diabetic foot ulcers evidenced based practice

1. Diabetic Foot UlcersEvidenced Based Practice Kendra Round, R.N. Northeastern State University EBP Symposium April 23, 2010 kd_round@hotmail.com

2. Background Jack C. Montgomery VA Medical Center, Muskogee 7,500 lower limb amputations annually in FY 1989-1991 5,180 veterans discharge with amputations in 1992 Preservation Amputation Care and Treatment (PACT) program Fotieo, Reiber, Carter, & Smith, 1999, p. 55 Mayfield, Reiber, Maynard, Czerneicki, Caps, Sangeorzan, 2001, p. 342 Robbins, 2007, p. 161

3. PICO Question Among patients with diabetic foot ulcers, will those who have oasis wound treatment, as compared to those who use pulsed radio frequency energy, experience improved wound healing time?

4. �Chronic skin breakdown is a significant clinical problem that has been described as a silent epidemic.� Grocott & Campling, 2009, p. 28

5. Significance of the Problem 23. 6 million people, or 7.8% of the population have diabetes More than 60% of nontraumatic lower-limb amputations occur in people with diabetes An estimated 57 million people in the U.S. have prediabetes The total estimated cost of diabetes for direct and indirect medical cost is $174 billion Centers for Disease Control, 2008, www.cdc.gov Dall, Mann, Zhang, Quick, Seifert, Martin, Huang, & Zhang, 2009, p. 157

6. A large portion of foot ulcers fail to heal in spite of months of treatment and they develop into chronic wounds when healing stops which leads to complications such as infections which in turn lead to amputation. Rando, 2009, p. 70

7. Extracellular matrix (ECM) and cellular proliferation ECM Physically support and orient cells Regulate cellular properties Regulate growth factor function Chokan, 2007, p. 122

8. ECM not only supports cell migration but activate cells to replicate, activate and bind growth factor. In hard to heal wounds, ECM cannot support healing due to systemic abnormalities such as diabetes. Chokan, 2007, p. 122

9. OASIS Biological extracellular matrix made from porcine small intestine Components Collagen Fibronectin Glycosaminoglycans Proteoglycans Chokan, 2007, p. 122

10. OASIS Provides and ECM for hard to heal wounds Stimulates Cellular adhesion Improving cellular motility Some growth factors Recurrent, chronic wounds or wounds that have failed standard care Chokan, 2007, p. 128

11. OASIS Debridement before application Apply weekly Each application will lead to new epithelialization 16 week study Chokan, 2007, p. 128 Romanelli, Dini, Bertone, & Brilli, 2007, p. 5

12. OASIS $250 per patient for 12 weeks Store at room temperature Reabsorbed by the body Contraindications Sensitivity to porcine material Third degree burns

13. Pulsed Radio Frequency Energy (PRFE)Provant Therapy System Cell proliferation induction (CPI) 27.12 MHz frequency Applicator pad 30 minutes twice per day Frykberg, 2009, p. 45-46

14. PRFE - Provant Frykberg, 2009, used Provant on 5 patients for 12 weeks which closed the wound and kept the wound closed for several months.

15. PRFE - Provant Short-wave diathermy Survey to determine clinical and safety practices Beneficial in management of soft tissue injuries Did not exacerbate other conditions Preferred treatment

16. PRFE- Provant Easy to use Non-invasive Confidential cost analysis $88 per patient/per day Contraindications Treatment of deep tissue and bone Metallic implants in area of application Cardiac pacemakers Pregnancy Immature bone development Implanted lead

17. Approach to Problem Comparable healing times Cost Application Contraindications Recommendation based on evidence Oasis wound treatment

18. Leadership Support Podiatrist and Wound Care Specialist Oasis Staff training PACT program

19. Evaluation Education on PACT program Wound Care Champions Tracking for further changes

20. QUESTIONS?