr. Schein that he said that if wounds don't heal or are 50% healed after four weeks, then either a different modality needs to be done or there's a problem that needs to be changed and just not keep kicking the horse, so to speak. And then they develop osteomyelitis and it goes on and on. So we try to form these paradigms in such a way that not only that it works for our multidisciplinary service, but we hope that they can translate to the community as well.

Christopher Abularrage, MD:

Yeah. I think that's 100% true. I think Dr. Sherman explained it well. Our group here has not only a comprehensive group of providers who tackle these patients with complex problems, but it's also completely integrated. And what I mean by that is that all three providers are there at every visit. And so there's interaction not only with the patient, but also amongst us trying to decide, "Okay. Well what's the next step? Should I jump in? Should he jump in? If I don't jump in now, should I be thinking about it next week?" Just planning ahead. And not only is it integrated in the outpatient setting, but it's also 100% integrated in the inpatient setting. What's a lot different in our world, and that's for a number of reasons that I won't get into today, but patients are admitted to our service. So it's not like they're getting admitted to a hospitalist service and then that person's trying to coordinate their care.

We're doing all the coordinating of care and then swinging it around again once they come back to the outpatient setting. So I think that's very different compared to the traditional wound care center paradigm where patients are seeing, probably a little bit more frequently, but not seeing every provider so that you're still getting that delay in care for the specialty referral. We see patients on a weekly basis altogether. However, there are a couple of other days where we may see patients separately or drag someone in, but that comprehensive group on the outpatient setting is in a single week, which is important because it's exceedingly difficult to get an endocrinologist and a vascular surgeon to see patients within a wound care center setting. It's just not viable. Now, the only way it works for us is because we really integrate home health into the long-term care of these patients and of their wound care.

And communication with home health has been integral to our success, not only with them communicating with us, but also with our wound care nurses and then getting patients in a little bit sooner if they need to be or just making sure that the wound is progressing in a manner that we had planned. So I think it's not easy to manage it completely as we're doing, however, by doing it on a single day a week and then integrating it across a continuum of care, both pre-op, op, and then post-op, I think that's where we've found success. Being in the same place is invaluable, period. I may think things are going well and Dr. Sherman may sort of point something out or vice versa and that changes care immediately rather than waiting two to three weeks for that next outpatient referral.

Ronald Sherman:

I think we also have developed some paradigms. So one of the paradigms we have is something called SACA, S-A-C-A. And what this means is S, source control. So when you see a diabetic, the first thing you have to do is obtain source control. That's trumps everything. SA, A means arterial revascularization. So you first must get rid of the infection, then you jump in and you do the revascularization. C, SAC, SACA, C means either closure or reconstruction. So we know that these patients will require debridement or debridements. And if we do that effectively, then we can either close them secondarily or we can actually use a variety of cellular tissue products. And then A, the finished SACA, means ambulation or smart ambulation. And we talked about this previously and this gets back to our computerized aided gait analysis study where we then understand the biomechanics of the way that a diabetic walks who have had an ulceration and retard the recurrence of that.

And what we found in our earlier days from our earlier publications that due to the paradigm that Dr. Abularrage has set up, that we've been able to have a 95% success rate in limb preservation, which was very astounding. But to that end, we also were finding that we were getting a recurrence rate of around 25 to 40% in 12 months. So we knew we had to do something different. And that's why we decided to embark on our IRBR research project to understand the abnormality and the gait analysis in these diabetics so that they don't continue to have wounds, go to wound care centers, get admitted to the hospital, have OR events, and then have amputations. So our service goes from soup to nuts. So not only do we have the paradigm from when we first see them, we treat the entire patient.

We just don't treat the wound, we treat the entire patient. And then once we do that and we get rid of the infection, we then reconstruct the foot, we re-vascularize the foot, we keep them intact by doing a computer assisted gait analysis. It's a seamless coordination amongst all the disciplines. And Dr. Abularrage mentioned our robust home health. This is essential. This is essential nowadays because with COVID and the dismantling of staffing in the subacute rehab centers, the level of care is sometimes suboptimal. But with home health, we've been able to reach out to them. We've been able to train them, educate them, so they too are seamless in all of our paradigms. So I think that it doesn't matter if a patient has a high deprivation index or a low deprivation index, we account for that problem by using our paradigms and by using our education out into the community.

Christopher Abularrage, MD:

I definitely think the paradigm thing is key. You can't get into our clinic without not only a three view x-ray of the foot that's in question, but without vascular testing as well. The main thing that we see in our second opinion referrals from the community is just a lack of vascular testing. And in that regard, it's one thing for a patient to present with sort of a chronic toe ulcer, it's another thing to present with a complex diabetic foot wound. It's the complex diabetic foot wounds that put you most at risk for major amputation and I think in those patients, understanding their perfusion and getting them re-vascularized early is key in allowing the success for the podiatric surgeon or the general podiatrist to get that wound to heal in the long run.

Even with our generalized vascular testing, it's still very challenging to understand who has good tissue perfusion to the region of the wound and what can best be done. But our experience of bringing people for early angiography in the setting of borderline perfusion or in the setting of a wound not healing despite maximal wound therapy has been probably one of the major keys to our success.