Documentation: The Crystal Ball of Wound Care

The global epidemic of type 2 diabetes can be managed if we recognize and alleviate its causes as early as possible.¹ A diabetic foot ulcer (DFU) need not be a sentence to amputation and early death with pre-emptive evaluation and effective care. Early detection of sensory loss, bone and soft tissue injury, impending infection,² and consistent 24/7 off-loading³ are important steps toward healing and maintaining a healthy diabetic foot. The 80%–90% healing in 12 weeks reported for non-infected, non-ischemic Wagner Grade 1 and 2 foot ulcers that are consistently off-loaded with either a total contact cast (TCC) or an “instant” TCC and moist wound environments, exceeds outcomes I’ve found for any other topical modality applied to similar DFU. What else can improve DFU healing? The Kurd et al study underscores the importance of informing wound care providers about healing progress, and builds on the discovery by Sheehan et al⁴ that one can recognize a DFU not on the path to healing after only 4 weeks of standardized care. The second study summarized in this Evidence Corner goes beyond healing to examine risk factors and likelihood of long-term DFU patient and wound outcomes. These studies suggest that to be forewarned is to be forearmed, enabling care providers to be proactive in achieving goals of DFU care.

Reference: Kurd SK, Hoffstad OJ, Bilker WB, Margolis DJ. Evaluation of the use of prognostic information for the care of individuals with venous leg ulcers or diabetic neuropathic foot ulcers. Wound Repair Regen. 2009;17(3):318–325.

Rationale: Earlier research showed that baseline venous leg ulcer (VU) and neuropathic DFU characteristics and 4-week reduction in wound area predicts wound-healing status at 24 weeks for VU or 20 weeks for DFU.

Objective: Determine if providing feedback about the healing or non-healing status of a VU or neuropathic DFU to its professional caregivers improves healing outcomes.

Methods: Existing electronic databases within 74 centers were used to provide 1 of 4 kinds of feedback to wound care providers for patients with either a VU (n =1506) or a DFU (n = 1810). Each center was considered a “cluster” that was randomly assigned to receive either no prognostic information (20 centers), baseline prognostic information only (19 centers), prognostic information based on 4-week wound area change (17 centers), or prognostic information at both baseline and after 4 weeks of treatment. The educational intervention gave wound care providers a facility-specific printout with the likelihood of healing within 24 weeks for VU or 20 weeks for DFU, but no added guidance on clinical treatment of the patient or wound. The baseline prognostic printout included likelihood of ulcer healing based on VU area and duration, or DFU area, duration, and depth. The 4-week prognostic printout informed providers that the patient had or had not passed a 4-week healing landmark of being at least 70% likely to heal in 20 weeks, as defined by complete epithelization or not requiring a wound dressing for at least 2 weeks. Healing outcomes were analyzed using chi-square analysis with logistic regression correcting for effects of patient age, gender, initial wound area, duration, and for DFU, depth.

Results: The likelihood of healing for both VU and DFU by study end improved significantly, even when corrected for age, gender, baseline ulcer area, and duration differences on enrollment, DFU patients with wound care providers informed only of healing predictions based on 4-week healing progress were 1.5 times more likely to heal in 20 weeks than those whose providers lacked this information (P < 0.05). No other DFU healing prognosis significantly affected healing improvement. Patients with a VU whose wound care providers knew either baseline or 4-week healing predictions or both were 1.4 times more likely to heal in 24 weeks than those who did not (P < 0.05).

Authors’ Conclusions: Providing prognostic information about likelihood of healing from existing facility databases was inexpensive, feasible, and effective in improving VU and DFU healing rates.

Reference: Ghanassia E, Villon L, Thuan Dit Dieudonné JF, Boegner C, Avignon A, Sultan A. Long-term outcome and disability of diabetic patients hospitalized for diabetic foot ulcers: a 6.5-year follow-up study. Diabetes Care. 2008;31(7):1288–1292.

Rationale: Long-term outcomes and functional status for patients hospitalized with a DFU are rarely reported, hence the true morbidity and mortality associated with diabetic foot disease is greatly underestimated.

