Problem Description
Diabetic foot ulcer (DFU) is type 2 diabetes (T2D)-related complication associated with the problem of high morbidity and lower quality of life among geriatric diabetics. It manifests as recurrent wounds or painless surface lesions attributed to sensory/motor neuropathy or ischemia (Hampton, 2015). Globally, T2DM is projected to affect over 366 million people by 2030 (Braun, Fisk, Lev-Tov, Kirsner, & Isseroff, 2014). The initiating agent may be a minor trauma or a bruise that causes serious pathologic changes to the lower limbs. Generally, DFU patients are prone to minor trauma due to repressed sensation at the lower extremities. In case of such bruises, proper wound care in elderly home settings is required to avert possible lower limb amputations that reduce the quality of life of patients.
Given the significant association between type II diabetes (T2DM) and DFU among elderly populations, DFU-related morbidity and disability are likely to increase. In the U.S., the DFU incidence rate stands at about 3% yearly (Braun et al., 2014). Inappropriate nursing care promotes wound progression, which increases the risk of amputation. Therefore, evidence-based wound care to manage comorbidities could help treat DFUs to avert amputations.
Given that DFUs cause significant morbidity and physical impairment that affects the quality of life of geriatric diabetics, proper nursing care is important to contain wound progression. The purpose of this paper is to compare the efficacy of vacuum therapy with the standard saline-moistened gauze dressing to provide evidence-based best practices for the management of DFUs. The PICOT question that will guide the evidence search is; in elderly DFU patients, does vacuum therapy/sealing, compared to saline-moistened gauze dressing, reduce recovery time and DFU-related complications?
Search Plan Method
The PICOT question guided the literature search. A comprehensive search for studies with scholarly evidence on wound care best practices for elderly diabetics was conducted in CINAHL, MEDLINE, and Cochrane databases. The key search terms used were drawn from the PICOT question. They included ‘diabetic foot ulcers care methods’, ‘type-2-diabetes Mellitus’, ‘moist wound dressing for DFUs’, and ‘vacuum-assisted closure’. The search yielded 41 articles, including primary studies and reviews.
Relevant studies were selected based on specific inclusion criteria. Each included study involved full-text research on the subject/intervention, written in English, and published within the last five years (2011-2016). The final list included five articles giving either high-level evidence on nursing care interventions for DFU cases. The inclusion criteria involved most current level I (systematic reviews) and II (RCTs) evidence and three of the articles had to be published in nursing journals.
Current/Existing Knowledge
Morbidity Associated with DFU
Foot ulcers and lesions constitute the major reason for the hospitalization of elderly diabetics. Studies show that lower extremity complications and comorbidities requiring surgical interventions in this patient group account for the high length of stay (LOS) when standard wound care (saline dressing) is applied (Braun et al., 2014). Further, there is a 25% lifetime risk of DFU in T2DM patients with 85% of these cases resulting in surgical removal of the limb (Braun et al., 2014).
Treatment Options
The optimal management of DFU requires the surgical removal of dead necrotic tissue to promote wound closure. The therapeutic method depends on three factors: “the severity of DFU, vascularity of the limb, and presence of infection” (Dumville et al., 2013, p. 5). The best practices in the topical management of the diabetic foot are not clear. While moist gauze dressing is considered standard practice, maintaining moist-wound conditions with this method is a challenge. As a result, “wound gels, growth factors, enzymes, and cultured skin substitutes” are fronted as alternative therapies for DFUs (Dumville et al., 2013, p. 8). However, these methods are not only costly, but they also lack scholarly evidence supporting their efficacy.
Vacuum Therapy versus Moist Wound Dressing
VAC is a novel method based on controlled negative or sub-atmospheric pressure as an adjunct to debridement of septic tissue to facilitate wound closure. This non-invasive therapy works by draining fluids from the injured tissues, lowering dropsy, and enhancing the growth of granulation tissue to close the wound (Dowsett et al., 2013). The method is effective in treating neuroarthropathy wounds that result from neuropathic damage or ischemia. Also, VAC has been applied in accelerating healing of wounds resulting from debridement, orthopedic surgery, and soft tissue reconstructive surgery (Dowsett et al., 2013). The moist wound dressing is the conventional alternative for DFU management.
A comparison of the two methods based on scholarly evidence would reveal the superior intervention. The better alternative should facilitate faster-wound closure, reduced risk of amputation, lower treatment-related complications, and improved bacterial clearance. The analysis and synthesis of scholarly evidence in the five articles will give the clinical significance of VAC over the moist wound dressing in treating DFU in geriatric cases.
