Wound Care Management in Indonesia:

Issues and Challenges on Diabetic Foot Ulcer

* Seminar and workshop at St Carolos Hospital Jakarta- July 2017

Abstract
In global prevalence diabetes mellitus continues to grow and one of the pointed areas of
morbidity associated with diabetes is the diabetic foot.i To improve the care of patients
with diabetic foot and to prove an evidence-based multidisciplinary management
approachii, the Indonesian Wound Care Clinician Association (InWCCA) and Wocare
center developed this clinical best practice and spreading the information continuously by
Indonesian ETNEP certification. Specific areas of focus DFU management included (1)
Prevention of diabetic foot ulceration, (2) Wound Care Protocol Management, (3) Off-
loading, (4) Adjunctive Treatments. We recommend using comfortable footwear in high-
risk diabetic patients, including those with significant neuropathy, foot deformities, or
previous amputation. The group has made practice recommendations for wound care
using the modified Bêtes Jensen scores reduce in 13 points to 10 points evaluate and
predict wound-healing process. iii iv This project provides recommendations in
comprehensive wound care management including various debridement methods in a
minimum of 2 - 4 weeks standard of tissue management and continue with off-loading
management. We also recommend adjunctive wound therapy options for difficulties
wound care. Whereas these protocols have addressed wound care of DFUs but they have
not cover all the aspects of this complex condition in DFU.

Introduction
Geographically, Indonesia's landscape is greatly varied. Java and Bali have the most
fertile islands and rice fields are concentrated in these two regions, whereas Sumatra,
Kalimantan, Sulawesi, Maluku and Papua are still largely covered with tropical rainforest
and open savannah and grassland characterize Nusa Tenggara. The country has
approximately 258,000,000 people; Indonesia is the world’s fourth most populated
country. Indonesia is one of the 21 countries and territories of IDF WP region. The 415
million people have diabetes in the world and almost 153 millions people in the WP
region; by 2040 this will be rise to 2152 million. There were 10 million cases of diabetes
in Indonesia, in individuals aged 20–79 years in 2016.v It also has the seventh largest
number of diabetic patients.
Recent documentation revealed that more than 15% of diabetic ulcer cases would lead to
amputation, despite the fact that most of the amputation cases are preventable and are
curable/ healable (Driver et al, 2014)vi. Furthermore, after an amputation, 13-40% of
people will die within a year, and 39-80% within 5 years. As a comparison, the 5-year
mortality for all cancers is 34.2% (Driver et al, 2014).
Therefore, the InWCCA struggle to develop a high quality wound care system, even
though modern dressings are mostly not covered by national health insurance. The
Government aims to achieve universal health coverage by 2021 by progressively
covering the national health insurance through BPJS. Indonesia is beginning to take
action on diabetes but needs to strengthen its response to meet the scale of the challenge,
notably in the area of operational policy; strategy and action plan for managing diabetic
ulcers.vii

Diabetic Foot Ulcer Management in Indonesia

The pointed area of morbidity and mortality associated with diabetes is the diabetic foot.
Almost 90% wounds treated in Wocare and clinical nursing private practices in Indonesia
are diabetic foot ulcers. To improve the care of patients with diabetic foot and to prove an
evidence-based multidisciplinary management approach, the Indonesian Wound Care
Clinician Association and Wocare center developed this clinical best practice (protocol)
and spreading the information continuously at Indonesian ETNEP-WCET program
certified and awareness program of “Stop Amputation, Prevention First”. The specific
areas focusviii on DFU management included (1) Prevention of diabetic foot ulceration,
(2) Wound Care Protocol Management, (3) Off-loading, and (4) Adjunctive Treatments.

Specific consideration to some unique characteristic of eastern community like Indonesia

should be integrated to day-to-day practice of wound clinicians. It has been noted that in
Indonesia the dominant staple food is rice, which is the potent source of carbohydrates.
This may hinder adequate blood glucose control as people are resistant to change or
reduce their rice consumption. Also there are strongly believed myths that surround
people with chronic wounds such as: fish should not be eaten as they may have itchy
effect on wound, chicken has to be avoided because it makes the wound slimy, meats are
forbidden as it brings foul odors on wound, and many more. Consequently patient’s diet
are lacking of protein, which is essential to support wound healing. Finally, erroneous
beliefs also exist around wound treatment. Some community groups believe that
neuropathic ulcer has to be managed by applying high temperature, which may lead to
tissue breakdown and burns. Some others believe that an infected wound has to be treated
using benzene or kerosene to eradicate the microbes. These factors often impair the
affectivity of wound care if not properly identified and addressed by wound clinicians.

