Avoiding amputation using the multi-disciplinary foot team and appropriate wound care: a case study utilising Eclypse

Written by: Rosalyn Thomas - Deputy Head of Podiatry, Diabetes Centre, Morriston Hospital, Email: rosalyn.thomas@wales.nhs.uk & Kathryn Brenton - Deputy Head of Podiatry, Diabetes Centre, Morriston Hospital

Introduction

Patients suffering with diabetes and develop a foot ulcer are at greater risk of early death, fatal stroke or myocardial infarction than those without a foot ulcer. Diabetic foot ulceration (DFU) is likened to “cancer” as more people die within 5 years from a foot ulcer than those who have colon, breast or prostate cancer. During their lifetime more than 25% of people suffering with diabetes will develop a foot ulcer.

The NHS spends 20% of its funds on caring for patients with diabetes which equates to £7,000 a minute, this does not include the indirect costs to the patients such as the inability to work and provide for their families and the physical and psychological effects on that patient.

Successful assessment and treatment of patients with a DFU can reduce the amputation rate by up to 85%, the multi disciplinary foot protection team has been shown to achieve this but unfortunately throughout the country there is inequality of services available for such patients.

This case study involves a 62 year old male suffering with type 2 diabetes that was admitted to hospital with sepsis of his right foot and was referred to the orthopaedic team for surgical debridement. The podiatry department at Morriston Hospital in Swansea, work closely with the foot surgeons who rely on us for advice on appropriate and timely wound care. This patient had four wounds left open to heal by secondary intention, 3 on the plantar arch and one on the lateral border over the styloid process, all grade 3 B (Texas wound classification).

The above pictures show the plantar and lateral aspect of his foot and the ulcers on the plantar communicated with those on the lateral border with plantar fascia exposed.

Initially post surgical debridement, the wounds appeared to be healthy and granulating but on the second dressing change the wounds were malodorous with copious purulent exudate. The patient was systemically unwell and feared losing his foot.

Method

Managing the exudate was an issue, this foot necessitated a super absorbent dressing, Eclypse was deemed the dressing of choice. His foot required further debridement but due to his poor health at the time we decided to offer Biosurgery to reveal the extent of the wound.

After discussing the risks and benefits to the patient allowing him time to arrive at informed choice, Bio-surgical debridement utilising “free range” Larvae were applied to his foot. On removal the wounds were again red and granulating although the plantar fascia were exposed on the 3 plantar wounds that communicated with the lateral wound. The exudates levels were still high post Biosurgery, so Eclypse was continued to manage this and prevent maceration of the intact tissue. After 7 days the patient was discharged home. Prior to him returning home the patient was fitted with a removable cast and temporary footwear. The district nursing services were contacted to visit, initially three times a week which quickly reduced to once a week in conjunction with weekly podiatry outpatient appointments.

Results

As podiatrists are part of the multidisciplinary team, the orthopaedic surgeon confidently discharged him to our care with the option of being referred back from podiatry if necessary. Within 8 weeks the wounds had practically healed on the plantar aspect and totally healed on the lateral border. Throughout this period the patient did not require any antibiotics or readmission.

Discussion

Working as a multidisciplinary team ensures the pathway for patients is smooth and the patient is kept informed of all procedures/treatments. Having an understanding of each other’s skills is paramount to patient care. The orthopaedic surgeons rely on the secondary care podiatrists for advice on wound care and learn from us how important a thorough and holistic assessment and dressing selection for each type of wound is crucial to aid healing.

Conclusion

Eclypse prevented maceration at the wound margins, which ensured epithelial migration was not compromised enabling complete healing to occur. Less frequent changes not only aids the healing process as the wound bed is not disturbed but is cost effective as the numbers of dressings required are reduced (Kerr 2012). The reduction in district nurse’s time is a key driver of costs, as work conducted by Drew and Posnett¹ illustrated. The time taken, not only to heal the wound, but the time involved to treat the wound has a positive effect on the patient’s quality of life.

Involving the Multi Disciplinary Foot Team enhances the patient’s pathway during their hospital stay. Incorporating Eclypse in treating the multi wounds that this patient originally presented with avoided unnecessary disruption to the wound bed and to the patient who was systemically unwell. Eclypse achieved this objective in this case and demonstrated to be clinically and cost effective and together with the Multi Disciplinary Foot Team prevented amputation.