title: Organization of wound healing services: The impact on lowering the diabetes foot amputation rate in a ten-year review and the importance of early debridement.
abstract: Diabetes foot ulceration (DFU) has a negative impact on the quality of life and leads to disabling morbidity, such as lower extremity amputation (LEA). This study aimed to evaluate the LEA trend before and after the establishment of the diabetes foot team, an on-time debridement, on-site screening, and multidisciplinary integration with standardizing care, in Chang Gung Memorial Hospital, Chia Yi, Taiwan, starting in 2010. The study retrospectively investigated the non-traumatic LEA rate in diabetes foot (identified by using ICD-9-Clinical Modification (CM) codes, 250.70-250.83) and whole patients with diabetes (ICD-9 250.XX) yearly from 2004 to 2013. Patients were enrolled from hospitalization, emergency room (ER), or outpatient departments, respectively. Despite the overall incidence of diabetes foot in patients with diabetes remaining constant, from 3.47% in 2004 to 3.58% in 2013, the incidence of hospitalized diabetes foot from diabetes reduced, from 2.83% in 2004 to 1.51% in 2013. Introduction of integrated wound care also led to a reduction of the average LEA rate in hospitalized patients, from 15.27% (2004-2009) to 6.08% (2010-2013) (P<0.001). A similar decline of the LEA rate was observed for patients from hospitalization, ER and outpatient departments together with an average LEA rate from 7.99% (2004-2009) down to 3.02% (2010-2013) (P<0.001). In trend analysis, the curve estimation revealed a quadratic trend in the relationship between LEA rate and time (R-square=0.869, P=0.001) for hospitalized patients as well as a linear (R-square=0.819, P<0.001) and quadratic (R-square=0.845, P=0.001) trend in the relationship between LEA rate and time for hospitalization, ER, and outpatient departments together. The LEA rate for DM patients declined from 372.72/100,000 in 2004 to 61.74/100,000 in 2013. With establishment of an organizing, standardized wound care protocol and integrated multidisciplinary team, we demonstrated a significant decline in the LEA rate both in diabetes foot patients and all patients with diabetes. These improvements can be attributed to introducing an efficient pathway with on-time debridement and early intervention of diabetes foot ulcers.
authors.affiliation: Division of Plastic Surgery, Chang Gung Memorial Hospital, Chiayi, Taiwan, ROC(1). Electronic address: josephinesheu@gmail.com.
authors.forename: Cherng-Ru
authors.initials: CR
authors.lastname: Hsu
authors.affiliation: Division of Plastic Surgery, Chang Gung Memorial Hospital, Chiayi, Taiwan, ROC(1). Electronic address: changcc@adm.cgmh.org.tw.
authors.forename: Chang-Cheng
authors.initials: CC
authors.lastname: Chang
authors.affiliation: Division of Plastic Surgery, Chang Gung Memorial Hospital, Chiayi, Taiwan, ROC(1). Electronic address: sunshinef91@yahoo.com.tw.
authors.forename: Yu-Tsung
authors.initials: YT
authors.lastname: Chen
authors.affiliation: Division of Plastic Surgery, Chang Gung Memorial Hospital, Chiayi, Taiwan, ROC(1). Electronic address: hippo720@adm.cgmh.org.tw.
authors.forename: Wei-Nung
authors.initials: WN
authors.lastname: Lin
authors.affiliation: Graduate Institute of Nursing, Chang Gung University of Science and Technology, Taiwan, ROC(2). Electronic address: meiyen@gw.cgust.edu.tw.
authors.forename: Mei-Yen
authors.initials: MY
authors.lastname: Chen
mesh_terms: D000368:Aged; D000671:Amputation, Surgical / Q000706:statistics & numerical data*; D003646:Debridement / Q000379:methods; D017719:Diabetic Foot / Q000601:surgery / Q000628:therapy*; D061345:Early Medical Intervention / Q000379:methods / Q000458:organization & administration*; D005260:Female; D005528:Foot / Q000473:pathology / Q000601:surgery; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D010348:Patient Care Team / Q000458:organization & administration*; D011788:Quality of Life; D012189:Retrospective Studies; D013624:Taiwan / Q000453:epidemiology; D014945:Wound Healing
keywords: Diabetes foot; Lower extremity amputation rate; Wound care center