3/2/2016

1

3/2/2016

Track 1 Breakout Session-

Cost Effective Clinical Tools

for Improved Diabetic Foot Outcomes

(Hands- on session)

R. Gary Sibbald, MD, M.Ed, D.Sc (Hons)

FRCPC (Med, Derm), FAAD, MAPWCA

Elizabeth A. Ayello, PhD, RN, ACNS-BC,

CWON, MAPWCA, FAAN

Kathya Zinszer, DPM, MPH FAPWCA

Participants Will:

Describe an evidence based 60- second screening tool for the high risk diabetic foot

Demonstrate the use of infrared thermography in the care of persons with diabetes mellitus

Identify areas of high pressure and shear on the diabetic foot that can lead to ulceration

Global Type 2 Diabetes Tsunami

IDF Atlas 5th edition diabetes

prevalence (age 20-79)

Guyana

15%

Year Persons with

Diabetes

Comment

2011 365 million • 4.6 million DM related deaths annually

• Spending on DM 465 million US

2030 552 million • 50% increase

• Additional 398 million at high risk

75% of people with diabetes now live in low-and middle-income countries

4th leading cause of death

Lifestyle interventions to prevent diabetes

Foot care for people at high risk

Glycemic control if HbA1c > 9%

Highest priorities for diabetes interventions

Low-Middle Income Countries (LMIC) are?

Dx and Rx Diabetic retinopathy

© WoundPedia

Diabetes Control Priorities in

Developing Countries1

Highest level priority:

Cost saving AND Highly feasible

Type 2 Diabetes

• Foot care if high risk

• Glycemic control to HbA1c < 9%

• Blood pressure control to BP < 160/95

1) Narayan V, et al. Diabetes: The Pandemic and Potential Solutions. In:

Jamison D, et al., editors. Disease Control Priorities in Developing

Countries. 2nd ed. Washington, DC: World Bank; 2006. p. 591-603.

Plantar Pressure Redistribution

You do not need a lot of money

or resources to make a big difference

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2

Plantar Pressure Redistribution

Standards of Care - Affordable

In Canada250 patients treated for

less than $7000 Canadian

In Guyana$150-200

$20-25

A Variety of Standard Offloading

Boots and shoes

$20-25

Darco Forefoot & Heel Offloading

Shoe & GlobalPed

$20-25

Forefoot OffloaderRearfoot Heel Offloader

Posterior Heel and Achilles Tendon offloader

Bledsoe & Pneumatic Walking Boots

$20-25

Total Contact Cast: Gold

Standard for Plantar Diabetic

Foot Ulcers

$20-25

Felted Foam: Lower risk for

Plantar Diabetic Foot Ulcers with

severe PDN

$20-25

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3

Every 20 seconds a lower limb is lost to diabetes somewhere in the world

Vast majority are preventable through patient centred interprofessional care (integrated, coordinated)

Diabetic foot screening (high risk foot) is one of the three most cost-savings diabetes interventions – yet the most neglected (others- HbA1c, blood pressure)

Diabetic Foot – Global View

Source: Williams, International Working Group for the Diabetic Foot & Narayan KV, Zhang P, Kanaya AM, DE, Engelgau MM, Imperatore G, et al. Diabetes: The Pandemic and Potential Solutions.

Disease Control Priorities in Developing Countries [Internet]. Washington D.C. World Bank; 2006 Available from: http://www.ncbi.nlm.nih.gov/books/NBK11777/

Benchmark HbA1c Data

• GPHC: 4302 1st tests – April 2010 to Feb

2013

• 295 F-up tests - 65% adherent to

protocol

• Percentage with HbA1c > 9%

o All persons with diabetes 38%

o Diabetic Foot patients 44%

Mean HbA1c from DFC patients 13% higher than from other facilities

High risk foot status is associated with poor glycemic control

Phase 1- Developed Center of Excellence at GPHC –

Diabetic Foot Centre

Interprofessional teams MD, Nurse, Rehab

Develop Key opinion leaders

4 levels of education – multi faceted,

longitudinal strategies

Focus on Prevention

Wound Bed Preparation Paradigm (Sibbald et al. 2011)

