Total
care of diabetic foot patients: a decentralized model in Rio de Janeiro
(Portuguese
PDF version)
Jackson
Silveira Caiafa1, Paulo Márcio Canongia2
1. Head
of the Endovascular Surgery Division, Hospital Municipal da Lagoa; in charge of
the Secondary Unit for the Treatment of Diabetic Foot, Hospital Municipal da Lagoa.
Leading Member of the Brazilian Society of Angiology and Vascular Surgery.
2. Head of the Vascular Surgery Division, Hospital Municipal do Andaraí;
in charge of the Secondary Unit for the Treatment of Diabetic Foot, Hospital Municipal
do Andaraí; Regional President of the Brazilian Society of Angiology and
Vascular Surgery. Correspondence:
Dr. Jackson Silveira Caiafa
Av. Nossa Senhora de Copacabana, 400/202
CEP:
22020-000 - Rio de Janeiro - RJ
Tel: +55 (21) 2255.4076 Fax: +55 (21) 2549.7855
E-mail: intervasc@easyline.com.br J
Vasc Br 2003;2(1):75-78
INTRODUCTION
Foot disorders
associated with diabetes mellitus are today one of the major problems
faced by health systems on a worldwide basis. The treatment incurs high
socioeconomic costs, and the characteristics of the disease vary among
different populations and geographic regions.
In 1996, the overall prevalence of diabetes amounted to 120 million
people, with an estimate of 250 million individuals in the year 2025
according to the International Consensus on Diabetic Foot.1
This consensus also provides the following data:
- 40 to 60% of all nontraumatic amputations of lower limbs are performed
in diabetic patients;
- 85% of lower limb amputations in diabetics are preceded by foot ulcers;
- four out of five foot ulcers in diabetic patients are caused by external
trauma;
- the prevalence of foot ulcers is of 4 to 10% among diabetics;
- the incidence of diabetes-related amputations probably affects 5-24/100,000
inhbitants/year or 6-8/1,000 diabetics/year.
Data provided by the 2000 Census carried out by the Brazilian Institute
of Statistics and Geography2 estimate that
Brazil has a population of 169,799,170 inhabitants, of which over five
million are believed to suffer from diabetes.1
The simple application of these figures to the probable incidence of
diabetes-related amputations, as described above, indicates that approximately
40,000 amputations/year are performed in diabetic patients in Brazil.
In Rio de Janeiro, data from the State Department of Health (provided
by the Diabetes Program Management of the State Department of Health
of Rio de Janeiro) show the following situation in 2000:
- Rate of diabetes-related amputations: 73.2%
- Incidence of amputations in diabetics: 8.8/1,000 individuals
- Amputations: thigh, 48%; toes, 25%; foot, 15%; leg, 11.6%
- rate of reamputations: 31.4%
THE
PROCESS
Several
projects and guidelines have been implemented and published in an attempt
to mitigate and solve this problem all over the world. In Brazil, the
Project Saving the Diabetic Foot, by Fundação Hospitalar
do Distrito Federal, implemented in 1988, and the recent publication
of the Brazilian Society of Angiology and Vascular Surgery3
guidelines are of special interest. In Rio de Janeiro, some attempts
have been made by the State Department of Health, but they have stumbled
upon the centralized model of education and action.
With the publication of an impressive article by Dr. Ivan Arbex and
Dr. Jorge Darze, entitled The Legion of Amputees,4
the District Attorney's Office was touched by the problem faced by the
population and by emergency hospitals and requested the Municipal Department
of Health further information about it. This process culminated in the
initiative of the Brazilian Society of Angiology and Vascular Surgery
- Regional Bureau of Rio de Janeiro (SBACV-RJ) - in its Scientific Meeting
held in May 2002, to organize a forum with the participation of representatives
of the Municipal and State Departments of Health, SBACV-RJ and the District
Attorney's Office. The meeting was a hallmark in diabetic foot care
in the city of Rio de Janeiro, and allowed the integration of SBACV-RJ
with the Municipal Department of Health, in addition to facilitating
the implementation of an ambitious project, which is now under way.
The project aims at reducing the amputation rate in diabetic patients
by 50% within three years, thus being consistent with the guidelines
established by the International Consensus on Diabetic Foot.1
PROJECT
FOR TOTAL HEALTH CARE OF DIABETIC FOOT PATIENTS
The ongoing
project consists of different actions at the primary, secondary and
tertiary levels.
Primary
level: Qualification of health professionals for the treatment of
diabetic foot at the basic health system of the Municipal Department
of Health.
Secondary level: Implementation of secondary health units for
the treatment of diabetic foot patients.
Tertiary
level: Reorganization of vascular surgery divisions at municipal
hospitals; implementation of centers for diagnosis and treatment in
endovascular surgery; qualification of professionals for the treatment
of diabetic foot at the emergency health system of the Municipal Department
of Health.
QUALIFICATION
OF THE BASIC HEALTH SYSTEM
Established
in August 2002 and at its final stage, this qualification course has
the objective of training doctors, nurses and nursing technicians and
providing them with proper knowledge about the fundamental treatment
of foot disorders in diabetic patients, also allowing for decentralized
prophylactic measures and early treatment of possible lesions.
The Municipal Department of Health of Rio de Janeiro consists of 108
primary health care units (outpatient clinics). The course aims at having
at least one qualified team at each outpatient clinic (one doctor, one
nurse and one nursing technician) specifically in charge of examining
and determining the risk of all diabetic feet registered at the unit,
both in the Diabetes Mellitus Program and in the Family Health Program
devised by the Ministry of Health. This investigation is neither reliant
on the developmental stage of the disease nor on the existence or not
of foot lesions. The results of the initial screening are published
in a special document that allows classifying the risk and recognizing
the developmental stage of the disease. Based on this screening, the
basic health team can follow up, prevent and treat lesions up to a certain
level of complexity, and refer patients that go beyond this level to
secondary health units specialized in diabetic foot care. In primary
care, the role of nursing technicians is essential. They are supervised
by the nursing team and a physician, and periodically follow up diabetic
patients and instruct them on how to take care of their feet.
