Diabetic Foot Complications Research Articles

Advanced Glycation End Products Assessed by Skin Autofluorescence: A New Marker of Diabetic Foot Ulceration

Accumulation of advanced glycation end products (AGEs) may contribute to diabetic foot ulceration (DFU). Our goal was to determine whether AGEs measurement by skin autofluorescence (SAF) would be an additional marker for DFU management. We performed SAF analysis in 66 patients with a history of DFU prospectively included and compared the results with those of 84 control patients with diabetic peripheral neuropathy without DFU. We then assessed the prognostic value of SAF levels on the healing rate in the DFU group. Mean SAF value was significantly higher in the DFU group in comparison with the control group, even after adjustment for other diabetes complications (3.2±0.6 arbitrary units vs. 2.9±0.6 arbitrary units; P=0.001). In the DFU group, 58 (88%) patients had an active wound at inclusion. The mean DFU duration was 14±13 weeks. The healing rate was 47% after 2 months of appropriate foot care. A trend for a correlation between SAF levels and healing time in DFU subjects was observed but was not statistically significant (P=0.06). Increased SAF levels are associated with neuropathic foot complications in diabetes. Use of SAF measurement to assess foot vulnerability and to predict DFU events in high-risk patients appears to be promising.

Screening for Osteomyelitis Using Thermography in Patients with Diabetic Foot

One of the most serious complications of diabetic foot (DF) is osteomyelitis, and early detection is important. To assess the validity of thermography to screen for osteomyelitis, we investigated thermographic findings in patients with both DF and osteomyelitis. The subjects were 18 diabetic patients with 20 occurrences of DF who visited a dermatology department at a hospital in Tokyo and underwent evaluation by magnetic resonance imaging (MRI) and thermography between June 2010 and July 2012. Osteomyelitis was identified by MRI. Thermographs were taken of the wounds and legs after bed rest of more than 15 minutes. Two wound management researchers evaluated the range of increased skin temperature. There were three types of distribution of increased skin temperature: the periwound, ankle, and knee patterns. Fisher’s exact test revealed that the ankle pattern was significantly more common in the group with osteomyelitis than in the group without osteomyelitis (P=0.011). The positive predictive value was 100%, and the negative predictive value was 71.4%. Our results suggest that an area of increased skin temperature extending to the ankle can be a sign of osteomyelitis. Thermography might therefore be useful for screening for osteomyelitis in patients with DF.

Super-Oxidized Solution (Dermacyn Wound Care) as Adjuvant Treatment in the Postoperative Management of Complicated Diabetic Foot Osteomyelitis

Surgery is usually used to treat diabetic foot osteomyelitis (DFO), whether primarily or in cases in which antibiotics are not able to control infection. In many cases, the bone is only partially removed, which means that residual infection remains in the bone margins, and the wound is left open to heal by secondary intent. The use of culture-guided postoperative antibiotic treatment and adequate management of the wound must be addressed. No trials exist dealing with local treatment in the postoperative management of these cases of complicated DFO. We decided to test a super-oxidized solution, Dermacyn Wound Care (DWC; Oculus Innovative Sciences Netherlands BV, Sittard, Netherlands) to obtain preliminary experience in patients in whom infected bone remained in the surgical wounds. Our hypothesis was that DWC could be useful to control infection in the residual infected bone and surrounding soft tissues and would thus facilitate healing. Fourteen consecutive patients who underwent conservative surgery for DFO, in whom clean bone margins could not be assured, were treated in the postoperative period with DWC. Eleven cases were located in the forefoot, 6 on the first ray and the rest in lesser toes, 1 in the Lisfranc joint, and 2 on the calcaneus. No side effects appeared during treatment. Neither allergies nor skin dermatitis were found. Limb salvage was successfully achieved in 100% of the cases. Healing was achieved in a median period of 6.8 weeks.

