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

Congratulations to our SALSAmigos at Harbor UCLA and their Harbor UCLA Limb Alliance (HULA). Following on their superb presentation at #DFCon17, their first outcomes are a validation of their Toe and Flow efforts.

Eric Pillado, BS, Kimberly Lauer, FNP-C, Eli Ipp, MD, Richard A. Murphy, MD, MPH, Ashley Miller, DPM, Frederic Bongard MD, JD. Harbor- UCLA Medical Center, Torrance, Calif

Objectives: 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.
Methods: 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
consultsdguided by routine culture and sensitivity testingdper 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.
Results: 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 ¼ .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.
Conclusions: 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.

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