(1) Prevention of diabetic foot ulceration: Diabetic foot nursing spa

Risk factor that can lead to ulceration in patients with diabetes related to loss of
protective sensation due to neuropathy. Prevention of diabetic foot ulceration focuses on
teaching counseling and prevention education in self-care behaviors in good foot care and
daily inspection of the feet will reduce the recurrence of diabetic ulceration. Protocol
management on diabetic foot nursing spa such as good foot care proper bathing and nail
care with home remedies coconut soap and sea salt following with several simple clinical
techniques used to identify sensory neuropathy with loss of protective sensation. The
presence of sensory neuropathy or neurological clinical examination for sensory loss
determined by testing with a 10 g Semmes Weinstein monofilament and 128 Hz tuning
forks for vibration perception threshold testing. Counseling as part of a comprehensive
care program in professional diabetic foot nursing spa, such as education about diabetic
sensory neuropathy that creates an environment in which repetitive trauma; injury and
infection are unrecognized by the patient and used comfortable shoes in high-risk diabetic
patients, including those with significant neuropathy, foot deformities, or previous
amputation.
(2) Wound Care Protocol Management:
The group made practice recommendations for wound care using the modified Bates
Jensen scores reduce in 13 points to 10 points for evaluation system of wound healing
process. The system with 10 point scores takes 12 weeks for promotes wound-healing
process includes optimizing glucose control. Wound healing are to be optimal in the
setting of good diabetes management such as abnormal glucose levels that affect the
nature of cellular immunity and infection control in the treatment of diabetic ulcers that
plays various roles in the etiology, healing process, and complications of diabetic ulcers.
The protocol of clinical implementations of DFU based on TIME management ixhas
divided into 3 points: (a) assessment of ulcer stages; (b) safe debridement and (c)
dressing selection.
(2.a) Assessment approach by ulcer stages
The classification wound assessment tools was based upon clinical evaluation of
integumentary system in size; tissue loss and depth ulcer presence; wound edges;
undermining and type of necrotic tissue. Complete the rating sheet will Asses the wound
status and put the expectation of healing in appropriate date. Evaluate once a week and
whenever a chance occurs the wound.
(2.b) Safe Debridement
Debridement is a step for doing wound bed preparation. There is pro and contra for doing
debridement as nursing skill in Indonesia. The protocols of debridement standardize
clinical debridement setting called safe debridement (without bleeding or minimal
bleeding) for managing wound bed preparation tissue management in more appropriate.
The literatures says that wound bed preparation is defined as the management of the
wound to accelerate healing process or facilitate the effectiveness of other therapeutic
measures.x (Falanga, 2000; Schultz et.al, 2003) The aim of wound bed preparation is to
convert the molecular and cellular environment of a chronic wound to get a progress of
wound healing. Debridement is required to remove the obvious necrotic tissue, excessive
bacterial burden, and cellular burden of dead and senescent cells. Maintenance
debridement is needed to maintain the appearance of the wound bed for healing. The
nursing skill competencies can choose from a number of debridement methods including
autolytic, mechanical, biological, hydro pressure (or pressure irrigation using dentist
ultrasonic scaler), or CSWD. There are five nursing skills debridement competencies that
they could use more than one debridement method may be appropriate. Cleanse the
wound is also part of wound bed preparation. Wound cleansing is defined as the process
of removing inflammatory contaminants from the wound surface and cleanse with the
cleansing solutions. xi

Cleansing method used scaler CSWD, safe debridement after Dressing used chitosan zinc
autolysis cream and others.
(2.c) Dressing selectionxii
It is thought that a moist wound environment will promote of cell migration and matrix
formation. There is several protocol criteria’s that should be considered when selecting a
dressing including the created moist environment, support autolysis debridement and
managing wound exudate. The cost of nursing time, healing rate, and the unit cost of
dressings should be considered when determining cost efficacy. That any dressing intact
to the wound is facilitate wound healing. In some condition, the modern dressing from
abroad is difficult to apply because of lack in financial but the goal of dressing selection
must to be addressed. A frequently used, inexpensive topical treatment, which promotes
moisture balance within the wound and allows easy removal of old dressings is a zinc
based paste composition called Metcovazin®. This topical ointment is locally produced
and contains Chitosan, Vaseline and zinc. Gauze is impregnated with Metcovazin® and
this is used as a primary wound contact dressing. Metcovazin® or zinc cream has unique
features as it is not only promotes moist wound environment, but also facilitating tissue
regenerationxiii.