EPIDEMIOLOGY OF AMPUTATION;

Amputation is stated to be a foremost but preventable community health problem causing intense financial, social andemotional effects on the patient and family particularly in developing countries where the prosthetic services are limited. The purpose ofthis study was to identify the causes and levels of amputation in low resource community, Sindh Pakistan. Methods: This was aretrospective chart review study that was carried out at first civilian Institute of physical medicine & rehabilitation-Dow University of healthsciences from October 2007 to June 2012. After verbal informed consent all patients, who underwent major or minor amputation wereenrolled for the study. Data was collected using a pre-tested, coded questionnaire and analysed using SPSS version 16. Results: A total of1115 patients were enrolled into the study. Their ages were ranged between 2–95 years (mean 38.40±17.38). Among total population ofamputees 83.58% were males. The most common cause for major limb amputation was road Traffic accident 38.38%, followed byDiabetes 15.42%, infection 14.26% and trauma 12.37%. Lower limbs (trans-tibial) amputations were in 47.35% of cases and transfemoralin 27.98% of cases. While for the upper limb trans-radial amputation (7.4%) were found to be more common than trans-humeral(5.56%). Other amputations were for shoulder, hip and knee disarticulations. Conclusions: Road traffic accidents, complications ofdiabetic foot ulcers, infections and trauma were the most common causes for major limb amputations found in low resource community,Sindh Pakistan. The majority of these amputations are preventable by endowment of traffic rules, health education, early preventions andappropriate management of the common infections.

An electronic diabetes foot risk calculator

Background The MMEx Diabetes Foot risk calculator was designed in response to the WA Department of Health’s High Risk Foot Model of Care to improve the systematic approach to screening and treatment for high risk foot complications and the 2011 National Health and Medical Research Council’s (NHMRC) National Evidence-Based Guideline on Prevention, Identification and Management of Foot Complications in Diabetes that state, “a solution to the current impasse on the integration of decision support tools into medical software is needed urgently” and “any trained health professional can complete a foot risk stratification”. Teaching foot assessments is straightforward, but practitioners have difficulty with risk stratification and deciding appropriate follow-up and referral.

Cutaneous Structural and Biochemical Correlates of Foot Complications in High-Risk Diabetes

OBJECTIVEImpairment of skin quality may contribute to diabetic foot ulceration (DFU). Our goal was to determine whether high-risk patients exhibited specific skin structural and metabolic deficits that could predispose to foot complications.RESEARCH DESIGN AND METHODSA total of 46 patients comprising 9 diabetic control subjects, 16 with diabetic peripheral neuropathy (DPN) alone, and 21 with recurrent DFUs (including 9 with Charcot neuroarthropathy [CNA]) were recruited and compared with 14 nondiabetic control (NDC) subjects. DPN was assessed using the Michigan Neuropathy Screening Instrument (MNSI). Skin punch biopsies (3 mm) were performed on upper and lower leg skin for measurements of intraepidermal nerve fiber density (IENFD), structural analysis, type 1 procollagen abundance, tissue degrading matrix metalloproteinases (MMPs), and poly(ADP-ribose) (PAR) immunoreactivity.RESULTSMNSI scores were comparable across DPN groups. IENFD was decreased by diabetes and DPN but did not differ between neuropathic groups. Skin structural deficit scores were elevated in all neuropathic subjects, particularly in the DFU group. Type 1 procollagen abundance was reduced in DFU subjects 387 ± 256 units (mean ± 1 SD) compared with NDC subjects (715 ± 100, P < 0.001). MMP-1 and MMP-2 were activated by diabetes. PAR immunoreactivity was increased in DFU (particularly in the CNA group; P < 0.01) compared with other DPN subjects.CONCLUSIONSIncreased PAR, reduced type 1 procollagen abundance, and impaired skin structure are associated with foot complications in diabetes. The potential of therapies that improve skin quality to reduce DFU needs to be investigated.

Relation Between Popliteal-Tibial Artery Atherosclerosis and Global Glycolytic Metabolism in the Affected Diabetic Foot

