Australian guideline on wound classification of diabetes‐related foot ulcers: part of the 2021 Australian evidence‐based guidelines for diabetes‐related foot disease

Abstract

Background Wound classification systems are useful tools to characterise diabetes-related foot ulcers (DFU) and are utilised for the purpose of clinical assessment, to promote effective communication between health professionals, and to support clinical audit and benchmarking. Australian guidelines regarding wound classification in patients with DFU are outdated. We aimed to adapt existing international guidelines for wound classification to develop new evidence-based Australian guidelines for wound classification in people with diabetes and DFU. Methods Recommended NHRMC procedures were followed to adapt suitable International Working Group on the Diabetic Foot (IWGDF) guidelines on wound classification to the Australian health context. Five IWGDF wound classification recommendations were evaluated and assessed according to the ADAPTE and GRADE systems. We compared our judgements with IWGDF judgements to decide if recommendations should be adopted, adapted or excluded in an Australian context. We re-evaluated the quality of evidence and strength of recommendation ratings, provided justifications for the recommendation and outlined any special considerations for implementation, subgroups, monitoring and future research in an Australian setting. Results After the five recommendations from the IWGDF 2019 guidelines on the classification of DFUs were evaluated by the panel, two were adopted and three were adapted to be more suitable for Australia. The main reasons for adapting, were to align the recommendations to existing Australian standards of care, especially in specialist settings, to maintain consistency with existing recommendations for documentation, audit and benchmarking and to be more appropriate, acceptable and applicable to an Australian context. In Australia, we recommend the use of the SINBAD system as a minimum standard to document the characteristics of a DFU for the purposes of communication among health professionals and for regional/national/international audit. In contrast to the IWGDF who recommend against usage, in Australia we recommend caution in the use of existing wound classification systems to provide an individual prognosis for a person with diabetes and a foot ulcer. Conclusions We have developed new guidelines for wound classification for people with diabetes and a foot ulcer that are appropriate and applicable for use across diverse care settings and geographical locations in Australia.

Australian evidence‐based guidelines for the prevention and management of diabetes‐related foot disease: a guideline summary

“…Further, it is recommended that SINBAD also be used as a minimum for any service audits to allow comparisons between institutions on DFU outcomes. 17 In people with infected DFU, the Infectious Diseases Society of America (IDSA)/IWGDF infection classification system is recommended to classify severity and guide infection management (see Infection section). 17,19 Additionally, in people with DFU who are being managed in settings with appropriate vascular expertise (such as interdisciplinary High Risk Foot Services), the Wound, Ischaemia and foot Infection (WIfI) classification system is recommended to aid decision making in the assessment of perfusion and likelihood of revascularisation benefit (see PAD section and Supporting Information, eTable 2).…”

“…17,19 Additionally, in people with DFU who are being managed in settings with appropriate vascular expertise (such as interdisciplinary High Risk Foot Services), the Wound, Ischaemia and foot Infection (WIfI) classification system is recommended to aid decision making in the assessment of perfusion and likelihood of revascularisation benefit (see PAD section and Supporting Information, eTable 2). 17,18 Otherwise, we highlight that classification using the above recommended systems is critical to achieving optimal outcomes for people with DFU, and important to facilitate effective communication among health professionals, referral, triage, and guide management decisions. 17 Further, we point out 16 The pathway aims to guide the health professional through assessing and classifying a person presenting with a diabetes-related foot ulcer, and also refers to the management pathways needed.…”

“…Here we summarise the key recommendations considered most relevant for the general medical audience, with a focus on prevention and classification. [16][17][18][19][20][21]45 In doing so, we highlight that many PAD, infection, offloading and wound healing management recommendations that are considered most relevant for specialist medical audiences have been omitted. [16][17][18][19][20][21] Thus, we strongly suggest people with DFD are referred to Examine all patients annually for PAD by taking a relevant history and palpating foot pulses.…”

“…We further edited the tabulated recommendations for brevity and flow, and we refer the reader to the full guidelines for complete details on each recommendation, including rationale, implementation, monitoring, and research considerations. [16][17][18][19][20][21] Otherwise, we highlight that most recommendations for DFD apply to healing or non-healing DFD; we denote recommendations specifically for non-healing DFD in Box 3, Box 4, Box 5 and Box 6. 26 The most obvious change in the new guidelines is that they contain 98 recommendations across six DFD fields, whereas the previous guideline contained 25 recommendations across four…”

“…15,23 ‡ Recommendation applying specifically to people with non-healing diabetes-related foot ulcers, defined as foot ulcers reducing in size by < 50% after four to six weeks of receiving best standard of foot ulcer care, 26 in alignment with the applicable recommendations in these guidelines. [16][17][18][19][20][21] Source: In a person with a neuropathic plantar heel ulcer, consider a knee-high offloading device Weak Low…”