Diabetes-related complications are responsible for diabetic foot ulceration and amputation. Cases of lower limb amputation have increased because of diabetes. In the year 2014, International Working Group on the Diabetic Foot [IWGDF] noted, “Every 20 seconds a lower limb is lost to diabetes somewhere in the world” (International Working Group on the Diabetic Foot, 2014). The rate of amputation has increased globally because of diabetes. Peripheral vascular disease (PAD) reduces the flow of blood to lower limbs due to narrowed arteries. Consequently, there is low supply of oxygen and delivery of medication to such limbs. Such individuals may have difficulty in healing and therefore experience high risks of ulceration.
Not all cases of foot ulcer heal successfully. The IWGDF notes that nearly one third of the cases may lead to amputation. At the same time, individuals with diabetes are also prone to foot ulcer infections.
Foot ulcers need medical attention based on the degree of infection. Interventions could be minor or major, but they may include the use of antibiotics to amputation. Foot ulcers and amputation have significant costs related to societal, economic, long lengths of hospital stay, rehabilitation and the need for long-term care services. In this regard, people with diabetic foot ulcers require effective management of their conditions.
The current specific standardized guideline
Assessment and Management of Foot Ulcers for People with Diabetes (2nd ed.).
A working link to the clinical guideline
Authors of the guideline
Highly qualified registered nurses and members of the Registered Nurses’ Association of Ontario (RNAO) developed the guideline for foot ulcers for people with diabetes.
How the guideline was developed
Purpose of the guide
- To highlight the issue of assessing and managing patients with long-term cases of diabetic foot ulcers
- To offer evidence-based recommendations for all health care providers and professionals who care for patients with long-term cases diabetic foot ulcers, type 1 or type 2 diabetes aged from 15 years old or more
The expert panel developed the guideline based on the best available evidence in foot ulcer management.
An expert panel consisting of health care professionals and other recommended individuals working under the RNAO conducted a systematic review on literature available on diabetic foot ulcers within the scope of the guideline. The panel reviewed studies conducted from 2004 to 2012. Four general aspects that the guideline considered were.
- The most effective way of assessing foot ulcers in individuals with diabetes
- Appropriate interventions to control foot ulcers and avoid re-ulceration
- Health care providers’ education and training experiences necessary to ensure that patients get optimal care for diabetic foot ulcers
- Promotional activities of health care institutions to support the best assessment and management for diabetic foot ulcers
The RNAO expert panel conducted a thorough review of the first edition or the original guideline of 2005.
It focused on identifying new evidence for safety, suitability and validity of the previous guideline recommendations. The panel had to identify any updated parts based on emerging evidence-based practices. The current guideline resulted from the expert panel’s work that consisted of adopting the best evidence-based practices to improve recommendations and support the previous guideline.
A team of project coordinators selected from the panel searched known databases and Web sites for any relevant studies published between 2004 and 212.
The team accounted for current knowledge on evidence-based practices and previous recommendations by scholars.
The team developed a list of relevant Web sites, a search strategy and inclusion criteria. The expert panel also facilitated identification of guidelines.
Members of the panel critically appraised nine international guidelines to develop the current guideline.
The RNAO expert panel managed the literature review process within the identified scope.
A health science librarian helped the expert panel to conduct the search. The expert panel concentrated on English-language published articles. Some of the Web sites searched included CINAHL, Embase, DARE, Medline, Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews.
There were two Master’s trained nurses who acted as research assistants. They assessed the relevance of the selected literature.
There was a team to resolve any potential conflicts among the expert panel members. The team assessed 17 articles on quality scores.
Credentials and credibility of the developers of the guideline
Professionals and registered nurses from the RNAO developed the guideline. Thus, contents of the guideline are credible.
The quality of the research base supporting the guideline since it was published
Although this is a recent guideline on diabetic foot ulcers, several recent studies have cited it. For instance, Bajnok et al. (2013) noted that RNAO emphasizes the adoption and implementation of the guideline in a systematic manner in order to account for all elements of the framework at various levels. Still, a study by Wilson, Bajnok, & Costa focused on the use of an ‘order set’, which consisted of a list of standardized interventions used in specific cases. These authors noted that the guideline provided nursing order set for diabetic foot ulcer care, which could be adopted to minimize variation in care provision for people with foot ulcers.
Links to national standards relative to the guideline
There are no major national standards for diabetic foot ulcer assessment and management. Some of the standards available are mainly studies by organizations and their expert panels, which provide best practices on assessment and management of diabetic foot ulcers.