We evaluated the extent and the degree of active atherosclerosis in the popliteal-tibial arteries by quantitative techniques using [(18)F]-2-fluoro-2-deoxy-d-glucose-positron emission tomography (FDG-PET). An effort was made to determine whether there was a positive correlation between the level of ongoing atherosclerosis and subsequent chronic ischemia in the diabetic foot. A total of 115 diabetic patients were enrolled in this prospective research study and underwent lower-extremity FDG-PET and magnetic resonance imaging. We selected 36 diabetic patients with complicated diabetic foot for this analysis (11 men, 25 women; mean age, 59.5 years; age range, 36-85 years). Ten nondiabetic control participants (6 men, 4 women; mean age, 59.7 years; age range, 27-88 years) were also included for comparison. Only patients with blood glucose levels less than 200 mg/100 mL were enrolled in this study. The metabolic volumetric product (MVP), for each patient was calculated multiplying foot average maximum standard uptake value (SUV(max)) by foot volume. Pearson correlation analysis between foot mean SUV(max) alone and the degree of atherosclerosis and between the foot MVP and the degree of atherosclerosis was performed as measured by FDG-PET. A t test was used to assess for significant differences in foot SUV(max) and foot MVP among varying degrees of atherosclerosis, using P < .05 as the criterion for statistical significance. Foot SUV(max) significantly correlated (P < .05) with the ratio of popliteal-tibial artery SUV(max) to background SUV (Pearson correlation coefficient = 0.49). Foot MVP was also significantly correlated (P < .05) with the ratio of popliteal-tibial artery SUV(max) to background SUV (Pearson correlation coefficient = 0.69). Using FDG-PET, one may be able to detect and quantify the degree of increased metabolic activity of early active atherosclerosis and the associated chronic tissue ischemic effects at the regional level and globally throughout the whole body during the asymptomatic phase of disease.

The experience of using infusions of thrombolytic agents in the complex treatment of complicated forms of diabetic foot syndrome

The article presents the experience of using infusion thrombolytic agents in the complex therapy of patients with complicated diabetic foot syndrome. Presented was a vivid clinical case. This method made it possible to optimize the treatment of this group of patient.

Physical abilities of patients in the late postoperative period after surgical treatment of complicated diabetic foot syndrome

Aim. To study physical abilities of patients in the late postoperative period after surgical treatment of complicated diabetic foot syndrome. Materials and methods. This questionnaire study included 116 patients operated in the Department of Purulent Surgery, Sverdlovsk Regional ClinicalHospital No 1, between 01.01.2005 and 31.12.2007. Their physical ability to perform simplest indoor actions was compared with that of 84 DMpatients without diabetic foot syndrome. Results. In less than half of the patients the support function of the lower leg recovered within 1-3 years after discharge due to the presence of nonhealingor new wounds, the necessity of unloading, and the absence of prosthetic treatment. Physical abilities were especially poor after above-the-ankleamputations. The operated patients retained the ability to perform simplest indoor actions comparable with that of control subjects depending on DMduration and BMI. Conclusion. The latter parameter should be corrected as appropriate before the discharge of the patients from the hospital.

A Novel Robotic Monofilament Test for Diabetic Neuropathy

The use of the Semmes-Weinstein (SW) monofilament test is recommended as a screening method for diabetic neuropathy. It offers an important chance to prevent further complications of diabetic foot. We aimed to develop a prototype Robotic Monofilament Inspector that can be used as a standard machine for screening of diabetic neuropathy. Development was divided into three parts: computer software, control box, and Robotic Monofilament Inspector. The examiner conducted the SW test (by hand and by robotic inspector), vibration perception threshold, and Toronto Clinical Scoring System without knowledge of patient information. The unpaired t test or Wilcoxon rank-sum test was used to determine the differences between independent groups in terms of continuous outcomes, while the χ(2) test was used to determine categorical outcomes. Agreement between the various diabetic neuropathy tests was measured using the kappa statistic. The SW test and vibration perception threshold were more valid tests for neuropathy than the Toronto test. The robotic test was in excellent agreement with the two former tests and appeared to be valid (kappa statistic, 0.35-0.81). Another indirect evidence for the validity of the robotic test was the finding that diabetic patients with foot ulcers had a higher prevalence of neuropathy (77%vs. 38%). This might indicate that the robotic test was more valid than the manual test. The Robotic Monofilament Inspector could be used as a simple screening machine. This prototype may be developed further for routine clinical use.