In clinic preceptorships:Doppler, infra-red thermometer, footwear

Conservative debridement

©

Major Amputations at GPHC

Risk Months Mean

St.

dev

95%

CI T test

Befor

e DFC 42 7.95 3.99 1.24 P <

0.0001After

DFC 42 4.14 2.36 0.73

48% reduction from pre-project levels

48 limbs saved each year = 192 limbs to July 2012

68% reduction in monthly proportion of DFU

despite 75% increase in DFU admissions

PLOS Med April 2015

Variable

Pre-DFC

(30months)

Post -DFC

(22 months)

Analysis

DF admissions

(ward records)

633 924

N Amputations 262 110 P<0.0001

Avg. Monthly

Proportion DFU

patient with Maj.

Amp.

41.4% 11.9% 71%

reduction

Diabetic Foot Ulcer Admissions and Amputation Rates at Georgetown Public Hospital Corporation

VariablePre-

Intervention

Post

InterventionTest-statistic p-value

Time in

months 42 48

N Above

knee amp124 113*

Mean (SD) 2.95 (2.44) 2.13 (1.81) -1.82 (t) 0.07

N Below

knee amp166 41*

Mean (SD) 3.95 (2.64) 0.77 (1.05) -7.35 (t) < 0.0001

Major Amputations by type at Georgetown Public Hospital Corporation

*Represents total with available dates. One AKA and 3 BKAs were not dated.

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Why were BKAs markedly lowered but AKAs were not?

Hypothesis:

Patients requiring AKAs are more likely to have associated peripheral vascular insufficiency (ischemia) which GDFP did not address.

Test:

Compare indices of PVD in patients with AKA and BKA

Reverse Innovation

…“innovation seen first, or likely to be

used first, in the developing world before

spreading to the industrialized world”.

Wikipedia

What innovations were applied in this project that

are not currently part of integrated coordinated care

in North America?

The 4 S’s of DM Ulcer Prevention

Screening Stop Smoking Shoes Shoes

© Sibbald & Ayello 2012

Skin Temperature

Screening – high risk status

Risk factor Ulcer yearly

incidence/ rate %

Odds ratio

(95%CI)

Group 0 (no PN, no PVD) 2%

Group 1

(PN, no PVD or deformity)

4.5% 2.4 (1.1.-5)

Group 2B (PVD) 13.8% 9.3 (5.7-15.2)

Group 3 PN/ PVD (history of

ulcer or amputation)

32.2% 52.7(27.2-109.8)

3/2/2016

Lavery LA, et al. … classification system of the International Working Group

on the Diabetic Foot. Diabetes Care 31(1):154-6, 2008.

Focus on Prevention:

60 Second Screening

•History

•Inspection abnormalities

•Palpate pulse

•Deformity

•Monofilament testing

(4 out 10 negative)

After Inlow 60 sec exam

Screening for the high risk diabetic foot: A 60-Second Tool (2012) ©

Sibbald

Name: _______________________________________________

ID#: ________ Phone #:_____________ Facility:____________

DOB (dd/mm/yy):_______/_______/_______

Gender: M □ F □ Years with diabetes:________

Ethnicity: Black □ Asian □ Caucasian □ Mixed □ Other □

Date of Exam (dd/mm/yy): ______/______/______

CHECK BOTH FEET

(Circle correct response)

“YES” on either foot = HIGH RISK

LEFT RIGHT

HISTORY 1. Previous ulcer NO YES NO YES

2. Previous amputation NO YES NO YES

PHYSICAL EXAM 3. Deformity NO YES NO YES

4. Absent pedal pulses

(Dorsalis Pedis and/ or Posterior Tibial) NO YES

NO YES

FOOT LESIONS Remember to check 4

th and

5th web spaces/nails for

fungal infection and check

for inappropriate footwear.

