Multidisciplinary Limb Salvage Service: Reducing Major Amputations in Diabetic Foot Infections

Abstract

Diabetic foot infections (DFI) can lead to limb loss and mortality. To improve patient care at a safety net teaching hospital, we created a multidisciplinary vascular limb salvage service (LSS). This study describes outcomes before and after creation of this service. Adults admitted to the newly established LSS for DFI during a 6-month period from 2016 to 2017 were included prospectively. Patients admitted to the LSS had routine endocrine and infectious disease consults—guided by routine culture and sensitivity testing—per a standardized protocol. Concomitantly, a retrospective analysis of patients admitted to the acute care surgical service for DFI before creation of the LSS during an 8-month period from 2014 to 2015 was performed. We excluded patients who underwent emergent procedures for necrotizing soft tissue infections. A total of 250 patients were divided into two groups: group 1 (pre-LSS, n = 92) and group 2 (LSS, n = 158). There were no significant differences in baseline characteristics (Table I). However, more patients in LSS had hypertension (56% vs 39%; P = .01) and prior wound infection (35% vs 14%; P < .001). Significantly, after the institution of LSS, fewer patients underwent a major amputation, defined as a below-the-knee or transmetarsal amputation (Table II). There was no difference in the hospital length of stay or the 30-day readmission rate between the groups. The initiation of a multidisciplinary LSS decreased the major amputation rate in patients with DFI, specifically below-the-knee amputation. We attribute this in part to culture-directed antimicrobials resulting from standardized protocol and infection disease consultation. Similarly, inpatient diabetes management was optimized by the endocrine service. Length of stay was not increased nor was the 30-day readmission rate affected. These results suggest that a robust multidisciplinary vascular LSS dedicated to the management of DFI is both feasible and effective even in safety net hospitals.Table IPatient characteristics at the time of hospital admissionVariableaGroup 1: Pre-LSS (n = 92)Group 2: LSS (n = 158)P valueMale75 (81.5)132 (83.5).68Age, years54.8 ± 11.252.5 ± 9.7.08BMI, kg/m230.5 ± 10.130.1 ± 8.0.75Insulin use45 (48.9)84 (53.2).52Prior amputation45 (48.9)58 (36.7).06Prior débridements11 (12.0)33 (20.9).07HbA1c, %10.1 ± 2.79.2 ± 2.2.06BMI, Body mass index; LSS, limb salvage service.aData are presented as number (%) or mean ± standard deviation. Open table in a new tab Table IIHospital course and outcomes prelimb salvage service (LSS) and during LSSVariableGroup 1: Pre-LSS (n = 92)Group 2: LSS (n = 158)P valueAmputation Toe37 (40.2)62 (39.2).88 Transmetatarsal11 (12.0)4 (2.5).001 Below knee12 (13.0)4 (2.5).01 Major20 (21.7)15 (9.6).01Use of antimicrobials39 (42.4)128 (81.0)<.001Hospital length of stay, days9.7 ± 21.27.1 ± 6.1.1630-day readmission19 (20.7)29 (18.4).66 Open table in a new tab