Strategies to educe severe diabetic foot nfections and complications uring pidemics (STRIDE)

Abstract

Aims Patients with diabetes, including those with foot complications, are at highest risk for severe outcomes during the COVID-19 pandemic. Diabetic foot ulcers (DFU) present additional challenges given their superimposed risk for severe infections and amputations. The main objectives were to develop a triage algorithm to effectively risk-stratify all DFUs for potential complications, complying with social distancing regulations, preserving personal protective equipment, and to assess feasibility of virtual care for DFU. Methods Longitudinal study during the COVID-19 pandemic performed at a large tertiary institution evaluating the effectiveness of a targeted triage protocol developed using a combined approach of virtual care, electronic medical record data mining, and tracing for rapid risk stratification to derive optimal care delivery methods. 2868 patients with diabetes at risk for foot complications within last 12 months were included and rates of encounters, hospitalizations, and minor amputations were compared to one year prior. Results The STRIDE protocol was implemented in 1-week and eventually included 2600 patients (90.7%) demonstrating effective triage. During normal operations, 40% (938 of 2345) of all visits were due to DFUs and none were performed virtually. After implementation, 98% face-to-face visits were due to DFU, and virtual visits increased by 21,900%. This risk stratified approach led to similar low rates of DFU-related-hospitalization and minor amputation rates 20% versus 24% (p > 0.05) during and prior the pandemic, respectively. Conclusions Implementation of STRIDE protocol was effective to risk-stratify and triage all patients with diabetic foot complications preventing increase in hospitalization and amputations while promoting both social and physical distancing.

Virtual triage and outcomes of diabetic foot complications during Covid-19 pandemic: A retro-prospective, observational cohort study

“…Other authors have also noticed an increased rates of major or minor amputations during the pandemic period attributed to predominantly ischemic ulcers or non infected DFU [ 23 – 25 ]. The amputation rates in our study was significantly less as compared to that observed by Caruso P, et al [ 21 ] and Schmidt et al [ 22 ] despite the inclusion of patients with active DFU (either ischemic or neuropathic) with or without DFI. Probable reasons for lesser amputation rates may be because we excluded patients (twelve in total) with limb threatening DFU, and those with suspected osteomyelitis as well as those with sign or symptoms of necrotizing fasciitis, SIRS or gangrene on video examination.…”

“…A hospital based study of patients coming to emergency department with severe DFU during COVID-19 pandemic observed three-fold higher risk of limb amputation as compared to the similar period in year 2019 (60% vs 18%, p = 0.001) [ 21 ]. Another study observed a similar number (24.25%) of minor amputation following foot ulcers during COVID-19 pandemic compared to (20.5%, p>0.05) pre-pandemic period [ 22 ]. Other authors have also noticed an increased rates of major or minor amputations during the pandemic period attributed to predominantly ischemic ulcers or non infected DFU [ 23 – 25 ].…”

“…We observed new onset DFU in only 10.2% of these patients with prior DFU which is comparable to the previous year (14%) and no amputations during the 24-week study observation period. Recently, integration of virtual care and EMR technologies (STRIDE protocol) has been shown to help in rapid triage, effective delivery of foot care, and limb salvage [22]. Another internet-based algorithm and online consultation service by instant messaging has been proposed as a feasible option for grading of the wound, risk categorization and modulation of home-care [26].…”

Management of diabetes‐related foot disease in the outpatient setting during the COVID‐19 pandemic

“…3 Similar strategies have been adopted in the United States, Turkey and India. 4,9,10 A multidisciplinary team in Zhejiang, China, developed an internet-based programme to manage people with DFU which included regular instant messaging and remote consultations. 11 A report from Italy, from a region which experienced severe impacts from COVID-19, including strict lockdown and significant interruption to outpatient services, described a marked increase in gangrene and amputations amongst patients hospitalised for DFU, highlighting the risk to patients with DFU from interruptions to usual podiatry and IHRF care.…”

“…2 The pandemic has led to significant stress on hospital systems worldwide and delays to acute hospital care for people with diabetes and diabetes-related complications. 3,4 People with diabetes are at higher risk of COVID-19 and its complications. [3][4][5]…”