5. Active ulcer NO YES NO YES

6. Ingrown toenail NO YES NO YES

7. Calluses (thick plantar skin) NO YES NO YES

8. Blisters NO YES NO YES

9. Fissure (linear crack) NO YES NO YES

NEUROPATHY MORE THAN 4/10 SITES

LACKING FEELING =

“YES”

10. Monofilament exam (record negative reaction): a) Right______/10 negatives ( 4 negatives = Yes) b) Left_______/10 negatives ( 4 negatives = Yes)

NO YES

NO YES

Total # of YES:_____ Total # of YES: ____

PLAN

a) POSITIVE SCREEN- Results when there are one or more “Yes” responses. Refer to a foot specialist or team

for prevention, treatment and follow up. (Bony deformity, current ulcer, absent pulse are most urgent).

These individuals are at increased risk of a foot ulcer and/or infection. Patients should be educated on what

changes to observe and report, while waiting for the specialist appointment.

Referral to: ____________________________ Appointment time:_______________________

b) NEGATIVE SCREEN- Results when there are all “No” responses. No referral required.

Educate patient to report any new changes to their healthcare provider and re-examine in 1 year.

One Year Date for Re-Examination (dd/mm/yy):________/________/________

Completed By: __________________________ Date: _________________________________

Additional Note: See reverse side for recommendations from the International Diabetes Federation, & International Working

Group on the Diabetic Foot.

Local referral patterns may vary depending on expertise and available resources.

Available at

www.diabeticfootscreen.com

www.WoundPedia.com

What % persons with DM

have a high risk foot?

RED: 48%

YELLOW: 73%

PINK: 92%

GREEN: 27%

BLUE : 14%

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Profile: 1266 consecutive PWD

ITEM NO % YES %

Previous Ulcer 91 9

Previous Amp 96 4

Deformity 92.1 7.9

Absent pulse 88 12

Active DFU 92.3 9

Ingrown toenail 81.7 18.3

Callus 77.7 22.3

Fissure 89.5 10.5

Neuropathy 76.6 23.4

REFERRED DFC 52 48

PL0S Med. 2015 Apr; 12(4):

The Guyana Diabetes and Foot Care

Project: A Complex Quality

Improvement Intervention to

Decrease Diabetes-Related Major

Lower Extremity Amputations and

Improve Diabetes Care in a Lower-

Middle-Income Country

• Interprofessional team

• Center of excellence

• Footwear- Footcare + VIPs

• Reduced amputations 68-72%

Julia Lowe, R. Gary Sibbald,

Nashwah Y. Taha, Gerald Lebovic,

Carlos Martin,Indira Bhoj, Rolinda Kirton,

Brian Ostrow, and the

Guyana Diabetes and Foot Care Project Team¶

60 Second Screen - History

1. Previous Ulceration 2. Previous Amputation

3/2/2016

Simplified 60 Second Screen Tool (2012)©

Physical Examination

3. Deformity OR Charcot Change

© Sibbald 2012

60 Second Screen –

Physical Examination

4. Pulses absent

Dorsalis Pedis and /or Posterior Tibial

3/2/2016

60 Second Screen – Foot Lesions

5. Active Ulcer 6. Ingrown toenail

3/2/2016

60 Second Screen – Foot Lesions

7. Calluses =

increased pressure

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60 Second Screen – Foot Lesions

4th – 5th Toe Web Space Nails- early fungus

3/2/2016

Also look for/ treat possible

fungus • 4th – 5th Toe Web Space

© Sibbald 2012

60 Second Screen – Neuropathy

10.Mono filament Exam

X for negative = 4/ 10

3/2/2016

X

X

X X

Lets go to the video tape!Simplified 60 Second Screen Tool (2012)©

International Diabetes Federation, International Working Group on the Diabetic Foot, 2008

Validation of the 60 second screening toolPLOS Medicine, June 2015 (Woodbury, Sibbald et.al)

• Multiple raters

– 6 Canadians

– 6 Guyanese KOL

• 18 subjects with various high risk diabetic foot features examined by all 12 rater clinicians

• Statistical analysis

– Cronbach's alpha as a measure of internal consistency

– Set of items= raters

– 0 to 1 (perfect agreement)

– Statistical cut off at 0.6

© WoundPedia

3/2/2016

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Validation of the Simplified 60 Second Tool