Advances in treatment of diabetic foot ulcers

Diabetic foot is a major health problem all over the world. Approximately 15% of the 200 million people with diabetes worldwide will develop a foot ulcer during their lifetime. Major amputation is a feared complication of diabetes. Many patients who undergo an amputation have a history of ulceration. More than 60% of non-traumatic amputations in the western world are carried out in diabetes patients. Major amputations increase morbidity and mortality and reduce the patient's quality of life. An important prelude to diabetic foot treatment is the differing diagnosis of neuropathic and neuroischemic foot. Treatment of a neuropathic plantar ulcer must correct pathological plantar distribution of pressures. Surgical treatment of deformities, with or without ulcerations, is an effective therapy. Charcot neuroarthropathy is a particular complication of neuropathy wich may lead to fragmentation or destruction of joints and bones. Additionally, in the diabetic population peripheral vascular disease (PVD) is the main risk factor for amputation. If PVD is not diagnosed, treatment of the ulcer cannot be successful. In diabetic patients PVD is distal, but often fully involves the femoral, popliteal and tibial vessels. It can be successfully treated with either open surgical or endovascular procedures. Finally, infection is a serious complication of diabetic foot. Phlegmon or necrotizing fascitis are not only limb-threatening problems, but also life-threatening ones. In this case emergency surgery is mandatory.

Screening People with Type 2 Diabetes at Risk for Foot Ulceration in Iran

Foot screening is one of the most effective means of preventing foot complications in diabetes. Therefore the aim of this study was to perform a screening program for people with type 2 diabetes at risk of foot complications. Physical examinations consisting of vascular, neurological, musculoskeletal, and dermatologic examinations were performed. We used a Semmes-Weinstein monofilament and a 128-Hz tuning fork to test peripheral neuropathy. The study population was categorized based on Scottish Intercollegiate Guidelines into three groups of low, medium, and high risk for diabetes foot disease. Of a total of 148 people with type 2 diabetes, 4.7% had an active foot ulcer, and 41.9% were classed as low risk, 40.6% as medium risk, and 12.8% as high risk. Considering the potential of developing risk of foot disease in people with diabetes, it is recommended that foot screening should be performed by primary care practitioners and specialists to detect foot disease in an early stage. Foot screening program for people with diabetes should also be taken into account by health policy makers in national guidelines.

Using a bilayer matrix wound dressing for closure of complicated diabetic foot wounds

Three case studies are described showing how use of this dressing, when combined with debridement, antibiotic therapy, topical negative pressure therapy, offloading and good local wound care, can promote healing in complex diabetic foot ulcers.

Diagnostic Performance of FDG-PET, MRI, and Plain Film Radiography (PFR) for the Diagnosis of Osteomyelitis in the Diabetic Foot

The early and accurate diagnosis of osteomyelitis in the diabetic foot is essential to provide appropriate treatment and obviate long-term complications of the disease. The currently employed non-invasive imaging modalities such as plain film radiography (PFR) lack the sensitivity to accurately exclude osteomyelitis, while magnetic resonance imaging (MRI) is limited by its low specificity and contraindications in certain patients. Therefore, accurate non-invasive detection of osteomyelitis in the diabetic foot remains a challenge. [18F]-2-fluoro-2-deoxy-D-glucose (FDG)-positron emission tomography (PET) has been proven useful in other settings to detect infection. In this ongoing prospective study, we assessed the diagnostic performance of FDG-PET to diagnose osteomyelitis in the diabetic foot and compared it with that of MRI and PFR. Patients who met the prespecified criteria for complicated diabetic foot underwent FDG-PET, MRI, and PFR of the feet. Each imaging study was then interpreted in a blinded fashion for presence of osteomyelitis or other abnormalities. The gold standard for diagnosis in each patient was based on surgical, microbiological, and clinical follow-up results. One hundred ten consecutive patients have been enrolled to date into this prospective project. FDG-PET correctly diagnosed osteomyelitis in 21 of 26 patients and correctly excluded it in 74 of 80, with sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of 81%, 93%, 78%, 94%, and 90%, respectively. MRI correctly diagnosed osteomyelitis in 20 of 22 and correctly excluded it in 56 of 72, with sensitivity, specificity, PPV, NPV, and accuracy of 91%, 78%, 56%, 97%, and 81%, respectively. PFR correctly diagnosed osteomyelitis in 15 of 24 and correctly excluded it in 65 of 75, with sensitivity, specificity, PPV, NPV, and accuracy of 63%, 87%, 60%, 88%, and 81%, respectively. FDG-PET is a highly specific imaging modality for the diagnosis of osteomyelitis in diabetic foot and, therefore, should be considered to be a useful complimentary imaging modality with MRI. In the setting where MRI is contraindicated, the high sensitivity and specificity of FDG-PET justifies its use after a negative or inconclusive PFR to aid an accurate diagnosis.

