A better way to heal diabetic foot ulcers

Community wound clinics are seeing faster healing, fewer visits and the potential to prevent amputations through total contact casting.

For people living with diabetic foot ulcers, a wound that refuses to heal can have life-changing consequences. Treatment can stretch over months, limiting mobility and independence while increasing the risk of infection and, in serious cases, lower-limb amputation.

A wound-care initiative in Western Canada is demonstrating how an evidence-based treatment known as total contact casting (TCC) can dramatically change that trajectory.

Total contact casting is considered the gold standard for offloading neuropathic plantar diabetic foot ulcers. By distributing pressure away from the wound and limiting repetitive trauma during walking, the cast gives the ulcer an opportunity to heal.

Despite strong clinical guidelines supporting TCC, its use remains inconsistent. Lack of training, concerns about patient safety and clinic workflow, resource limitations and uncertainty about how to introduce casting into existing wound-care programs can all stand in the way.

A Health Authority’s Wound Care Strategy Team set out to change that by developing a practical model for bringing TCC into community clinics.

The need was significant. Approximately 12,000 clients receive community wound care within the Health Authority each year, with diabetic foot ulcers accounting for roughly one-third of complex chronic wounds. These ulcers contribute to more than 100 amputations annually.

Before the initiative, average healing time for diabetic foot ulcers was 162 days and the healing rate was 46 per cent. The organization had also experienced a 16 per cent increase in diabetic foot ulcers alongside declining healing rates.

From evidence to everyday practice

The initiative began at three community ambulatory clinics representing different settings and levels of experience with diabetic foot offloading.

Rather than simply introducing a new clinical technique, the team focused on building the infrastructure needed to make TCC sustainable.

Clinical champions were identified, leadership support and funding were secured, standardized protocols and patient-selection criteria were established, and nurses received both theoretical and hands-on training.

Clinics were provided with approximately $10,000 in start-up funding for equipment and initial supplies. Nurses specializing in wound, ostomy and continence care received education in offloading, diabetic foot ulcer management and TCC application and removal, followed by supervised hands-on practice.

Most required about two weeks of practice – approximately eight cast changes – before feeling confident performing the procedure independently.

Clinics also adapted their schedules to accommodate casting. Initial casts were generally applied early in the week, followed by reassessment within 48 to 72 hours. Subsequent casts were typically changed every five to seven days.

The average course of TCC therapy lasted just 36 days.

Healing faster

The results were striking.

Across the three demonstration sites, 71 per cent of wounds treated with TCC healed, compared with 38 per cent of wounds receiving standard care – an absolute difference of 33 percentage points.

The improvement wasn’t limited to healing rates.

Among wounds that ultimately healed, clients had received an average of 188 days of treatment before TCC was initiated. Once casting began, average healing time was 36 days.

The faster healing also translated into fewer health-care encounters. Clients receiving standard care at the demonstration sites required an average of 20 nursing assessments, compared with 11 for clients treated with TCC.

For a health system facing workforce pressures and increasing demand for community care, reducing the number of visits required to heal a chronic wound can free nursing capacity for other patients.

There are potential benefits beyond the clinic as well. Cost modelling suggested faster healing reduced cumulative treatment costs, while fewer clinic visits were projected to reduce travel-related carbon emissions.

Most importantly, better wound healing could help prevent some of the most devastating consequences of diabetic foot disease.

Modelling based on the program’s findings suggests that broader implementation of TCC among appropriate patients could reduce amputations and associated mortality.

More than healing a wound

Clinicians also saw changes that weren’t captured in the formal study outcomes.

One client had been attending a wound clinic twice weekly for approximately 15 months, accumulating more than 240 visits with little improvement. After starting total contact casting, the client’s foot pain resolved within two days and the wound subsequently healed.

Another client who had relied on a walker because of the severity of an ulcer regained the ability to walk independently following successful wound closure.

Staff reported benefits too. Nurses described the satisfaction of seeing chronic wounds finally heal after months of ongoing treatment – an important consideration at a time when health-care organizations continue to grapple with workforce burnout.

The experience also reinforced that healing the ulcer is not the end of treatment. Some patients experienced recurrence after leaving the cast, prompting the team to strengthen the transition to removable offloading boots, customized insoles and appropriate footwear.

The initiative demonstrates that closing the gap between clinical evidence and everyday practice requires more than simply recommending a treatment. It requires leadership, training, standardized protocols, appropriate patient selection and ongoing measurement.

For community wound-care programs considering total contact casting, the experience provides a practical roadmap – and evidence that relatively modest investments in training and infrastructure can translate into meaningful improvements for patients.

For people living with diabetic foot ulcers, those improvements can mean far more than a healed wound. They can mean fewer months in treatment, greater mobility and independence, and potentially avoiding the loss of a limb.

By Christina E. Hagne, MN RN NSWOC WOCC(C), Jeff Wang, RN NSWOC, and Nicholas Salterio, M.Sc.

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