Clinical practice

Wound care management in Indonesia:

issues and challenges in diabetic foot ulceration
The increasing prevalence of diabetes mellitus has been linked with increased
morbidity and mortality, especially when associated with diabetic foot ulcer
(DFU). To improve the care of patients with DFU and provide an evidence-
based multidisciplinary approach, the Indonesian Wound Care Clinician
Association continuously develops best clinical practice and disseminates
this information through Indonesian ETNEP certification. DFU management
focuses on: prevention; wound care protocols; off-loading; and adjunctive
(alternative) therapy. DFU characteristics should be assessed using the
modified Bates-Jensen score to evaluate and predict the wound-healing
process. Management recommendations include debridement every 2–4
Authors:
Widasari Sri Gitarja, weeks, continued use of offloading, and adjunctive wound therapy. Although,
Ahmad Jamaluddin,
Ahmad Hasyim
these protocols have attempted to delineate DFU management, they do not
Wibisono, Vonny cover all aspects of this complex condition.
Nurmalya Megawati,
Kana Fajar

T
here are 415 million people aged 20–79 systems to improve DFU outcomes in Indonesia.
years with diabetes worldwide, almost Improvements are limited, however, because
153 million of them live in the Western modern wound care dressings are not currently
Pacific region (Ogurtsova et al, 2017). The number available through national health insurance. The
of people with diabetes is predicted to rise to Government plans to provide universal health
642 million worldwide by 2040 (Ogurtsova coverage by 2021 through its social security
et al, 2017). Indonesia has approximately 258 programme (Badan Penyelenggara Jaminan
million citizens, making it the world’s fourth Sosial), but by only providing health insurance
most populated country. It is one of 21 countries is not enough to overcome DFU management
and territories in the International Diabetes problem nationally. There is need for sustained
Federation Western Pacific region. According to and robust action from the Government to
the International Diabetes Federation (2017), formulate health policies, strategies and action
Widasari Sri Gitarja is Enterostomal about 10.3 million Indonesians have diabetes. plans to tackle the increasing prevalence
Therapy Nurse and CEO at Wocare DFU is not unpreventable. Most DFU cases are of diabetes, particularly in relation to the
Indonesian Foundation; Wocare preventable (Driver et al, 2014). DFU prevention management of DFUs (Soewondo et al, 2013).
Center-Private Practice and is important, as recent research has revealed There are also other challenges that need to be
Corporate University of Wocare,
Indonesia; Ahmad Jamaluddin
that >15% of DFUs will progress to amputation overcome. In Indonesia, the dominant staple food
is Enterostomal Therapy Nurse at (Liu et al, 2018). Furthermore, after amputation, is rice, which has a high glycaemic index (GI). This
GOcare-Private Practice and State 13–40% of people will die within a year, and may be an obstacle for people trying to control
University of Gorontalo; Ahmad 39–80% within 5 years (Driver et al, 2014). This is a their blood glucose. Many Indonesians struggle
Hasyim Wibisono is Certified comparable mortality to that caused by all types to change their diet, particularly when reducing
Wound Care Clinician, School of
Nursing, Brawijaya, University and
of cancers (34.2%) within the same period (Driver their consumption of high GI foods or substituting
Pedis Care Center-Private Practice; et al, 2014). high GI foods for lower GI options. Furthermore,
Vonny Nurmalya Megawati is myths persist that deter dietary changes. For
Certified Wound Care Clinician at Challenges example, some individuals believe that people
DM Wound Care Mojokerto; Kana It is a huge challenge for wound care clinicians with chronic wounds should not eat fish as it may
Fajar is Enterostomal Therapy Nurse,
Wocare Indonesian Foundation,
to reduce the mortality associated with DFUs. cause the wound to itch, that chicken will make
Wocare Center-Private Practice, The Indonesian Wound Care Clinician Association the wound slimy, or that meat in general should
Bogor, West Java, Indonesia (InWCCA) develops high-quality wound care be avoided as it may produce foul wound odours.