Vacuum assisted closure (VAC) in the treatment of advanced diabetic foot

IntroductionDeep diabetic foot lesions pose an enormous therapeutic problem. The purpose of this study was to present the experience of the use of vacuum assisted closure (VAC) in the treatment of advanced and complicated diabetic foot lesions. Material and methodsFive cases of advanced diabetic foot that were treated with VAC were prospectively studied. Three patients were diagnosed with renal failure, including one with renal transplant, who were receiving immunosuppression therapy. Four patients had undergone local foot surgery. The foot lesions were classified as grade 3 or 4 according to the Wagner classification. In all patients extensive debridement was performed that resulted in open minor amputations in 4 cases and resection of the metatarsophalangeal joint in 1 case. The VAC was applied during the same procedure. The median follow-up period of the patients was 9 months. ResultsFoot salvage was achieved in all cases. The median number of changes of VAC was 16 within median period of 8 weeks. Half of the changes were performed as an outpatient procedure. There were no major complications or clinical signs of infection observed. In 1 case before treatment with VAC began, angioplasty of the iliac artery and superficial femoral artery was performed. Other interventions carried out after the treatment was started were, 2 distal revascularizations and 2 partial transmetatarsal amputations. ConclusionsVAC appears to be very useful in the treatment of advanced diabetic foot lesions.

El sistema de cierre asistido al vacío en el tratamiento del pie diabético avanzado

Introduction Deep diabetic foot lesions pose an enormous therapeutic problem. The purpose of this study was to present the experience of the use of vacuum assisted closure (VAC) in the treatment of advanced and complicated diabetic foot lesions. Material and methods Five cases of advanced diabetic foot that were treated with VAC were prospectively studied. Three patients were diagnosed with renal failure, including one with renal transplant, who were receiving immunosuppression therapy. Four patients had undergone local foot surgery. The foot lesions were classified as grade 3 or 4 according to the Wagner classification. In all patients extensive debridement was performed that resulted in open minor amputations in four cases and resection of the metatarsophalangeal joint in one case. The VAC was applied during the same procedure. The median follow-up period of the patients was 9 months. Results Foot salvage was achieved in all cases. The median number of changes of VAC was 16 within median period of 8 weeks. Half of the changes were performed as an outpatient procedure. There were no major complications or clinical signs of infection observed. In one case before treatment with VAC began, angioplasty of the iliac artery and superficial femoral artery was performed. Other interventions carried out after the treatment was started were, two distal revascularizations and two partial transmetatarsal amputations. Conclusions VAC appears to be very useful in the treatment of advanced diabetic foot lesions.

Toenail Onychomycosis in Diabetic Patients

Diabetes mellitus may be associated with serious sequelae, such as renal disease, retinopathy, and diabetic foot. A recent large prospective study has shown that onychomycosis is among the most significant predictors of foot ulcer. As the severity of onychomycosis may be associated with the length of time the individual has had the infection, early intervention is advisable owing to the progressive nature of the fungal infection. If left untreated, toenails can become thick, causing pressure and irritation, and thus act as a trigger for more severe complications. In the treatment of onychomycosis, compliance and drug interactions are important considerations, as diabetic patients frequently take concomitant medications. Terbinafine and itraconazole have been investigated for the treatment of onychomycosis in diabetic patients and have been shown to have efficacy and safety profiles comparable to those in the nondiabetic population. Data from clinical trials and postmarketing surveillance suggest that drug interactions resulting in hypoglycemia may not be an important issue when itraconazole and terbinafine are used to treat diabetic patients receiving concomitant hypoglycemic medications. Patient advice and education in improved foot care are an integral part of onychomycosis management, and help achieve long-term cure and reduce the complications of diabetic foot.

Infecciones del pie diabético. Prevalencia de los distintos microorganismos y sensibilidad a los antimicrobianos