Objective: Analyze long-term functional status and disability outcomes of patients after hospitalization with a DFU and investigate possible prognostic factors.

Methods: All 94 patients admitted to a French University Hospital from January 1998 to December 2002 with limb-threatening DFU infection or non-favorable progress despite a recognized standard of outpatient care were followed as a prospective cohort for a mean of 79.5 ± 13.3 months. Outcome measures were primary healing, recurrence, new DFU development, amputations, mortality, disability using Katz⁵ index, and global therapeutic success (GTS) as defined by primary healing with no recurrence or disability at the end of follow up. Univariate and multivariate analyses respectively identified correlated and independent predictors of GTS.

Results: Among the 89 patients with successful follow up, 92% had sensorimotor diabetic neuropathy, 66% had an ischemic DFU, 54% were purely neuropathic, and 17% underwent vascular procedures. DFU healing occurred in 78% with 61% DFU recurrence. Insulin treatment before admission was the only predictor of recurrence (P < 0.015). Amputations occurred in 44% with 1 in 4 amputations being major. Predictors of amputation included critical (P < 0.01) or ischemic (P < 0.003) DFU, and suprapopliteal (P < 0.01) and popliteal (P < 0.003) stenosis. Popliteal stenosis was the only independent predictor of amputation in multivariate analysis (P < 0.01). Predictors of first amputation included ischemia and diabetic nephropathy, the latter being the only independent predictor. By the end of follow up or at the time of death, 28% of subjects experienced disability (Katz index < 3). Increasing age, renal impairment, and prior amputation were correlated predictors of disability. Among the 52% who died, 26% succumbed to cardiovascular disease. Disability, age, renal impairment, and myocardial infarction history jointly predicted mortality, but only renal impairment was an independent predictor of all mortality. Only insulin therapy on admission was a predictor of cardiovascular mortality. Overall, 40 subjects (45%) experienced global therapeutic success—28 lived and 12 had died at the end of follow up. Univariate analysis identified age > 70 years, prior DFU history, and insulin therapy before admission as factors associated with failure to achieve GTS. Only age > 70 years independently predicted GTS in the multivariate analysis. 

Authors’ Conclusions: Despite satisfactory initial healing, global long-term outcomes for patients hospitalized with a DF remain poor. Impaired renal function and age > 70 years emerged as important predictors of DFU patient outcomes. Multicenter trials are needed to establish recognized criteria for successful outcomes for patients hospitalized with a DFU.

To my knowledge, the study by Kurd et al is the first prospective, randomized, controlled trial with evidence that provides feedback for clinicians regarding VU and DFU progress improves healing outcomes. It heralds a new wound management paradigm in which wound care providers wield wound documentation to improve outcomes. Documenting wound status on admission and progress toward healing is more than a chore or a legal necessity. Reliable, valid documentation, if heeded by wound care providers, identifies risk factors to address and guides care decisions that can help providers predict and even improve outcomes. Good documentation identifies goals of care so providers focus effective resources on the right patients and wounds at the right time to avoid costly complications in order to achieve care goals efficiently.⁶ Regularly repeated, it alerts providers to whether their patients and wounds are making progress toward those goals. It is no wonder that wound care providers in acute, long-term, and home care have used patient and wound documentation as a valuable tool to achieve important patient and wound care goals.⁶

Gahnassia et al expand our field of vision beyond wound healing to appreciate other important DFU patient outcomes. What improvements in long-term DFU outcomes might one achieve by consistently informing providers about documented risk factors and their implications for the likelihood of therapeutic success? What complications would be averted by an early warning system for DFU patient risk factors? Would it work as the Braden Scale has by reducing pressure ulcer likelihood when resources are focused on important patient risk factors?^7,8 Documentation is gaining recognition as valuable information empowering wound care providers to evaluate the effectiveness of care protocols, gauge their likelihood of success, and when possible, avert catastrophe.

Adjunct Associate Professor Department of Surgery, UMDNJ

WOUNDS Editorial Advisory Board Member and Department Editor