Multidisciplinary diabetic foot care in Sweden - A national survey

Trends and prospects in nursing care for diabetic foot: A bibliometric analysis from 2003 to 2023

BACKGROUNDS

Diabetic foot (DF) is a globally significant concern, with complications like diabetic foot ulcers (DFUs) posing major challenges despite medical advancements. Effective nursing strategies are crucial to preventing DF progression and reducing disability risk. However, nursing research in DF care is fragmented, necessitating a comprehensive bibliometric analysis to identify key trends, influential contributors, and critical research areas.

PURPOSE

This study explored current trends in nursing methods for DF care and their impact on patient outcomes, utilizing CiteSpace, VOSviewer, and Bibliometrix to identify key contributors, influential countries, and noteworthy topics, aiming to provide valuable insights for healthcare professionals and researchers in the field.

METHODS

Relevant publications from the Web of Science (WOS) Core Collection Science Citation Index Expanded were retrieved for the period between 2003 and 2023. We included peer-reviewed original articles or reviews related to diabetic foot (DF) and nursing. The following criteria were used for exclusion: ① conference abstracts or corrigendum documents, ② unpublished articles, ③ repeated publications, ④ unrelated articles, ⑤ case reports, and ⑥ qualitative studies. CiteSpace was employed to identify top authors, institutions, countries, keywords, co-cited authors, journals, references, and research trends. VOSviewer was used to generate a network of authors, journals, and references. Bibliometrix was utilized to create maps of cooperating countries and keyword frequency charts, as well as a Sankey diagram illustrating the relationship between authors, keywords, and countries.

RESULTS

A total of 305 relevant articles were included in this study. The research pertaining to nursing aspects of diabetic foot care exhibited a noticeable upward trend. The analysis in this study revealed that "amputation" held the highest centrality, indicating a critical area of focus in nursing interventions to prevent severe outcomes. "Diabetic foot ulcer" ranked first in terms of citation rate, emphasizing the ongoing challenges in managing DFUs through nursing care. In recent years, there was a shift in focus towards keywords such as "pressure ulcers", "burden", and "chronic wound" highlighting the evolving priorities in nursing research to address complex wound care, patient burden, and long-term management strategies.

CONCLUSIONS

The current primary research focuses in nursing care for diabetic foot (DF) include wound management, offloading techniques, sensory protection, anti-infective treatment, education and self-management, and multidisciplinary teamwork. Future research should prioritize developing innovative nursing interventions tailored to individual patient needs, integrating advanced technologies like telemedicine and wearable devices for continuous monitoring, and exploring the psychological aspects of DFU management to improve patient adherence and outcomes. Additionally, more longitudinal studies are needed to assess the long-term effectiveness of various nursing strategies on patient quality of life.

Health professionals involved in diabetic foot and their tasks in a country without podiatrists: From a Japanese Nationwide Survey

Although there are no podiatrists in 85% of countries worldwide, how diabetic foot is managed in those countries is still unknown. We sought to identify the health professionals involved in diabetic foot and their tasks in Japan, where no podiatrists exist. This cross-sectional study used the Japanese Nationwide Survey on Foot Ulcer Management dataset, consisting of 249 medical doctors and 680 allied health professionals. The types of health professionals involved in the diabetic foot were identified, and the tasks performed by each professional were compared within subgroups (medical doctors and allied health professionals). We found that the primary medical doctors involved in diabetic foot care in Japan were plastic surgeons (33.5%), dermatologists (21%), cardiovascular/vascular surgeons (15.2%), and cardiologists (12.1%). Nurses were the main allied health professionals (80%), and the rest consisted of prosthetists/orthotists (7.6%), physical/occupational therapists (5.9%), and clinical engineering technologists (3.6%). Medical doctors performed tasks related to their specialties significantly more than others (p < 0.001); however, they also engaged in tasks outside of their specialty, such as plastic surgeons performing preventive foot care (72%). Among allied health professionals, clinical engineering technologists performed more vascular assessments (p < 0.001), and half were engaged in wound management, preventive foot care, and self-foot care education. In conclusion, the type and proportion of health professionals in our study differed from those in countries with podiatrists, and many performed tasks outside their specialties. This is the first nationwide cross-sectional study of diabetic foot care in a country without podiatrists and is unique in examining multiple specialists/professionals in one study.

Clinical guidelines recommending prosthetics and orthotics in Sweden: Agreement between national and regional guidelines

BACKGROUND

Despite the presence of both national and regional clinical practical guidelines (CPGs) in Sweden, no previous studies have investigated the quality of CPGs or the level of agreement between national and regional CPGs.

