Treating a foot ulcer: One step in diabetic care

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One step for foot treatment, one giant step for overall diabetic care. That’s how the team at the Diabetic Foot Wound Healing Clinic at the South East Toronto Family Health Team (SETFHT) are approaching foot ulcers; with a holistic approach that encompasses treatment, education and prevention.

Foot wounds are usually not serious enough to cause great alarm, but for diabetic patients, it’s an area that can lead to severe complications. Approximately one in seven people with diabetes will develop a foot ulcer at some point during the course of their disease, which can lead to morbidity and mortality.

Diabetes affects the foot particularly through nerve damage, poor circulation, higher probability of infection, and stiffness in the joints. As the prevalence of diabetes increases, so will the rate of complications. By catching and managing these issues early, the quality of a patient’s life improves, while health-care dollars are saved.

“There aren’t many foot clinics available, which means that diabetic patients don’t have a lot of options,” says Ajai Rooprai, a chiropodist at the clinic. “They don’t need to be in an emergency department because they can get the treatment here, which is more cost effective to the health-care system. We’re taking a load off the ER and giving these patients shorter wait times, which is improving their quality of life.”

Toronto East General Hospital (TEGH) is a community partner of SETFHT and being located directly across the street, it’s one of the clinic’s biggest referral centres. The hospital’s endocrinologists, infection control specialists and plastic surgeons have all referred patients to the clinic.

“I think [the clinic’s] a valuable asset as patients with diabetes really don’t have a lot of resources in this regard,” says Dr. Rebecca Fine, Endocrinologist at TEGH. “Finances are really a constraint so having to see a chiropodist is not an option for many patients.”

“Not all patients can pay and this becomes a barrier,” says Dr. James Downey, Infection Control Officer at TEGH. “This clinic has been a godsend. It’s really wonderful. It’s a seamless spectrum of care for those who develop diabetic foot problems. This is central to speedy healing.”

During their foot wound care, patients have access to an interprofessional team of health providers that address concerns related to their diabetic foot ulcers. The core team consists of Rooprai, Dr. Louisa Huband and a registered nurse, while other members include a dietitian, pharmacist, mental health/addictions counsellor and care navigator.

“The wound care team does not only look at the hole in the foot, they look at the patient as a whole,” says Rooprai, a former TEGH staff member of 14 years. “They are referred to other team members for further assessment. Once healed, the patient is discharged with the resources in the community for their primary diabetic foot care.”

SETFHT received funding from HealthForceOntario’s Optimizing Use of Health Providers’ Competencies Fund whose strategy is to engage partners in health care and to develop teams that make the most of their abilities. The clinic opened in January 2009 and has shifted from holding bimonthly to weekly clinics as word has spread, to better accommodate the demand for diabetic foot care in the community. The team has made a commitment to ensure patients do not wait more than one to two weeks for an appointment.

“The focus is more than the foot ulcer,” admits Carol Toenjes, Program Coordinator. “It’s about controlling diabetes.” The clinic’s goal is diabetes education in hopes that by providing proper foot care principles, further foot complications will be avoided.

One patient of TEGH suffered recurring foot problems for nearly a decade. Periodically the patient developed blisters, which turned into osteomyelistis (bone infection). He was referred to the SETFHT Diabetic Foot Wound Healing Clinic where there was immediate improvement. “It cleared up in half the time I thought it would,” says Dr. Downey. “It had to do with the fact that the clinic gave him regular health care.”

Another patient spent 13 months with a foot ulcer and had a home care nurse visiting every day. After they were referred to the clinic, the ulcer was cleared up in three weeks.

“People were coming to my clinic before that didn’t need to be,” says Dr. Downey.

“Diabetes is a disease that affects so many different aspects of health care. We are fortunate that most of these are now covered by our current health- care system, but feet currently are not,” states Dr. Fine.

Currently, the clinic’s funding enables it to accept new referrals until September 2009, although the team and TEGH physicians are hopeful and optimistic that it will remain accessible to every member of the South East Toronto community.

The team is exploring ways to remain sustainable and through an ongoing evaluation, they hope that the results will speak for themselves. “We’ll be happy to continue with this service – happy to improve the quality of people’s lives,” says Rooprai.