Analysis and Synthesis of the Evidence/Articles
Efficacy in Wound Healing
The studies analyzed in this paper include systematic reviews and RCTs, which give the highest level of evidence. In general, scholarly evidence supports the efficacy of VAC in the management of DFUs over the standard moist wound dressing. A Cochrane review by Dumville et al. (2013) established that negative pressure wound therapy is effective in treating “acute, postoperative” foot wounds” in adult diabetics (p. 24). The method was shown to lower the recovery time and amputation risk. Therefore, there is evidence for adopting VAC nursing care plans for the treatment of DFUs.
Secondary Complications
DFU is associated with a high risk of lower limb amputation with implications for the quality of life of the patient. Therefore, a superior intervention should reduce this risk to improve patient outcomes. The studies reviewed indicate that VAC devices result in fewer amputations compared to a standard moist wound dressing. An RCT by Dowsett et al. (2013) found that wound healing was faster in the cohort receiving negative pressure therapy (NPT) than in the group receiving moist wound therapy (MWT). Also, the proportion of NPT patients amputated was lower than that in the MWT patients (4.1% vs. 10.2%). Comparable studies found a significant correlation between NTP and a higher number of DFUs healed, reduced recovery time, and improved post-surgical tissue regeneration (Dowsett et al., 2013; Dumville et al., 2013).
In terms of patient safety and outcomes, the evidence indicates that the NPT is associated with fewer DFU-related complications and better patient satisfaction scores, which augurs well with patient-centered care. However, Guffanti (2014) found no significant difference in the risk of DFU-associated “infections and cellulitis, and osteomyelitis” between the two methods (p. 235). The wound healing method was used after surgical debridement of the wound to prevent infection.
Improved Outcomes
Another significant finding of the studies is the cost-effectiveness of NPT over MWT. The associated hospital costs for complete wound healing using NPT was found to be $13,000 lower than when MWT is utilized (Hampton, 2015). Therefore, it can be concluded that aside from clinical benefits, NPT methods such as vacuum-assisted closure can lower the treatment cost for the patient. Further, the reduced recovery time also contributes to lower hospitalization costs.
Although the treatment conditions – VAC environment, MWT type, and wound size – varied between the studies, the results can be used to determine cost savings. The evidence shows no significant difference between the MWT dressing type and wound healing outcomes (Hampton, 2015). This shows that the efficacy of standard moist dressings is less superior to that of NPT methods in wound care. Therefore, it is feasible to conclude that the NPT has significant cost savings than any MWT dressing type.
Uncontrolled Diabetes
DFU is associated with multiple comorbidities that impede wound closure. A significant challenge to wound closure is uncontrolled T2DM, which limits the body’s capacity to produce factors essential in healing (Guffanti, 2014). The studies show that even in patients with uncontrolled diabetes NPT has better outcomes than MWT dressing. The condition predisposes such patients to a greater risk of developing DFUs. Therefore, negative pressure therapy would be appropriate because it minimizes the frequency of new dressing. It also contributes to improved patient compliance with the treatment, which translates into better clinical outcomes.
Conclusions
The evidence from the RCTs and systematic reviews examined to establish a statistically significant decrease in recovery time when NPT is applied to DFUs after the initial debridement. Also, the proportion of wounds healed is higher when NPT is used compared to using moist dressing procedures. NPT-treated patients also have a lower risk of amputation than MWT-treated ones. Based on these findings, negative pressure therapy, e.g., vacuum-assisted wound therapy, is more effective in DFU management than standard MWT dressing. The method lowers the recovery time (length of stay), reduces lower limb amputation risk, and enhances wound closure/regeneration. Post-treatment complications were not statistically different between the two methods. Further, most of the studies found a correlation between NPT and patient satisfaction and quality of life due to decreased amputations. Therefore, there is evidence for the use of NPT as a nursing intervention in diabetic foot treatment for elderly patients with T2DM.
References
Braun, L., Fisk, A., Lev-Tov, H., Kirsner, S., & Isseroff, R. (2014). Diabetic foot ulcer: An evidence-based treatment update. American Journal of Clinical Dermatology, 15(3), 267–281.
Dowsett, C., Grothier, L., Henderson, V., Leak. K., Milne, J., Davis, L.,…Timmons, J. (2013). Venous leg ulcer management: Single use negative pressure wound therapy. British Journal of Community Nursing, 20(6), 8–12.
Dumville, J. C., Hinchliffe, R. J., Cullum, N., Game, F., Stubbs, N., Sweeting, M., & Peinemann, F. (2013). Negative pressure wound therapy for treating foot wounds in people with diabetes mellitus. Cochrane Database of Systematic Reviews, 10, 1-10.
Guffanti, A. (2014). Negative pressure wound therapy in the treatment of diabetic foot ulcers: A systematic review of the literature. Journal of Wound, Ostomy, and Continence Nursing, 41(3), 233–237.
Hampton, J. (2015). Providing cost-effective treatment of hard-to-heal wounds in the community through use of NPWT. British Journal of Community Nursing, 20(6), 14-20.