Dr. Almoutaz Alkhier Ahmed
Saudi Arabia
Gurayat North
Diabetic Center
P.O.Box 672
Email: khier22yahoo.com

Gurayat province is a border province located in the north west of Saudi Arabia. The population of Gurayat province is more than 125,000 citizens.⁽¹⁾ The prevalence of diabetes mellitus in Gurayat province is around 6-7%.⁽¹⁾ The prevalence of diabetic foot ulcers in Gurayat province is around 5.5%.(1)

Gurayat General Hospital is one of the Saudi Ministry of health hospitals providing secondary medical care services to Gurayat province with a capacity of 220 beds and 10 beds for intensive care. The surgical wards in Gurayat General Hospital contain 70 beds (35 beds for surgical male ward and 35 beds for surgical female ward)
The work started at the diabetic center in Gurayat General Hospital on the 1st of January 2006. Before that date, patients with diabetes were seen at the diabetic clinic at King Faisal Hospital in Gurayat province where there were no facilities for foot care. Patients with diabetic foot lesions were seen at surgical clinics. Before initiating the work at the diabetic center, there were no trained personnel on foot care, no special dressing materials were available and no written protocols for diabetic foot care were established.
After the initiation of the work at the diabetic center, diabetic patients suffering from diabetic foot lesions were seen at the diabetic foot care clinic, which is one of the diabetic center clinics. Although most cases were seen and followed at our center; other cases were seen and followed at surgical clinics.
The diabetic foot care clinic is run by a team composed of two highly trained nurses in foot care, supervised by a highly trained physician in diabetes care. Special dressing materials are available for dressing (Table 6) .The clinic is responsible for the preventive and curative part of care. The diabetic foot clinic saw 13 patients per day of whom 7 patients needed dressing for foot ulcers, 3 patients attended for routine foot screening and 3 patients for foot self care education.
Patients are usually admitted to surgical wards through surgical clinics or through Accident and Emergency department in Gurayat General Hospital. Others attend the hospital with referral forms from the primary health centers or other hospitals in the region.
Gurayat General Hospital is the only hospital with the capability to admit patients with diabetic foot lesions in the region.

Objective:
To evaluate the effect of our diabetic center on the outcome of diabetic foot cases. This was done through comparing the following parameters before and after starting work:
Number of admissions due to diabetic foot lesions
Duration of hospital stay due to diabetic foot lesions
Number of lower limb amputations due to diabetic foot.

A retrospective study was designed. The medical records of patients admitted to the surgical wards during the period from 1st of Jan 2005 to 29th Dec 2006 were reviewed.

Only medical records of patients admitted due to diabetic foot problems were reviewed. In each month, the number of admissions and the number of amputations due to diabetic foot was calculated. The duration of stay for each patient was calculated. A comparison between these three parameters in year 2005 and year 2006 was done.

Home computer statistical software was used to analyse the data.

During the year 2005, seventy-three (73) cases of diabetic foot were admitted to surgical wards (Table 1). The total duration of hospital stay for those patients was 614 days (Tables 3 & 4).
Four amputations were done during the year 2005 (Table 5) due to diabetic foot problems.
During the year 2006, only 40 cases were admitted to the surgical wards due to diabetic foot problems (Table 2). The total duration of hospital stay was 561 days (Tables 3 & 4). Only one case needed amputation, below the knee, during the year 2006 (Table 5).

There are significant statistical differences on the mentioned parameters (P-value < 0.000). This suggests the high efficacy of the diabetic foot clinic in improving the outcome of patients with diabetic foot problems attending Gurayat General Hospital. Amputation was higher among males with diabetic foot lesions than females (Table 5)

Figure 1: Comparison Based on Total Number of Admissions/Month (2005/2006)

Figure 2: Comparison Based on the Total Number of Admitted Patients (05/06)

Figure 3: Comparison based on total duration of admissions (05/06)

Figure 4: Comparison Based on Total Number of Amputations 1997-2001/2005/2006

Diabetes mellitus is one of the rising health problems worldwide.⁽²⁾ The importance of this disease depends on its high mortality and morbidity.

Diabetic foot is one of the less common complications but it is among the serious complications of diabetes mellitus.

The diabetic foot lesions may occur in diabetic patients at any time in their diabetes life. It is estimated that approximately 15% of all people with diabetes will be affected by a foot ulcer during their lifetime.⁽³⁾
One study done at King Khalid University hospital in Saudi Arabia showed that the prevalence of diabetic foot lesions was 10.4% among the Saudi population.⁽⁴⁾ In our center the prevalence of diabetic foot ulcer was 5.5%.⁽¹⁾ In Taiwan the prevalence of diabetic foot ulcers was 2.9%.(5) This variation related to multiple factors such as availability of national registry, ethnicity or abundance of other risk factors to develop diabetic foot ulcer.⁽⁵⁾