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 Clinical practice

Table 1. Modified Bates-Jansen score As a result of these myths, patients’ diets Sensation in the feet should be
(maximum score of 50) tend to lack protein, which is essential for assessed with a 10 g Semmes Weinstein
Item Assessment supporting wound healing. monofilament and 128 Hz tuning forks. If
Erroneous beliefs also exist around neuropathy is present, patients should be
Wound size Length x width <5 cm2
wound treatment. For example, some informed that they are at increased risk of
Length x width 5<20 cm2
community groups believe that developing a DFU. This knowledge may
Length x width 15<40 cm2
neuropathic ulcers should be managed encourage them to practice good foot care
Length x width 40<85 cm2
by the application of heat, which may and take extra precautions to lower their
Length x width >85 cm2
lead to further tissue damage and thermal risk of DFU.
Wound stages Stage 1 injury. Others believe that an infected
Stage 2 wound has to be treated using benzene Wound care management protocol
Stage 3 or kerosene, as these substances will The modified Bates-Jensen score is
Stage 4 eradicate the microbes. recommended to predict and evaluate the
Un-stage These cultural factors often impair wound healing process. Based on clinical
Wound base edge Intact skin wound healing and education remains our evidence it takes 12 weeks on average to
for granulation Red-granulation tissue 100% best tool in eradicating these obstacles. promote wound healing, as measured by
tissue Red 50%, yellow/black 50% the 10-item Bates-Jensen tool. Each item is
Red 25% DFU management in Indonesia scored from 1 to 5
Slough/necrotic 100% DFUs make up almost 90% of wounds [Table 1], to give a maximum score of 50.
Type of exudate Bloody treated at private nursing clinics. The protocol includes the optimisation
Serosanguineous Therefore, the InWCCA developed a of glycaemic control, nutrition,
Serous clinical best practice protocol which oxygenation and management of
Purulent is disseminated through Indonesian other systemic conditions. The wound
Foul purulent Enterostomal Therapy Nursing Education healing process will be suboptimal until
Programmes. The program is recognized appropriate diabetes management
Amount of exudate Dry
by The World Council of Enterostomal is accomplished, as hyperglycaemia
Moist
Therapists. The InWCCA has also detrimentally affects healing and the
Mild/small
developed a “Stop Amputation, Do Early immune system, predisposing patients
Moderate
Prevention” DFU awareness programme to infection. The protocol advocates DFU
Heavy
that aims to improve the patient management based on the TIME (Tissue;
Surrounding skin Pink or normal care and provide an evidence-based, Infection/inflammation; Moisture; and
color Red bright multidisciplinary approach. Edge of wound) principle (Leaper et al,
Hypopigmentation The best practice advocated by InWCCA 2012). It is divided into the classification
Dark red focuses on four areas of DFU management: of the ulcer, safe debridement and
Hyperpigmentation DFU prevention; wound care management dressing selection.
Surrounding skin Soft and healthy protocol; off-loading; and alternative Classification is based upon clinical
Visible, fused with the base (adjunctive) therapy. evaluation of DFU size, tissue loss, depth
Visible, not fused with the base of of the ulcer, wound edges, undermining
the wound DFU prevention and the type of necrotic tissue present.
Clear, not fused with wound base The loss of protective sensation due to Completion of the rating sheet enables the
Fibrotic, hyperkeratosis neuropathy leaves patients with diabetes current wound status to be identified and
Epithelisation 75–100% epithelisation at an increased risk of developing a predicts the healing outcome. Evaluation
50–75% epithelisation DFU. DFU prevention focuses on patient should be carried out once a week and
25–50% epithelisation education, support and encouraging whenever a change occurs the wound.
<25% epithelisation positive self-care behaviours. Daily foot A protocol should be followed to ensure
None inspection, careful nail cutting, gentle safe debridement in the clinical setting.
bathing of feet in tepid water and Initial wound bed preparation accelerates
Oedematous No swelling
moisturising the skin, e.g. with coconut the healing process or facilitates the
Oedema—non-pitting oedema
soap, are components a good foot care effectiveness of therapeutic measures
Pitting oedema <4 cm
regimen. Methods of preventing thermal (Dowsett and Newton, 2005) by moving
Pitting oedema>4 cm
or mechanical injury should be explained. a chronic wound into an acute phase.
Crepitus
The use of appropriate footwear should Debridement should remove obvious
Wound tunnels None be emphasised. Patients should also be necrotic tissue and reduce the bacterial
<2.5 cm—all around educated in the cardinal signs of infection burden. Repeated debridement may be
2.5–3.5 cm <50 % (heat, redness, pain, swelling and pus) and needed to maintain an optimal wound
3.5–4.5 cm >50% advised on where to seek help should they bed. Various methods can be used to
>4.5 cm all around notice any of these symptoms. debride a wound, such as autolytic,