OBJECTIVES

This study aimed to assess the quality of national CPGs recommending prosthetics and orthotics (P&O) and quantify the agreement between national and regional CPGs in Sweden.

STUDY DESIGN

Literature Review.

METHODS

National and regional CPGs were identified in public databases and by surveyed local nurse practitioners. Quality of the national guidelines was assessed by using AGREE II. Agreement between recommendations in the national and regional CPGs was quantified on a 4-grade rating scale ("similar," "partially similar," "not similar/not present," and "different").

RESULTS

Of 18 national CPGs, 3 CPGs (CPGs of Diabetes, Musculoskeletal disorders, and Stroke) had 9 recommendations related to P&O. The Musculoskeletal disorders and Stroke CPGs had quality scores .60% in all domains, and the Diabetes CPG had scores .60% in 5 of 6 domains according to AGREE II. Seven regional CPGs for P&O treatment were identified. Three national recommendations (in Diabetes CPGs) showed "similar" content for all regions, and 2 national recommendations (in Diabetes CPGs) showed "not similar" content for all regions. The remaining recommendations (Diabetes, Musculoskeletal disorders, and Stroke CPGs) had varying agreement with regional CPGs.

CONCLUSIONS

There is a limited number of national recommendations for treatment within P&O. There was variation in the agreement of P&O-related recommendations in national and regional CPGs, which might lead to unequal care throughout the national healthcare system.

Lower Extremity Amputation Rates in People With Diabetes Mellitus: A Retrospective Population Based Cohort Study in Zwolle Region, The Netherlands

OBJECTIVE

Lower extremity amputations are a major complication of diabetes mellitus (DM). In a previous Dutch study, the incident rate of major amputations was 89.2 per 100 000 person years. The primary aim of this study was to describe the lower extremity amputation rates in people with DM in the Zwolle region, where preventive and curative footcare is organised according to the guidelines of the International Working Group of the Diabetic Foot (IWGDF). The secondary aim was to evaluate outcomes and underlying characteristics of these people.

METHODS

This was a retrospective regional population based cohort study. Data from all people with DM treated in primary and secondary care, living in the region Zwolle were collected. All amputations in the period 2017 to 2019 were analysed. Comparisons were made between those with and without an amputation.

RESULTS

In the analysis 5 915 people with DM were included, with a mean age of 67.8 (IQR 57.9, 75.9) years. Of those people, 47% were women and the median HbA1c was 53 (IQR 47, 62) mmol/mol. Over the three year study period 68 amputations were performed in 59 people: 46 minor, 22 major. This translated into an average annual crude amputation incidence rate of non-traumatic major and minor amputations of 41.5 and 86.9 per 100 000 person years among people with diabetes. Compared with those not undergoing amputations, those who underwent an amputation were more often men, older, mainly had T2DM, were treated in secondary care, had higher diastolic blood pressure, worse diabetic footcare profile, longer DM duration and higher HbA1c. At the end of the follow up, 111 people died: 96 (1.6%) without and 15 (25.4%) with amputations (p < .001).

CONCLUSIONS

This retrospective study provides detailed insight into the rate of amputations in Dutch people with diabetes in the region Zwolle. Compared with previous Dutch estimates, these data suggest a considerable decrease in the major amputation incidence rate.

Offloading of diabetes-related neuropathic foot ulcers at Swedish prosthetic and orthotic clinics

AIMS

This study aimed to assess (1) the use of different offloading interventions in Sweden for the healing of diabetes-related plantar neuropathic forefoot ulcers, (2) factors influencing the offloading intervention choice, and (3) the awareness of current gold standard offloading devices.

METHODS

An online questionnaire was distributed via SurveyMonkey to 51 prosthetic and orthotic clinics in Sweden.

RESULTS

Thirty-five (69%) practitioners responded to the questionnaire. Eighty-six percent of the practitioners provided modified off-the-shelf footwear combined with insoles to treat diabetes-related plantar neuropathic forefoot ulcers. A total contact cast (TCC) was provided by 20% of the practitioners, and a nonremovable knee-high walker was provided by 0%. Multiple practitioner-, patient-, intervention-, and wound-related factors were considered when practitioners provided offloading interventions to patients with this type of ulcer. The majority of the practitioners did not or were unsure whether they considered TCC or a nonremovable knee-high walker to be the gold standard treatment.

