The Comprehensive Wound Care Center at Dr. P. Phillips Hospital applies a physician driven, multi-disciplinary approach that directs critical resources required for the treatment of patients with wound healing failure.

 

Diabetes mellitus affects 20.8 million people in the U.S. with 3,651 new cases diagnosed daily. Diabetes is the fifth leading cause of death and the leading cause of blindness, renal failure, and lower extremity amputation. Costs of diabetes care approach $173 billion annually with an estimated $3 billion attributed to foot ulceration. The two year cost of a new diabetic foot ulcer is approximately $28,000. 9 to 20% of diabetic foot ulcers end in amputations while 84% of all lower extremity amputations are preceded by an ulcer. What is often not appreciated (as shown in Figure 1) is that the relative 5-year mortality following lower extremity amputation in a diabetic is greater than for prostate or breast cancer and equal to colon cancer. Therefore, early recognition of the presence of ulceration and aggressive intervention can significantly reduce the risk of amputation and the short and long term costs of care for patients with diabetes.

 

Further complicating the delivery of healthcare by physician practices in Florida and the greater Orlando area is the increasing trend of deaths associated with diabetes (Figure 2). The Comprehensive Wound Care Center, in collaboration with community physicians and hospital based resources, applies evidence based clinical practices with a goal of achieving optimal wound healing, reduction in the rate of amputation, and restoring quality of life to the patients we serve.

 

Optimal care of the diabetic foot ulcer patient has been well described in recent peer reviewed clinical practice guidelines, particularly those published by the Wound Healing Society. Key elements in diabetic foot ulcer management include surgical exploration and debridement of the ulcer to accurately define its extent, remove all necrotic tissue, and drain any local infection, identification of lower extremity peripheral arterial disease and correction of flow obstruction whenever possible, identification and treatment of underlying osteomyelitis if present, effective offloading utilizing total contact casting or prefabricated walking boots that are affixed to prevent patient removal, metabolic control, and aggressive and early use of advanced therapeutic interventions.

 

A number of advanced therapeutic interventions have been shown to be of benefit in accelerating or completing ulcer healing. Surgical revascularization or endovascular procedures to increase periwound blood flow should be attempted whenever possible. Daily topical applications of the recombinant human growth factor PDGF (becaplermin, Regranex®) have been shown in a large, randomized, controlled clinical trial to facilitate healing in well perfused, non-infected diabetic foot ulcers. Likewise, human derived cultured cell grafts (Dermagraft® and Apligraf®) also contribute to significant improvement in healing outcomes. Negative pressure wound therapy may be of benefit in more complex, infected diabetic foot ulcers following aggressive debridement or when open amputations of toes or the distal foot are necessary. While brief hospital inpatient stays may be required, most of these interventions can be provided on an outpatient basis.

 

Since 2002, Medicare has reimbursed the use of hyperbaric oxygen treatment in deep, infected or severely ischemic diabetic foot ulcers based upon the results of an elegant randomized, controlled clinical trial reported in by Faglia in Diabetes Care in 1996 (ref 1). Hyperbaric oxygen treatment is the provision of 100% oxygen breathing to a patient at a pressure of greater than 1.5 atmospheres. This treatment requires a specialized hyperbaric chamber nd medical staff specifically trained in managing patients under these treatment conditions. Benefits include temporarily correcting wound hypoxia even in the setting of decreased arterial perfusion, improved local response to infection, and direct stimulation of tissue growth and angiogenesis. Subsequently a large multicenter cohort series of 1144 diabetic foot ulcer patients receiving hyperbaric oxygen treatment was published supporting the findings of the earlier Faglia clinical trial (ref 2).

 

Hyperbaric oxygen treatment administered once or twice daily five days per week significantly increases complex ulcer healing rates and reduces limb loss due to major amputations.

 

A final major contributor to improved diabetic ulcer healing and amputation prevention has been the development of specialized wound care centers like the center located at Dr. P. Phillips Hospital. The Comprehensive Wound Care Center provides access to the medical and surgical specialists who have received additional training in complex wound management, expert nursing staff, and diagnostic and therapeutic technology necessary to achieve optimal outcomes. In some cases these wound care centers are part of national networks that allow for comparative assessment of outcomes and continuous process improvement.