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 Clinical practice

mechanical, biological, hydro pressure (or autohaemotherapy, where blood is withdrawn,

pressure irrigation using ultrasonic dental tools), mixed with ozone and put back in the body. The
and/or conservative sharp wound debridement. method we use in Indonesia was using ozone
The wound should be cleansed to remove machine and plastic, the wound was placed
contaminants from the wound surface as part of inside the plastic then the ozone air was flowed
wound bed preparation (Cutting, 2010).A moist to the plastic using a cannula.
wound environment promotes cell migration Infrared light may have a positive effect on
and matrix formation (degli Agosti et al, 2004). In wound healing (de Abreu Chaves et al, 2014)
principle, the ideal dressing should create a moist as it has demonstrated increased migration,
environment, manage exudate levels, support viability and proliferation of diabetic cells in
autolytic debridement and have an antimicrobial vitro (Houreld, 2014). It has been shown to
component, as well as requiring limited nursing have beneficial effects on diabetic ulcers that
time to apply and having low financial cost. are unresponsive to conventional treatment;
Access to modern dressings is limited as they however, well-designed clinical studies are
are expensive; however, the principles of an needed as the current studies are limited and
ideal dressing should be applied wherever and reported responses vary due to methodological
however possible. Metcovazin is an inexpensive heterogeneity (Houreld, 2014).
topical zinc-based cream that promotes moisture
balance within the wound and allows easy Case studies
removal of the old dressing. It is locally produced Case studies 1–3 demonstrate the challenges
and contains chitosan, petroleum jelly and zinc. associated with DFU management and some of
Zinc cream has several unique features, as it is the creative innovations used in Indonesia to
not only promotes a moist wound environment address these problems.
but also facilitates tissue regeneration (George
and Gitarja, 2011). Gauze impregnated with Statutory changes
Metcovazin is commonly used as a primary A number of statutory changes are underway
wound contact dressing in Indonesia. that will change how wound care patients
are treated and develop nursing practice in
Off-loading Indonesia in the next few years, although
DFUs on the sole of the foot are often associated there are a number of issues to overcome. The
with moderate to high pressures, primarily due Ministry of Health regulation statute number
to foot deformity, limited joint mobility and 148/2013 is currently in force, despite the
neuropathy. Off-loading devices, such as total Nurses Act being passed in 2014, as the manual
contact casts, reduce pressure on the sole of the for the Nurses Act has only recently been
foot and may aid in reducing the patient’s activity established. The law itself is not technically
levels. Off-loading has become the mainstay of applicable without the manual, therefore the
DFUs treatment. old statute still applies.
Protective and comfortable footwear should be To address this situation, the InWCCA
recommended for any patient at risk of DFUs and and Ministry of Health have created a task
for those who have already had a DFU. force develop a standard for private nursing
Advocating suitable footwear in patients at practice. This standard will give nurses who
high risk of DFU and implementing offloading wish to run private practices as individuals
are cost-effective actions that help improve the or groups a stronger legal standing when
patient’s quality of life by preventing it is passed. The draft was presented at the
DFU recurrence. 7th Asia Pacific Enterostomal Therapy Nurse
Association conference in Bogor, Indonesia, in
Adjunctive (alternative) treatments April 2017 and the final version will hopefully
Adjunctive, or alternative, therapies have been be published later this year. It will provide more
used in Indonesia to accelerate wound healing than 10000 certified wound clinicians with clear
in patients with DFUs. However, there is no and applicable standards for managing their
strong recommendation to use these treatments patient’s wounds in clinical practice.
due to its limited evidence from clinical trials to The Indonesian Nurses Act 2014 defines
support their use. Patients may be treated with a nurses as vocational (on completion of a 3-year
combination of electrical stimulation, ozone and diploma) or professional, which is separated
infrared therapies. into two tiers. The first is those who complete
Several studies have found that electrical bachelor degree and the second is those who
stimulation accelerates wound healing and/ finish master degree (they set out the role of