CONCLUSIONS

Practitioners mainly provided the offloading intervention that the International Working Group on the Diabetic Foot strongly recommends not be provided, namely, modified off-the-shelf footwear with insoles. In contrast, TCC and nonremovable knee-high walkers, as the gold standards, were vastly underutilised. Therefore, the pattern of providing offloading interventions was almost exactly opposite to the recommendations of evidence-based guidelines. Different factors were considered when providing offloading interventions to patients with diabetes-related plantar neuropathic forefoot ulcers. The practitioners' lack of awareness regarding gold standard devices may have contributed to the underutilisation of TCC and nonremovable knee-high walkers.

Editor's Choice - Incidence of Lower Limb Amputations in Sweden from 2008 to 2017

OBJECTIVE

This study examined the recent national and regional incidence of lower limb amputations (LLAs) in Sweden and their annual changes.

METHODS

This was an observational study using Swedish national register data. All initial amputations were identified in Sweden from 2008 to 2017 in individuals 18 years or older using the national inpatient register. The amputations were categorised into three levels: high proximal (through or above the knee joint), low proximal (through the tibia to through the ankle joint), and partial foot amputations. To examine the national and regional incidence and annual changes, the age, sex, and region specific population count each year was used as the denominator and Poisson regression or negative binomial regression models were used to estimate incidence rate ratios (IRRs) and 95% confidence intervals (CIs) adjusted for age and sex.

RESULTS

The national annual incidence of LLAs was 22.1 per 100 000 inhabitants, with a higher incidence in men (24.2) than in women (20.0). The incidence of LLAs (all levels combined) declined during the study period, with an IRR of 0.984 per year (95% CI 0.973 - 0.994). This was mainly due to a decrease in high proximal amputations (0.985, 95% CI 0.974 - 0.995) and low proximal amputations (0.973, 95% CI 0.962 - 0.984). No change in the incidence of partial foot amputations was observed (0.994, 95% CI 0.974 - 1.014). Such declines in LLA incidence (all levels combined) were observed in nine of the 21 regions. Compared with the national average and with adjustment for age, sex, diabetes, and artery disease, the regional IRR varied from 0.85 to 1.36 for all LLAs, from 0.67 to 1.61 for high proximal amputations, from 0.50 to 1.51 for low proximal amputations, and from 0.13 to 3.68 for partial foot amputations.

CONCLUSION

The incidence of LLAs has decreased in Sweden. However, regional variations in incidence, time trends, and amputation levels warrant further research.

The Effect of MDT Collaborative Nursing Combined with Hierarchical Nursing Management Model on the Quality of Life and Comfort of Patients with Gallbladder Stones Combined with Acute Cholecystitis after Surgery

Objective

To explore the effect of MDT (multidisciplinary team) collaborative nursing combined with hierarchical nursing management mode on the quality of life and comfort of patients with gallbladder stones combined with acute cholecystitis after surgery.

Methods

A total of 120 patients with gallbladder stones and acute cholecystitis who were treated in our hospital from March 2019 to March 2021 were selected as prospective research objects. According to the order of care, they were divided into control group and observation group with 60 cases each. Among them, the control group implements a hierarchical nursing management model, and the observation group implements MDT collaborative nursing based on this and compares the impact of the two groups on patient's quality of life scores, daily self-care ability, nursing satisfaction, and comfort after nursing.

Results

Before nursing, the comparison of the quality of life score, nursing comfort, and nursing ability of the two groups of patients was not statistically significant (P > 0.05). After nursing, the mental vitality score, social interaction score, emotional restriction score, and mental status of the observation group were significantly higher than those of the control group. Statistics showed that the difference was statistically significant (P < 0.05). After nursing, the scores of social comfort, physical comfort, and psychological comfort of the observation group were significantly higher than those of the control group, and statistics showed that the difference was statistically significant (P < 0.05). The health knowledge level, self-care skills, self-care responsibility, and self-concept of the observation group after nursing were higher than those of the control group, while the score of depression and mood disorder was significantly lower than that of the control group. Statistics showed that this difference was statistically significant (P < 0.05). After nursing, patients in the observation group had higher operating technique scores, service attitude scores, health education scores, psychological intervention scores, and nursing quality scores than those of the control group. Statistics showed that the difference was statistically significant (P < 0.05).

Conclusion

MDT collaborative nursing combined with hierarchical nursing management mode can effectively improve the self-care ability of patients with gallbladder stones complicated with acute cholecystitis, effectively improve the quality of life of patients, and improve the satisfaction and comfort of patients with nursing care. The postnursing care of patients after inflammation has a certain reference value.

Will Multidisciplinary Collaboration Reduce the Disability Rate of Diabetic Foot (2009-2019)?-A Study Based on the Perspective of Organizational Reform

Objectives: Discuss the experience and practice of multidisciplinary cooperation of diabetic foot in China and analyze its impact on the quality of care.

