Clinical Pathways for the 5 Wound Types

Choose a wound type to view the associated clinical pathways and guidelines.

Diabetic Ulcer Pathway

References

Glycemic control and post-operative healing. Journal of Foot and Ankle Research; Lower Extremity Review. Naohiro Shibuya, DPM, MS, FACFAS, Jon M. Humphers, DPM, and Daniel C. Jupiter, PhD. July 2013

Guidelines for the treatment of diabetic ulcers; Wound Repair and Regeneration (2006). Wound Healing Society. Steed, David

Diagnosis and treatment of peripheral arterial disease in diabetic patients with a foot ulcer. A progress report of the International Working Group on the Diabetic Foot. Diabetic foot infection: Antibiotic guidelines. Johns Hopkins. Eric Nuermberger. 6/16/2009

Lipsky BA, Berendt AR, Deery HG, et al.; Diagnosis and treatment of diabetic foot infections.; Clin Infect Dis; 2004; Vol. 39; pp 885-910; ISSN: 1537-6591; PUBMED 15472838

Debridement: A Vital Component of Wound Bed Preparation. Kirshen C, Ayello E, Sibbald, R. Advances in Skin Wound Care 2006; 19:506-17; Lippincott Williams & Wilkins.

Diabetic Ulcer Guidelines

Patients with diabetic ulcers:

Patients with diabetic ulcers require a multidisciplinary approach with primary care coordination of a variety of specialists to promote healing and prevent limb loss.

Illnesses that compromise healing:

For patients with prior diabetic foot or leg wounds, poor diabetic control, peripheral vascular disease, renal disease or other illnesses that compromise healing, we strongly recommend referral to a wound clinic for evaluation and management.

This includes patients with ulcers that expose subcutaneous structures when probed to tendon or bone, if wound is >30 days old or debridement of necrotic tissues/callous is needed.
For patients with poor or limited self-care who are homebound due to illness, referral to home care wound nurse specialist is highly recommended.

Diabetic ulcer healing is best managed with well-controlled diabetes:

Optimizing glucose control improves wound healing.
High HgA1c (>8%) is associated with poor outcomes.

Diabetic ulcers can result from arterial disease and/or neuropathy:

Clinically significant vascular disease should be assessed by checking for palpable pulses.
Due to frequent calcification of arteries in diabetics, basic vascular studies with toe-brachial indexes (TBI) are more reliable indicators of adequate perfusion.
TBI should be >7.0.

For diabetic wound infections:

Initial course of antibiotics is 1-2 weeks for mild infections and >3-6 weeks for moderate to severe infections.
May need Infectious Disease consult.
If wound is severely infected and patient is acutely ill, recommend hospitalization for IV antibiotics.

Wound bed preparation:

Wound bed preparation with debridement of necrotic, non-viable tissues is necessary to reduce infection, stimulate new tissue growth, and promote healing.

ABI Value	Interpretation	Recommendation
Greater than 1.4	Calcification/vessel hardening	Refer to vascular specialist
1.0 - 1.4	Normal	None
0.9 - 1.0	Acceptable	None
0.8 - 0.9	Some arterial disease	Treat risk factor
0.5 - 0.8	Moderate arterial disease	Refer to vascular specialist
Less than 0.5	Severe arterial disease	Refer to vascular specialist

Diabetic Ulcer