During the course, the data recorded on the evaluation sheet are transferred
to a specific software program (Figure 1) allowing the observation of
results, as shown in Table 1.
 Figure
1 - Registry software main screen.
Table
1 - Data
collected during the qualification course of the basic health system between August
and December 2002.
 |
| Number
of diabetic patients cared for | |
1,070 | | Number
of treatments | | 1,796 |
| Mean
age | | 58.2
years | | Gender | Female | 720
(67.25%) | | Male | 350
(32.71%) | | Insulin
users | | 367
(34.30%) | | Hypertensive
diabetic patients | | 761
(71.12%) | | Diabetic
patients with foot ulcers | | 242
(22.61%) | | Diabetic
patients with infected lesions | | 97
(9.07%) | | Diabetic
patients with previous amputation | | 85
(7.94%) | | Diabetic
patients with neuropathy of lower limbs | | 331
(30.93%) | | Diabetic
patients who wear inadequate shoes | | 924
(86.36%) | | Diabetic
patients with severe lesions, referred to emergency services | | 93
(8.69%) | |
The qualification of the basic health system aims at training 700 professionals
in the municipal health system, of which 331 had already been qualified until
2002 (106 primary foot health professionals, 102 nurses and 123 doctors/physical
therapists/occupational therapists). After this qualification, periodical refreshment
courses are going to be offered to professionals in the secondary health system.
SECONDARY
HEALTH SYSTEM FOR THE TREATMENT OF DIABETIC FOOT PATIENTS
Three secondary
units, which will receive patients from the basic health system and
will allow a more accurate and specialized evaluation, are to be implemented.
These units include angiologists and/or vascular surgeons, endocrinologists,
physical therapists, nutritionists, psychologists, social workers, in
addition to experienced nurses and primary foot health professionals.
The secondary health teams will be in charge of critically ill patients
(infections, deep ulcers, etc) and will follow up the patients for a
limited time period that is sufficient for the resolution of less severe
cases or for presurgical preparation and referral to elective hospitalization
in more complex cases (e.g.: revascularization). On the other hand,
the cases with advanced infection, necrosis or extensive gangrene will
continue to be referred to the municipal hospital emergency services.
So far, two secondary health units have been implemented. They serve
as training centers for the human resources of the basic health system.
The units were implemented at Hospital Municipal da Lagoa and at Hospital
Municipal do Andaraí.
TERTIARY
CARE
To support
the action of primary and secondary health units, the Municipal Department
of Health of Rio de Janeiro has devised a project for the expansion
and reorganization of vascular surgery divisions at city hospitals.
This project was first implemented at Hospital Municipal da Lagoa, and
has the aim of increasing the number of hospital beds, hiring more physicians,
and updating technological resources, thus allowing more efficient and
quicker treatment of diabetic foot patients and of patients with vascular
diseases.
Concomitantly
with these measures, the first center for diagnosis and treatment in endovascular
surgery, now in operation at Hospital Municipal da Lagoa, was created by the Municipal
Department of Health. The aim of this service is to offer angiographic exams and
endovascular therapeutic procedures, in addition to training and qualifying vascular
surgeons from other city hospitals for the implementation of new endovascular
surgery centers. The endovascular surgery centers of Hospital Municipal do Andaraí
and Hospital Municipal Salgado Filho will be operational in 2003 and 2004, respectively.
Finally, in order to attend to patients included or not in the project who
have severe complications and require hospital admission and immediate intervention,
the Municipal Department of Health will provide professionals in emergency services
with a qualification course. This course, basically designed for vascular surgeons
and on-call chiefs of the municipal emergency services, is expected to keep track
of specific care of diabetic foot patients and advertise the classification of
foot risk adopted by the Municipal Department of Health. These measures facilitate
the care and counter-referral of patients that are admitted to emergency services
who could be treated at other levels, as well as the proper referral of patients,
taken in for emergency procedures, after hospital discharge. The course is offered
and run by SBACV-RJ in conjunction with specific organizations of the Department
of Health.
All measures, at all levels, are always reliant on an adequate
referral and counter-referral system and on centralized management and regulation.
The final result of such effort is supported by the implementation of regional
centers for physical and occupational therapy, which can receive the patients
included in the project and provide them with orthesis and prosthesis, thus reducing
the recurrence of ulcerative lesions and late complications of lower limb amputations.
The excellent acceptance by patients and health professionals and the repercussion
of these measures at the secondary and tertiary levels makes us believe in the
success of this project, which attempts to solve or mitigate the severe complications
of those afflicted by this major public health problem. REFERENCES
1.
Consenso Internacional sobre Pé Diabético - 1999. Tradução
do International Consensus on the Diabetic Foot, impresso pela Secretaria de Estado
de Saúde do Distrito Federal. 2.
Censo IBGE 2000: disponível em URL: http://www.ibge.gov.br/home/ estatística/população
/censo2000. 3.
De Luccia N, Fidelis C, Silva ES, Marino HLT, Grupo de Elaboração
de Normas de Orientação Clínica dos Transtornos na extremidade
inferior do paciente diabético da SBACV. Normas de orientação
clínica para diagnóstico, prevenção e tratamento dos
transtornos na extremidade inferior do paciente diabético. Belo Horizonte:
SBACV; 2001. Disponível em URL: http://www.sbacv-nac.org.br/noc.
4.
Arbex I, Darze J. A legião dos mutilados. Jornal do Brasil, 05/05/2000.
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