Methods: This study observed the medical procedure by interviewing 12 key personnel in-depth. We extracted data from medical records and assessed the effect of MDT in three dimensions: quality, efficiency, and cost, to eventually achieve a final conclusion.

Results: The studied reform includes the following three aspects: the adjustment of hospital buildings layout and disciplines, one-stop outpatient, and one-stop inpatient service. After the multidisciplinary collaboration, the rate of above-knee amputation is reduced by 3.63%, the disability score per 100 diabetic foot patients decreases by 6.12, the average length of stay decreases significantly, and the cost of hospitalization shows an increasing trend.

Conclusions: Multidisciplinary collaboration is performed based on spatial layout adjustment and clinical pathway optimization, which provide more comprehensive and integrated care than a general medical team or a single specialist, thereby reducing the rate of disability, shortening the length of hospitalization. Besides, the new measurable indicator called disability score per 100 diabetic foot patients has been verified to evaluate the living ability of patients after surgery. This paper provides a reference for organizational reform of multidisciplinary diseases to support treatment and management of other multiorgan diseases.

The utilisation of vascular limb salvage services in the assessment and management of chronic limb-threatening ischaemia and diabetic foot ulceration: A systematic review

Specialist vascular limb salvage services have gained prominence as a new model of care to help overcome barriers which exist in the management of patients with chronic limb-threatening ischaemia (CLTI) and/or diabetic foot ulceration (DFU). This systematic review aims to explore the nature of reported services, investigate their outcome in the management of CLTI/DFU, and assess the scope and quality of the evidence base to help make recommendations for future practice and research. A systematic search of MEDLINE, Embase, The Cochrane Library, Scopus and CINAHL, from 1st January 1995 to 18th January 2019, was performed. Specialist vascular limb salvage services were defined as those services conforming to the definition of "centres of excellence" within the 2019 Global Vascular Guidelines. A study protocol was registered at the International Prospective Register of Systematic Reviews (PROSPERO) (CRD42019123325). In total, 2260 articles were screened, with 12 articles (describing 11 services) included in a narrative synthesis. All services ran akin to the "toe-and-flow" model, with a number of services having additional core input from diabetology, microbiology, allied health professionals and/or internal/vascular medicine. Methodological weaknesses were identified within the design of the included articles and only one was deemed of high quality. The inception of services was associated with improved rates of major amputation; however, no significant changes in minor amputation or mortality rates were identified. Further research should adopt more a standardised study design and outcomes measures in order to improve the quality of evidence within the literature.

A systematic review of multidisciplinary teams to reduce major amputations for patients with diabetic foot ulcers

OBJECTIVE

Multiple single-center studies have reported significant reductions in major amputations among patients with diabetic foot ulcers after initiation of multidisciplinary teams. The purpose of this study was to assess the association between multidisciplinary teams (ie, two or more types of clinicians working together) and the risk of major amputation and to compile descriptions of these diverse teams.

METHODS

We searched PubMed, Scopus, Cumulative Index to Nursing and Allied Health, and Cochrane Central Register of Controlled Trials from inception through May 24, 2019 for studies reporting the association between multidisciplinary teams and major amputation rates for patients with diabetic foot ulcers. We included original studies if ≥50% of the patients seen by the multidisciplinary team had diabetes, they included a control group, and they reported the effect of a multidisciplinary team on major amputation rates. Studies were excluded if they were non-English language, abstracts only, or unpublished. We used the five-domain Systems Engineering Initiative for Patient Safety Model to describe team composition and function and summarized changes in major amputation rates associated with multidisciplinary team care. A meta-analysis was not performed because of heterogeneity across studies, their observational designs, and the potential for uncontrolled confounding (PROSPERO No. 2017: CRD42017067915).

RESULTS

We included 33 studies, none of which were randomized trials. Multidisciplinary team composition and functions were highly diverse. However, four elements were common across teams: teams were composed of medical and surgical disciplines; larger teams benefitted from having a "captain" and a nuclear and ancillary team member structure; clear referral pathways and care algorithms supported timely, comprehensive care; and multidisciplinary teams addressed four key tasks: glycemic control, local wound management, vascular disease, and infection. Ninety-four percent (31/33) of studies reported a reduction in major amputations after institution of a multidisciplinary team.

CONCLUSIONS

Multidisciplinary team composition was variable but reduced major amputations in 94% of studies. Teams consistently addressed glycemic control, local wound management, vascular disease, and infection in a timely and coordinated manner to reduce major amputation for patients with diabetic foot ulcerations. Care algorithms and referral pathways were key tools to their success.