Body of Evidence Summary Table.
|Research Study |
|Brief Summary of the Study and Results||Levels of Evidence|
|Monteiro-Soares, M., Boyko, E. J., Ribeiro, J., Ribeiro, I., & Dinis-Ribeiro, M. (2011). Risk stratification systems for diabetic foot ulcers: a systematic review. Diabetologia, 54(5), 1190-1199.|| ||Level I|
|Gardner, S.E., Frantz, R.A., Bergquist, S. & Shin, C.D. (2005). A prospective study of the pressure ulcer scale for healing (PUSH). The Journals of Gerontology, 60(1), 93-97.|| ||Level II|
|Warriner, R., Snyder, R., & Cardinal, M. (2011). Differentiating diabetic foot ulcers that are unlikely to heal by 12 weeks following achieving 50% percent area reduction at 4 weeks. International Wound Journal, 8(6), 632-637.|| ||Level III|
|Lavery, L. A., Armstrong, D. G., Wunderlich, R. P., Tredwell, J., & Boulton, A. (2003). Predictive value of foot pressure assessment as part of a population-based diabetes disease management program. Diabetes Care, 26(4), 1069-1073.|| ||Level IV|
|Gardner, S. E., Frantz, R. A., & Doebbeling, B. (2001). The validity of the clinical signs and symptoms used to identify localized chronic wound infection. Wound Repair and Regeneration, 9(3), 178-186.|| ||Level V|
|Wilson, Rita, Bajnok, Irmajean, & Costa, Tanya. (2014). The assessment and management of foot ulcers for people with diabetes nursing order set: Expediting knowledge translation. Diabetic Foot Canada, 2(1), 16-20.|| ||Level VI|
|Butalia, S., Palda, V. A., Sargeant, R. J., Detsky, A. S., & Mourad, O. (2008). Does this patient with diabetes have osteomyelitis of the lower extremity? Journal of American Medical Association, 299(7), 806-813.|| ||Level VII|
How the guideline fits into a practice setting
The guideline indicates approaches to foot ulcer assessment and management for clinicians. It advocates for scientific, standardized tools for assessing and managing diabetic foot ulcers.
The guideline shows the need to improve foot ulcer care based on the best evidence-based practices.
Possible barriers and facilitators to the change
The main stakeholders are patients and health care providers. Health care providers are likely to facilitate change if they understand contents of the guideline. Thus, they require training on the guideline to facilitate implementation. On the other hand, they are likely to resist changes if the guideline will require additional time spent on patients, resources and special skills.
Patients would facilitate change because foot ulcers disrupt their normal lifestyles and activities and they therefore require positive outcomes from care providers.
The decision to change health care practices is a responsibility of key stakeholders in the health care sector. These stakeholders include physicians and nurses, patients, policymakers, lawmakers, and institutions.
Planning for Change
The guideline requires effective implementation. It is imperative to determine skills, knowledge and attitudes required to implement the guideline. In addition, resources associated with the implementation of the guideline must be identified. Once implemented, care providers must evaluate the guideline through collecting and analyzing data.
Positive outcomes would indicate the effectiveness of the guideline and its implementation. Results must be used to improve the guideline and facilitate adoption of the best practices in diabetic foot ulcers.
- Foot ulcers are responsible for growing cases of amputation globally
- A guideline provides the best approaches in assessing and managing foot ulcers
- Controlling foot ulcers is a multidisciplinary effort
- Clinicians should collect data to improve the guideline
A guideline requires students to review many studies that show the best practices in a given area. This review shows that guidelines are well-researched documents that only include the best practices and outcomes. Moreover, it requires an expert panel to accomplish such tasks and provide the best guidelines for practitioners to adopt.
Bajnok, I., Grinspun, D., Lloyd, M., McConnell, H., Mo, J., & Teague, L. (2013). Assessment and Management of Foot Ulcers for People with Diabetes: Second edition of RNAO’s clinical practice guideline. Diabetic Foot Canada, 1(1), 24–8.
Butalia, S., Palda, V. A., Sargeant, R. J., Detsky, A. S., & Mourad, O. (2008). Does this patient with diabetes have osteomyelitis of the lower extremity? Journal of American Medical Association, 299(7), 806-813.
Gardner, S. E., Frantz, R. A., & Doebbeling, B. (2001). The validity of the clinical signs and symptoms used to identify localized chronic wound infection. Wound Repair and Regeneration, 9(3), 178-186.
Gardner, S.E., Frantz, R.A., Bergquist, S. & Shin, C.D. (2005). A prospective study of the pressure ulcer scale for healing (PUSH). The Journals of Gerontology, 60(1), 93-97.
International Working Group on the Diabetic Foot [IWGDF]. (2014). International consensus on the diabetic foot and practical and specific guidelines on the management and prevention of the diabetic foot 2011. Web.
Lavery, L. A., Armstrong, D. G., Wunderlich, R. P., Tredwell, J., & Boulton, A. (2003). Predictive value of foot pressure assessment as part of a population-based diabetes disease management program. Diabetes Care, 26(4), 1069-1073.
Monteiro-Soares, M., Boyko, E. J., Ribeiro, J., Ribeiro, I., & Dinis-Ribeiro, M. (2011). Risk stratification systems for diabetic foot ulcers: a systematic review. Diabetologia, 54(5), 1190-1199.
Warriner, R., Snyder, R., & Cardinal, M. (2011). Differentiating diabetic foot ulcers that are unlikely to heal by 12 weeks following achieving 50% percent area reduction at 4 weeks. International Wound Journal, 8(6), 632-637.
Wilson, R., Bajnok, I., & Costa, T. (2014). The assessment and management of foot ulcers for people with diabetes nursing order set: Expediting knowledge translation. Diabetic Foot Canada, 2(1), 16-20.