Simplified 60-second screen

items

Canadians &

Guyanese

Canadians Guyanese

Previous Ulcer .966 .975 .942

Previous Amputation .969 .920 .948

Deformity .874 .833 .665

Absent Pulses .868 .828 .669

Fixed Ankle .909 .909 .759

Fixed Toe .798 .600 .696

Active Ulcer .971 .923 .961

Ingrown Nail .723 .481 .636

Callus .874 .882 .690

Blisters .768 .704 .587

Fissures .553 .245 .415

Monofilament Test R foot .983 .966 .971

Monofilament Test L foot .978 .966 .955

Tool for Rapid & Easy Identification of High Risk Diabetic Foot: Validation & Clinical Pilot of the Simplified 60 Second Diabetic Foot Screening Tool

M. Gail Woodbury, R. Gary Sibbald,* Brian Ostrow, Reneeka Persaud, and Julia M. LowePlos-one June 29, 2015

© WoundPedia

Perform a 60 second screen exam

with your neighbour

Comment on:

How easy was the test to perform

Where would you suggest the test be performed/ implemented?

What type of referral network should be set up for individuals

with a positive test result?

Why should we look for fungus?

Answer: Higher Incidence of Secondary Infections

in Persons with Diabetes & Onychomycosis

0

1

2

3

4

5

6

7

Gangrene Foot Ulcer Gangrene + FootUlcer

Incid

en

ce (

%)

Without Onychomycosis

Boyko, W. L., Doyle, J. J., Ryu, S., & Gause, D. O. (1999). PDD5: ONYCHOMYCOSIS AND ITS IMPACT ON

SECONDARY INFECTION DEVELOPMENT IN THE DIABETIC POPULATION. Value in Health, 2(3), 199.

© WoundPedia

Onychomycosis Presentations

Mild PSO/DLSO Mild DLSO Moderate DLSO

Dermatophytoma

Severe Onychomycosis

Gupta AK, et al. J Eur Acad Dermatol Venereol. 2000;1:466–469Photographs: collection of A Gupta

PSO Candida

Onychomycosis

Differential Diagnosis of Onychomycosis

• Disease at

other sites

• Nail ridging

• Splitting or

thinning

• Loss of

nails

• Dorsal pterygium

Lichen

Planus

Eisman et al. BM J. 2014;348:g1800.

Trauma Image: Alex Lozupone

Afifi et al. Can Fam Physician. 2005 Apr;51:519-25.

American Academy of Dermatology National Library of

Dermatologic Teaching Slides.

Psoriasis

• Subungual hyperkeratosis

• Splinter hemorrhages

• Leukonychia

• Dystrophy

• Nail pitting

• Psoriatic plaques

• Oil drop sign

Trauma

• Abnormal nail

plate

• Normal nail bed

• Distal onicholysis

• Single nail

affected

• Nail shape

change

• Homogenous

colour change

Tinea Investigations

Scraping or nail clipping for culture and

sensitivity

• Scraping from the edge of the lesion

• Clipping should include the subungal debris

About 20% falsely negative

Reasonable to perform 3 cultures before classed

as negative

Order 1% Hydrocortisone powder in

Clotrimazole cream when waiting for the results

(order 100 gms)

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Fungal Nail Infections (L.I.O.N.)Evans EG, Sigurgeirsson B: Br Med J 99

Dose and Time Mycological Cure

Terbinefine 250 od for 3

months

75.7%

Terbinefine 250 od for 4

months

80.8%

Itraconazole 400 od x 1 wk

/mo x3

38.3%

Itraconazole 400 od x 1 wk

/mo x3

49.1%

A evidence: Double blind random study of more than 120 patients in each group

Dry Diabetic Foot: What cream should I use:

Fungus: X2 per day for 2 weeks

Cicloprox Rx – 60%

Azoles- 70%-80% Miconazole

Clotrimazole

Econazole

Ketoconazole

X1 per day for 1 week

Allylamines – 90%

Terbinefine Rx

naftifine

Recurrences 7-16% per year,

Use cream x 2 week to prevent recurrences

Dry Skin: Moisturizers

Humectants Urea

Lactic Acid

Glycerin

Ceramides

Lubricants Silicone, dimethacone

Lanolin, petrolatum

When in doubt, RX

1% hydrocortisone powder in Clotrimazole cream

Twice daily (BID) and give 100 grams

Pathway to the Prevention & Treatment of Toenail Onychomycosis

Detail: III Treatment strategies

1. Elewski B, et al. J Am Acad Dermatol 2013;68(4):600-8

2. Gupta AK, et al. J Drugs Dermatol. 2014

Topical efinaconazol e = Jublia, Valeant

Bacterial Soup

Compress a wound with saline or water

Do not use foot soaks or you are spreading any bacteria anywhere on the foot into the open areas (toe webs, nail folds, fissures or ulcers)

3/2/2016

How can you determine if shoes

are too small ?