Foot infections are a common reason for hospitalization and a cause of complications in patients with diabetes. The aim of this study was to determine the prevalence of microorganisms found on culture in complicated diabetic foot infections in hospitalized patients, and the sensitivity of the causative microorganisms to antimicrobial agents. Between December 2001 and December 2005 in our department, 84 samples in 62 diabetic patients with moderate/severe infection were collected for microbiological study. At least one microorganism was isolated in 88% of samples. The most frequently isolated germ group was gram-positive bacteria (55% of the samples), with Staphylococcus aureus (33%) in the first position, followed by Pseudomonas aeruginosa (12%), Enterococcus spp. (9%), and Escherichia coli (8%). Culture for anaerobic microorganisms was only performed in half the samples; 25% were positive, and Peptostreptococcus spp. predominated. Among the multiresistant microorganisms, methicillin-resistant staphylococci aureus (MRSA) were the most common, accounting for 38% of the isolated strains of S. aureus, ie, 12% of all samples. As to the gram-negative microorganisms, nearly 30% of E. coli strains were resistant to amoxicillin/clavulanic acid and ciprofloxacin. Most of the cultures in our study were monomicrobial, with S. aureus being the most prevalent microorganism, followed by enterobacteria and P. aeruginosa. The main resistant microorganism in diabetic foot infections requiring hospitalization was methicillin-resistant golden staphylococcus, which was found in 12% of the series.

Quality of Life with Diabetes-associated Foot Complications: Comparison Between Lower-limb Amputation and Chronic Foot Ulceration

Diabetic foot complications result in huge costs for both society and individual patients. Because our team performs numerous amputations each year for complicated diabetic foot ulcers, we conducted a study comparing the quality of life of diabetic amputees with a non-amputee group experiencing a diabetic foot ulcer. The aim of this study was to get better comprehension of the influence of amputation on physical and social aspects of our patients' quality of life. This study evaluated the influence of amputation for a diabetic foot ulcer on quality of life. We compared patients having experienced an amputation for a diabetic foot ulcer at least 1 year before the study, and outpatients experiencing regular visits for a current foot ulcer with no previous history of amputation. Quality of life was reported using the Medical Outcome Study Short Form 36 item health survey (MOS SF-36). Most of the chronic ulcers were neuroischemic (8/9). Except for the bodily pain, which was significantly higher in the ulcer group, no difference was found between the amputee and the ulceration-group, when considering the different items of the MOS-SF 36 scales. The ulceration-group had significantly more physical limitations and pain than the toe-or-transmetatarsal-amputation-group, whereas physical limitations were identical between the transtibial-amputation-group and the ulceration-group. Median scores were quite low in both groups, reflecting strong social and psychological consequences of diabetic foot ulcers. Global prognosis was bad with 56% of the amputees having experienced another major cardiovascular event within 20 months after amputation. Better understanding of the consequences of diabetic foot complications is important for the general population and especially general practitioners. Psychological evaluation and support is important before and after amputation since it is a traumatic step for patients.

Insights about the process and impact of implementing nursing guidelines on delivery of care in hospitals and community settings

BackgroundLittle is known about the impact of implementing nursing-oriented best practice guidelines on the delivery of patient care in either hospital or community settings.MethodsA naturalistic study with a prospective, before and after design documented the implementation of six newly developed nursing best practice guidelines (asthma, breastfeeding, delirium-dementia-depression (DDD), foot complications in diabetes, smoking cessation and venous leg ulcers). Eleven health care organisations were selected for a one-year project. At each site, clinical resource nurses (CRNs) worked with managers and a multidisciplinary steering committee to conduct an environmental scan and develop an action plan of activities (i.e. education sessions, policy review). Process and patient outcomes were assessed by chart audit (n = 681 pre-implementation, 592 post-implementation). Outcomes were also assessed for four of six topics by in-hospital/home interviews (n = 261 pre-implementation, 232 post-implementation) and follow-up telephone interviews (n = 152 pre, 121 post). Interviews were conducted with 83/95 (87%) CRN's, nurses and administrators to describe recommendations selected, strategies used and participants' perceived facilitators and barriers to guideline implementation.ResultsWhile statistically significant improvements in 5% to 83% of indicators were observed in each organization, more than 80% of indicators for breastfeeding, DDD and smoking cessation did not change. Statistically significant improvements were found in > 50% of indicators for asthma (52%), diabetes foot care (83%) and venous leg ulcers (60%). Organizations with > 50% improvements reported two unique implementation strategies which included hands-on skill practice sessions for nurses and the development of new patient education materials. Key facilitators for all organizations included education sessions as well as support from champions and managers while key barriers were lack of time, workload pressure and staff resistance.ConclusionImplementation of nursing best practice guidelines can result in improved practice and patient outcomes across diverse settings yet many indicators remained unchanged. Mobilization of the nursing workforce to actively implement guidelines and to monitor the delivery of their care is important so that patients may learn about and receive recommended healthcare.