The diabetic foot care clinic is one of the diabetic center clinics. This clinic is responsible for the preventive and curative part of foot care.
Thirteen patients attend the diabetic foot clinic per day. The diabetic foot care team are responsible for the routine screening of diabetic patients according to written protocols adopted by the clinic as well as dealing with cases requiring acute or chronic management according to the protocols of the clinic. The diabetic foot care team also follows admitted patients with diabetic foot lesions upon request. Special dressings are used for managing diabetic foot lesions.⁽⁶⁾ Choice of dressings depends on the type of lesion. These dressings were highly effective in treating diabetic foot wounds.^(7,8) Documentation of the cases was done using digital camera and follow up files were opened for every patient who attends the clinic. Categorization of each lesion is always done first and a management plan designed for each case. Tight blood glucose was also assured. The diabetic foot care clinic in our center is using a written protocol for care based on the National Institute of Clinical Excellency in the United Kingdom.⁽⁹⁾ Following written protocols for foot care will facilitate the work and allow patients to get the best expected results.⁽¹⁰⁾
Early multidisciplinary intervention for diabetic foot cases will prevent the occurrence of major problems.
The multidisciplinary approach inside our center helped the diabetic foot care team to give their patients the best available standards of care, such as frequent check of their blood glucose while they are inside the center, we support them with strips and glucometers for self monitoring inside their houses, provide diet consultation, and sufficient time with diabetic educators and opportunities to meet physicians to improve and re-evaluate their blood glucose control.
In our study we had noticed a statistically significant difference on number of admissions between year 2005 and year 2006 (P-value <0.0001) and on the duration of hospital stay (P-value <0.0001). Interestingly we had noticed that some patients had been admitted for a long time (>2 months) for non-medical reasons. For example in 1427H we had noticed that one patient had been admitted for more than 3 months after below knee amputation due to lack of prosthetic and orthotic facilities in Gurayat province(11). Infection of the wound was the major cause prolonging duration of hospital stay of patients with diabetic foot (>1 month) especially those with severe deep infection. Also in our study we had noticed that females were staying longer than males but with an admission rate less than males.
In the general population lower leg amputation is suffered by between 5 and 25 people per 100,000; among people with diabetes the figure is between 6 and 8 for every 1,000.⁽³⁾ There are 3,000 diabetic patients registered in our diabetic registry.⁽¹⁾ According to this, the expected rate for amputation among our registered patients will be 18 - 24 amputations. In our study we had noticed a decline in the number of lower limb amputations to become only one case in the year 2006 which is outlined below. This makes the rate of amputation among our diabetic patients below the expected international rate which was 13 and 3.3 amputation for 10,000 diabetic patients in 2005 and 2006 respectively (P value <0.000).
In year 2006, only one recorded case had undergone amputation due to diabetes.
In our study the mean hospital stay in 2005 was 50.25 + 43.7 days, while it was 46.67+ 43.6 days in 2006. We had noticed that the range of the variables (duration of hospital stay/patients/month) was wide in both years. This is due to the unexpected figure due to the long hospital stay for non-medical reasons. This is noticed obviously in year 2006. In this year one patient stayed for more than 90 days while the maximum stay in year 2005 was 60 days. Interestingly, we had noticed that free beds give surgeons more feasibility to admit patients for a longer time. We had noticed that the non-medical indications and the presence of osteomylitis were the tow major reasons for increasing the hospital stay more than 30 days.
In one study done by Akbar D and Qari F they found that the mean hospital stay was 21.44 + 17.7 days.⁽¹²⁾ In another study done in Riyadh the mean hospital stay was 47.6 days.⁽¹⁾ In our study, if we exclude cases with non medical indications for hospital stay, our findings on the duration of hospital stay will be near the findings of both results.
In our study the number of admitted patients has declined obviously. This is due to the role played by the diabetic foot care clinic. The clinic saw nearly all patients who attended the hospital with diabetic foot. The implementation of programs of early screening for diabetes complications in our center had been successesful in preventing the occurrence of many diabetic foot lesions.
The multidisciplinary approach also helps to decrease the recurrence of diabetic foot lesions. The difference on number of admissions between year 1426H and 2006 was statistically significance (P-value <0.000).
The over-all decrease in the duration of hospital stay, number of admissions and number of amputations decreases successively the cost of diabetic foot care after the initiation of the diabetic center.
One of the limitations of our study is that we cannot calculate those patients who decide to do amputations out of the Guryat General Hospital. We have no link with the higher centers that we usually referred our patients to, to know if these patients have undergone amputation or not. This may weaken our findings in the rate of amputation before and after initiating the work in our center.

The other limitation was that we did not classify type of diabetic foot problems. For clarifying this point, all patients included in our study were patients with foot lesions that necessitated management.

Treating diabetic foot patients inside diabetic centers is more effective than treating them in separate surgical clinics. Diabetic centers can offer the multidisciplinary approach to patients with diabetic foot problems

Recommendations
The idea of diabetes centers should be supported and all patients with diabetic foot problems should be advised to be managemed inside these centers.

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