No Smoking: Double indemnity

• Every cigarette will decrease the circulation in the leg or foot up to 30% for an hour or

increase sympathetic tone for 8 hours

Cigarette smoking decreases tissue oxygen. –Jensen JA - Arch Surg - 01-SEP-1991; 126(9): 1131-4 © Sibbald & Ayello 2012

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The 4 S’s of DM Ulcer Prevention

Screening Stop Smoking Shoes Shoes

© Sibbald & Ayello 2012

Skin Temperature

Dermal Thermometry: An Important Tool to Prevent Amputation: Bit by Bit

Blood supply – unequal

Infection: Deep and surrounding

wound infection

Trauma = Patient self monitoring-4-10 OF

Charcot = Acute & hot 10-20 OF

Infrared Thermometry CE-Sibbald, Mufti, Armstrong

Advances Skin + Wound Care 2015

Infrared Thermometry

CE-Sibbald, Mufti, Armstrong

Advances Skin + Wound Care 2015

Acute Charcot & Infrared Dermal ThermometryTemperature

Provides an early warning sign with patient self monitoring of repetitive

trauma

Acute stage may be 10-15 degrees Fahrenheit warmer than the mirror image on the other foot

Temperature normalization may allow gradual re-ambulation with plantar

pressure redistribution devices

Armstrong DG, Lavery LA: Predicting neuropathic ulceration with infrared dermal thermometry. J Am Podiatr Med Assoc 87:336–337, 1997David G. Armstrong and Edgar J. G. Peters (2002) Charcot’s Arthropathy of the Foot. Journal of the American Podiatric Medical Association: July 2002, Vol. 92, No. 7, pp. 390-394.

EXERGEN scanning thermometer

Charcot foot –Neurological Exam

• Sensory –

– Semmes - Weinstein 5.07 monofilament

– Vibratory test - Diminished

• Autonomic- Dry skin (R/O Tinea)

• Motor-

– Reflex - ankle jerk diminished

Stage Management

0 – Prodromal

? 4-8 deg. F

Non-weight-bearing cast

Minimum immobilization: 8–12 weeks

1 - Developmental, acute

?8-15+ deg. F

Non-weight-bearing cast

Immobilization or graduate to a removable

cast walker

2 - Coalescence, subacute

? 4-8 deg. F.

Patellar tendon-bearing brace (PTB)

Charcot restraint orthotic walker (CROW

walker)

3 - Reconstruction, chronic

Normal/ similar mirror image

Custom-made shoes with or without a brace54

Management of the Charcot Foot:Use the infrared thermometry to measure stages

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Pillars of Charcot Treatment

1. Early recognition

2. Off-loading to reduce

the deformity that will

result from continued

weight-bearing and

3. Management of

complications

Validation of Commercially Available Infrared Thermometers for Measuring Skin Surface

Temperature Associated with Deep and Surrounding Wound Infection

Asfandyar Mufti MD (c)Pat Coutts RN, IIWCCR. Gary Sibbald MD

Advances in Skin + Wound Care Jan 2015

Infrared Thermometer Screens

OBJECTIVE:

• Compare 4 less expensive, commercially available non-contact infrared thermometers to the scientifically accepted Exergen DermaTemp 1001™.

DESIGN, SETTING, AND PARTICIPANTS:

• observational study design• Consenting participants with open wounds were sequentially selected from a chronic wound clinic (n=108). • Skin temperatures were recorded using five non-contact infrared thermometers under consistent

environmental conditions.