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 Clinical practice

Table 2. Mrs A Modified Bates-Jensen Case Study 1

examination scores Mrs ‘A’ is a 40-year-old woman who was diagnosed with type 2 diabetes, two years
Item Initial 5 weeks prior to presentation with an ulcer. The DFU had been present for the past 2 weeks
and had deteriorated, becoming painful. The wound bed was necrotic and sloughy
Wound size 4 3
with significant malodour. She scored a total of 36 on Bates-Jensen examination
Wound depth 5 4 [Table 2].
The wound was cleansed using wound soap and saline. Conservative sharp
Wound bed for 4 3
wound debridement was then performed to remove the necrotic tissue and
granulating tissue
sloughy tissue. The wound was treated with zinc cream to facilitate autolytic
Exudate type 2 1 debridement and an antimicrobial dressing containing cadexomer iodine. An
Exudate amount 4 2 absorbent dressing was applied and fixed in place with a crepe bandage.
The patient received standardised wound care for 5 weeks before returning to
Surrounding skin 4 5
her village in a rural area. At her last appointment, her wound had significantly
colour
improved. There was a reduction in slough and the patient reported that her pain
Surrounding skin 3 2 was now under control. The improved appearance of the wound was reflected in a
Epithelialisation 5 4 significant improvement in Mrs A’s Bates-Jansen examination score [Table 2].
Oedema 4 1
Wound tunnel 1 1
Total 36 27

Table 3. Mrs A Modified Bates-Jensen Case Study 2

examination scores Mr ‘B’ is a 45-year-old man with diabetes who presented with a wound around
Item Initial 4 weeks the lateral malleolus. The wound had previously been treated with topical herbal
therapy but had continued to deteriorate and was predominantly necrotic
Wound size 4 4
[Figure 1a]. On examination the patient had a Bates-Jensen score of 39 [Table 3].
Wound depth 5 3 The wound was washed with wound soap and mineral water then conservative
wound debridement was used to remove the necrotic tissue and slough. The wound
Wound bed for 4 1
was treated using a combination of antimicrobial dressing with cadexomer iodine,
granulating tissue
topical Metcovazin and IntraSite Gel to support autolytic debridement, before being
Exudate type 4 1 covered with an absorbent dressing fixed with gauze and a crepe bandage
[Figure 1b]. After 4 weeks of care, granulation tissue had replaced the slough and
Exudate amount 3 2 necrotic tissue, and the Mr B’s Bates-Jensen score had reduced to 21 [Figure 1c].
Surrounding skin 4 1
colour
[a] [b] [c]
Surrounding skin 4 2
Epithelialisation 5 5
Oedema 4 1
Wound tunnels 1 1
Total 39 21
Figure 1. Mr B presentation at the start treatment [a]; after 2 weeks of treatment
[b]; after 4 weeks after treatment [c].

the clinical nurse specialist) (Suba and of Health (Suba and Scruth, 2015).
Scruth, 2015). When it comes into force,
all nurses will be required to pass a Conclusion
competency examination. Importantly, There are many opportunities to improve
the Nurses Act will authorise nurses to the prevention, management and
perform independent nursing practice, outcomes of DFUs. The InWCCA continue
such as wound care in form of private to improve current standards, working
nursing practice or on behalf with with the Government and educational
other practicioners. Such actions will be bodies to spread knowledge and
regulated by codes set out by the Ministry improve practice. WAS

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 Table 4. Case 3: Modified Bates-Jensen Case Study 3
examination scores Mr ‘C’ is a 45-year-old man who presented with a large ulcer on top of his left
Item Initial 12 week foot. The wound bed consisted of 80% slough, 10% necrotic tissue and 10%
granulation, and there was a deep abscess. After washing the wound with wound
Wound size 4 2 soap and sodium chloride, the necrotic tissue and slough was debrided. The
wound was then treated using the same regimen as in case 2.
Wound depth 5 2 After 12 weeks of treatment, the wound bed was covered with granulation
Wound bed for 4 1 tissue, was epithelializing, and had decreased in size. At this time, the patient’s
granulating tissue Bates-Jensen score had improved from 41 to 14 [ Table 4].
Exudate type 5 1
Exudate amount 5 1
[a] [b]
Surrounding skin 4 1
colour
Surrounding skin 4 2
Epithelialisation 5 2
Oedema 4 1
Wound tunnels 1 1
Total 41 14
Figure 2. Mr ‘C’ s wound was extensive and contained an abscess on presentation
[a]; the wound was healing well after 12 weeks of treatment [b].

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