*Division of Infectious Diseases, Department of Medicine, Boston, MA.
¶Harvard Medical School, Boston, MA.
J Am Podiatr Med Assoc. 2022 Nov-Dec;112(6). doi: 10.7547/20-178.
Diabetic foot osteomyelitis is a common infection where treatment involves multiple services, including infectious diseases, podiatry, and pathology. Despite its ubiquity in the hospital, consensus on much of its management is lacking.
Representatives from infectious diseases, podiatry, and pathology interested in quality improvement developed multidisciplinary institutional recommendations culminating in an educational intervention describing optimal diagnostic and therapeutic approaches to diabetic foot osteomyelitis (DFO). Knowledge acquisition was assessed by preintervention and postintervention surveys. Inpatients with forefoot DFO were retrospectively reviewed before and after intervention to assess frequency of recommended diagnostic and therapeutic maneuvers, including appropriate definition of surgical bone margins, definitive histopathology reports, and unnecessary intravenous antibiotics or prolonged antibiotic courses.
A postintervention survey revealed significant improvements in knowledge of antibiotic treatment duration and the role of oral antibiotics in managing DFO. There were 104 consecutive patients in the preintervention cohort (April 1, 2018, to April 1, 2019) and 32 patients in the postintervention cohort (November 5, 2019, to March 1, 2020), the latter truncated by changes in hospital practice during the coronavirus disease 2019 pandemic. Noncategorizable or equivocal disease reports decreased from before intervention to after intervention (27.0% versus 3.3%, respectively; P = .006). We observed nonsignificant improvement in correct bone margin definition (74.0% versus 87.5%; P = .11), unnecessary peripherally inserted central catheter line placement (18.3% versus 9.4%; P = .23), and unnecessary prolonged antibiotics (21.9% versus 5.0%; P = .10). In addition, by working as an interdisciplinary group, many solvable misunderstandings were identified, and processes were adjusted to improve the quality of care provided to these patients.
This quality improvement initiative regarding management of DFO led to improved provider knowledge and collaborative competency between these three departments, improvements in definitive pathology reports, and nonsignificant improvement in several other clinical endpoints. Creating collaborative competency may be an effective local strategy to improve knowledge of diabetic foot infection and may generalize to other common multidisciplinary conditions.
糖尿病足骨髓炎是一种常见的感染，其治疗需要多学科的参与，包括传染病学、足病学和病理学。尽管这种感染在医院中普遍存在，但对于其大部分治疗方法仍缺乏共识。
对质量改进感兴趣的传染病学、足病学和病理学代表共同制定了多学科机构建议，最终形成了一项教育干预措施，描述了治疗糖尿病足骨髓炎（DFO）的最佳诊断和治疗方法。通过干预前后的调查评估知识获取情况。对干预前后的前足 DFO 住院患者进行回顾性分析，以评估推荐的诊断和治疗操作的频率，包括对手术骨边缘的适当定义、明确的组织病理学报告以及不必要的静脉内抗生素或延长抗生素疗程。
干预后调查显示，抗生素治疗持续时间和口服抗生素在管理 DFO 中的作用的知识有显著提高。在干预前队列（2018 年 4 月 1 日至 2019 年 4 月 1 日）中有 104 例连续患者，在干预后队列（2019 年 11 月 5 日至 2020 年 3 月 1 日）中有 32 例，由于在冠状病毒病 2019 大流行期间医院实践的变化，后一队列的病例数量减少。无法分类或不确定的疾病报告从干预前到干预后减少（分别为 27.0%和 3.3%；P =.006）。我们观察到正确的骨边缘定义没有显著改善（分别为 74.0%和 87.5%；P =.11），不必要的外周插入中心导管线放置（分别为 18.3%和 9.4%；P =.23），以及不必要的延长抗生素疗程（分别为 21.9%和 5.0%；P =.10）。此外，通过作为一个跨学科小组工作，解决了许多可解决的误解，并调整了流程，以提高对这些患者的护理质量。
这项针对糖尿病足骨髓炎管理的质量改进举措提高了提供者的知识，改善了这三个部门之间的协作能力，提高了明确的病理学报告，并且在其他几个临床终点方面没有显著改善。建立协作能力可能是提高糖尿病足感染知识的有效局部策略，并可能推广到其他常见的多学科疾病。