MAIN RESULTS:

• No statistical difference was reported between the “ΔT” values for the five different thermometers (F(4, 514) = 0.339, p=0.852)

• intraclass correlation showed high reliability and agreement between raters, as the ICC values for all thermometers were >0.95.

Validation Commercially available low cost infrared thermometers

Device Measurement Range

Operating Range

Accuracy (Ambient

temperature = 25°Ca)

Distance to Size Ratio

Continuous Scanning

“Maximum” temperature

Cost

(US Dollars)

Exergen DermaTemp1001TM 18 to 43°C

(65 to 110°Fb)

16 to 43°C

(60 to 110°F)

± 0.1°C (0.2°F) 1:1 Yes Yes $650.00-750.00

Mastercraft Digital Temperature

ReaderTM

-30 to 480°C

(-22 to 896°F)

0 to 50°C

(32 to 122°F)

±2.0°C (4.0°F)c 8:1 Yes Yes $99.99

ATD Tools 70001 Infrared

Thermometer®

-60 to 550°C

(-76 to 1022°F)

0 to 50°C

(32 to 122°F)

±1.5°C (2.7°F) 12:1 Yes Yes $37.00-80.00

Pro Point Infrared Thermometer -60 to 500°C

(-76 to 932°F)

0 to 50°C

(32 to 122°F)

±1.0°C (1.8°F) 12:1 Yes Yes $99.99

Mastercool©

MSC52224-A-58 to 932°C

(-50 to 500°F)

0 to 40°C

(32 to 104°F)

±2.0°C (4.0°F) 12:1 Yes Yes $57.00 - $68.00

Device Specifications and Features

Neuropathic

Foot Ulcer

22%

Malignancy

3%

Infection

6%

Inflammation

10%

Venous/

Lymphatic

Ulcers

20%Post Surgical

Wound

8%

Pressure

Ulcer

7%

Trauma

11%

Arterial Ulcer

6%

Other

7%

STUDY PATIENT WOUND ETIOLOGYINFRARED THERMOMETER STUDY

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11

Thermometer Mean “ΔT”

Exergen DermaTemp 1001TM 2.39 °F (SD = 3.54)

Mastercool© MSC52224-A 2.68 °F (SD = 4.06)a

ATD Tools 70001 Infrared Thermometer®

2.67 °F (SD = 3.93)b

Mastercraft Digital Temperature ReaderT M

2.72 °F (SD = 4.26)c

Pro Point Infrared Thermometer 3.01 °F (SD = 3.90)d

a p = 0.987; b p = 0.985; c p = 0.972; d p = 0.774

RESULTS – “Mean Temperature Gradients”

N = 108P= 0.852

Thermometer ICCa

Exergen DermaTemp 1001TM 0.967 (0.92, 0.987)

ATD Tools 70001 Infrared Thermometer®

0.970 (0.925, 0.988)

Pro Point Infrared Thermometer 0.969 (0.922, 0.987)

Mastercool© MSC52224-A 0.968 (0.92, 0.987)

Mastercraft Digital Temperature ReaderT M

0.952 (0.884, 0.981)

a95% CI values stated in parenthesis.

RESULTS – “Inter- Rater Reliability”

N = 20

MastercraftDigital

Temperature ReaderTM

ATD Tools 70001 Infrared Thermometer®

Pro Point Infrared

Thermometer

Mastercool©

MSC52224-A

less expensive, industrial grade non-contact infrared thermometers have reliable temperature readings

Conclusion:

Asfandyar Mufti MD (c)Pat Coutts RN, IIWCCR. Gary Sibbald MD

Advances in Skin + Wound Care Jan 2015

Wound Bed Preparation 2015Person

with a Chronic Wound

Identify & Treat the cause

Patient/Family Centered Concerns

Determine Healability for patient outcomes &

local wound care

DebridementInflammation/

InfectionNERDS/STONEES

Moisture Balance

Edge Effect© Sibbald , Elliott, Ayello, Sumayaji -Advances in Skin – Wound Care- Oct. 2015

Levine Technique

Speaker, Title, Hospital

• Non-healing

• Exudate

• Red + Bleeding

• Debris

• Smell

NERDS Superficial

critical colonization :

Treat topically

• Size is bigger

• Temperature ↑

• Os (probes, exposed)

• New breakdown

• Exudate,

• Erythema, Edema

• Smell

STONEES

Deep

+ Surrounding

Treat Systemically

PAIN AND WOUND

Superficial Critical Colonization Deep / Surrounding Infection

Sibbald, Woo, Ayello 06

Woo, Sibbald 09

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12

NERDS STONEES

NERDS and STONEESWoo & Sibbald 2009

Critical Colonization Deeper infection

N 0.42 (0.18-0.97)* by history S 5.00 (1.82-13.76)

E 5.36 (0.54-53.66) T 8.05 (2.90-22.38)

R 5.07 (1.7-14.83) O 2.76 (1.04-7.31)

D 5.63 (2.19-14.45) N 5.71 (1.79-18.21)

S 3.59 (1.22-10.58)

E 4.88 (1.79-13.27)

E 4.13 (1.72-9.91)

S 3.59 (1.22-10.58)

Clinicians often need to triangulate and look for 2 or 3 of these signs and symptoms

before they make a diagnosis of increased superficial bacterial burden.

Infection vs. peri-wound skin temperature

Skin Temperatures group II a & b

-2

0

2

4

6

8

10

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22

One way AVOVA

between and within

wounded non-

infected

and infected

groups:

F = 44.238

Significance =

.000

0.5˚F 6.4˚F

Range

-0.5 -

8.7˚F

Mean

4.3 ˚F

+/-2.44

Range

-1.0-

3.0˚F

Mean

.383 ˚F

+/-.893

Fierheller Advances 2010

4 Point Technique Whole Wound Technique

3/2/2016

13

OBJECTIVE: Non- Contact Infrared Thermometer Comparison: • “whole wound” continuous scanning technique vs. • “head-to-toe/4 perimeter spot point” technique To detect the maximum wound temperature

DESIGN, SETTING, AND PARTICIPANTS:• Observational study design, • Participants with open wounds were randomly selected

from a chronic wound clinic (n=100). • Skin temperatures were recorded using four non-contact

infrared thermometers under consistent environmental conditions.

Infrared Thermometry – Scanning TechniqueRESULTS – “Mean Temperature Gradients”

Thermometer Mean “ΔT” – Whole Wound Method

P=0.095 Anova one way

Mean “ΔT” – 4 Point MethodP=0.10

Anova one way Exergen DermaTemp

1001TM

1.912°FP=0.786

Independent t test

2.037 °F

Mastercool© MSC52224-A

2.672 °FP=0.763

Independent t test

2.830 °F

Mastercraft Digital Temperature ReaderTM

2.92 °FP=0.383

Independent t test

3.377 °F

Etekcity® ETC-8250 Temperature Heat Pen

2.686 °F

N = 100

Infrared Thermometry –Scanning Technique

Conclusion: Results indicate

Deep and Surrounding infection can be identified with:

• Less expensive, industrial grade non-contact infrared thermometers

• Similar results using either:• the 4-point method • whole wound method

Infrared Thermometry –Scanning Technique

Infrared Thermometry should be

part of my clinical practice

YELLOW: Equivocal

GREEN: Somewhat agree

?RED: Strongly agree

BLUE: Somewhat disagree

PINK : Strongly disagree

Wound Bed Preparation 2015

Prevent or Manage a chronic Wound

Identify & Treat the cause

Patient/Family Centered Concerns

Determine Healability for patient outcomes &

local wound care

DebridementInflammation/

Infection

Moisture Balance

Edge Effect

© Sibbald, Elliott, Ayello, SumayajiAdvances Oct. 2015

Confidential July 29, 2013

Recommendations for

Treat the Cause: Vascular Protection

A…….A1C

B…….B/P

C…….Cholesterol

D…….Drugs to protect the heart

A-----ACE or ARB

S-----Statin

A-----Aspirin if indicated

E……..Exercise—regular physical activity

S……..Smoking Cessation

3/2/2016

14

What is HbA1c and what does it reflect?

• average blood sugar over 3 month period– Lifespan of red blood cell

(RBC)

• Glycation of hemoglobin irreversible– average level of glucose to

which RBC exposed

Nathan DM et al. Diabetes Care 31 (8): 1473–8

What is the A1C?

Blood test

which shows

average blood

sugar over

past 3 months

What is

your

A1C (%) ?

Your Average Blood Sugar

13 18 - 19 324-342

12 16 - 17 288-301

11 14 - 15 252-270

10 13 - 14 234-252

9 11 - 12 198-216

8 10 - 11 180-198

7 8 - 9 144-162

6 7 126

mmol/L mg/dl

Translating the hemoglobin A1c assay into estimated av erage glucose v alues

Dav id M. Nathan, Judith Kuenen, Rikke Borg, Hui Zheng, Dav id Schoenf eld, and Robert J. Heine, f or the A1c-Deriv ed Av erage Glucose

(ADAG) Study Group. Diabetes Care 2008 . Av erage Blood Glucose (mmol) = 1.59 x A1C - 2.59

MH CCACCWCA 2012-Diabetes Related Data

19.3

25.655

Client with Foot Ulcers: Has the client had HbA1c

assessment in the last year

Yes

No

Toronto Regional Wound Healing Clinic Inc2016-03-02

HbA1c blood test measures the percentageof red blood cells that have glucose attached. Normal levels for people with Diabetes is <7.0%.HbA1c should be monitored regularly by physician and patient.

VIPS of Treat the Cause

Vascular

Insufficiency

Inflammation and /

or Infection

Pressure

downloading

Sharp Surgical

debridement

3/2/2016

Diagnostic tests VASCULAR SUPPLY AND HEALING ABILITY

Palpable pulse >80 mm Hg

Ankle-brachial

pressure index

(ABPI)

>0.5 and <1.3

Transcutaneous

O2 tension>30 mm Hg

Toe pressure >55 mm Hg

Audible hand

held Doppler

Triphasic,

Biphasic Sound

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15

AUDIBLE HAND HELD DOPPLER ULTRASOUND DETERMINES RELIABLE & INEXPENSIVE EXCLUSION OF SIGNIFICANT PVD

ALAVI A, SIBBALD RG, NABAVIZADEH R, VALAEI F, COUTTS P, MAYER DVASCULAR. 2015 JAN 27. PII: 1708538114568703. EPUB AHEAD OF PRINT

• Accuracy audible hand held

Doppler ultrasound (AHHD)to identify PVD

• 200 patients, 379 legs

• All had ABPI, toe pressures at

certified vascular lab

(Gold Standard)

Criteria Meaning Result PT/ DP

Specificity No PVD 98.6%/ 97.8%

Sensitivity PVD identified 37.5% / 30.19%

+ Pre.Value (PPV) Abn. AHHD

+ PVD

81.2%/ 72.75%

- Pre. Value (NPV) Normal AHHD/

no PVD

90.91%/ 88.10%

Conclusion: AHHD reliable, simple, rapid,

inexpensive bedside exclusion test

PVD in Diabetic/ non-diabetic subjects

The gold standard of plantar pressure

redistribution is:

YELLOW: Irremovable cast walker

PINK: Contact cast

?RED: Deep toed shoes and custom

orthotics

BLUE: Orthopedic plaster of Paris cast

GREEN: Removable Cast Walker

Plantar Pressure Redistribution

Group A: Walking casts

Pneumatic walker

Contact cast

Group B: Special Shoes

Med- Surg. Shoe

Rocker soles

Special half shoes

Group C: Home Made

Simple materials/ modifications

Option D: With Caution

Surgical pressure

offloading

Group A

Group B

Group C

Downloading % healed Time (days)

RCW 51.9 58.0 +/- 15.2

ITCC 82.6 41.6 +/- 18.7

MH CCACCWCA 2012

Toronto Regional Wound Healing Clinic Inc

139/240 clients with Foot Ulcers were without plantar pressure redistribution.

Examples- Demonstrations of Foot Wear

90

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16

Give your approach to treating this foot: Give your approach to treating this foot:

Participants Have:

Described an evidence based 60- second screening tool for the high risk diabetic foot

Demonstrated the use of infrared thermography in the care of persons with diabetes mellitus

Identified areas of high pressure and shear on the diabetic foot that can lead to ulceration