Dressing changed

(3) Off-loading: total contact cast and comfortable shoes

Diabetic ulcerations on the sole of the foot are often associated with moderate to high
pressures because of foot deformity, limited joint mobility, and neuropathy.
Off-loading devices reduce pressure on the sole of the foot and often reduce the activity
level of the patient. Off-loading the area of high pressure has been the mainstay to heal
DFUs and prevent recurrence of foot ulcerations. Protective and comfortable footwear
should be recommend in any patient at risk for amputation. It would be effective to
reduction in recurrent ulcerations in high-risk patients with a previous foot ulcer or risk
amputation. Homemade of special comfortable and cheap footwear is available in
Indonesia for diabetes patients.
Patient with Charcot foot Off loading used dressing Homemade diabetic
comfortable shoes

(4) Adjunctive Treatments

Adjunctive therapies have been used to accelerate wound healing in patients with diabetic
foot ulcers especially for hard to heal chronic wound. In the clinical practice some cases
that hard to heal treated with combination of (a) electrical stimulation; (b) ozone therapy
and (c) Infra Red.

(4.a) Electrical Stimulation: Electrical stimulation has been shown to accelerate wound
healing and increase cutaneous perfusion in human xiv . Electrical stimulation is an
adjunctive therapy of wound care in Diabetic foot ulcer especially in vascular disease.
Electrical stimulation is given for 20 minutes and the sensation of the stimulation
depends on the patient’s perceptions, it can be low or high.

Electrical stimulation Electrode for tendon stimulation

(4.b) Ozone therapy: In-patient with non-healing wounds, oxygen-ozone could be helpful
in speeding the healing and reducing the pain thanks to its disinfectant property and by
the increase of endogenous oxygen free radical’s scavenging properties.xv The ozone
therapy used to infected diabetic foot ulcers wound, after wound cleansing, ozone therapy
given for 15 minutes, every 2 until 3 days treatment. The previous study about “the
effectiveness of modification modern dressing and ozone therapy on wound healing of
patient with pressure ulcer in Wocare Cinic Bogor” xvi . The results of this study,
demonstrated the value of α = 0,000 < 0,05. Therefore, it can be concluded, “The use of
modern modification of dressings and ozone therapy more effective on wound healing
compared with the use of modern dressings course in patients with pressure ulcers".
These results are consistent with the theories that support this study. Based on these, as a
nurse can apply ozone therapy as a complementary therapy for wound care to decrease
the incidence of infection that can cause mortality.

Infrared and ozone therapy that used at diabetic foot ulcer

(4.c) Infra-Red: Infrared lamp therapy is an effective method of treatment on wound

healing, several studies shown that when heat applied on wound blood circulation
increases, prevent growth of microorganism, losing tight muscles, aids in healing
damaged tissue, reducing redness, pain relief, provide comfort and fast wound healing.xvii
The infrared treatment is given after wound cleaning, using infrared light therapy for 15
minutes every treatment.

Clinical Cases
The following case studies demonstrate the challenges associated with DFU management
and some of the creative innovations used in Indonesia to manage these problems.

Pic.1. Wound Care Nurse doing wound debridement

Case 1.
Mrs. A Female 40 years old, has DM history for 2 years, diabetic wound was suffered for
last 2 weeks, there was wound in the left side, the wound had already bigger and painful,
the condition of the wound is necrotic, slough and stink. Bates Jansen examination
wound: wound size: 4, wound depth: 5, wound edge: 3, cave: 1, Exudate type: 2,
Exudate amount: 4, Skin Color surrounding skin: 4, Peripheral tissue edema: 4,
Granulation tissue: 4, Epithelization: 5, total score 36. Wound care : washing the wound
using wound soap and saline, then mechanical debridement using conservative sharp
wound debridement to remove the necrotic and slough tissue, next giving antimicrobial
dressing with mixed Cadexomer iodine and zinc cream as topical therapy to support the
autolysis debridement , and absorbent dressing, finally fixation with crepe bandage.
The wound care almost done for 5 weeks but the patient back to her village in the rural
area and continue her wound care by another clinician. The last wound care showed
better condition where there is no more slough tissue and pain, and it can be seen by
wound care examination which are: wound size: 3, wound depth: 4, wound edge: 2, cave:
1, Exudate type: 1, Exudate amount: 2, Skin Color surrounding skin: 5, Peripheral tissue
edema: 1, Granulation tissue: 3, Epithelization: 4, total score 27.

Pic. Ny A1. 30-11-2014 Pic. Ny A2. 13-12-2014 Pic. Ny A3. 07-01-2015

Case 2.
Mr.NB Male 45 years old, has DM and diabetic wound, there was wound in the left side,
the wound had already given a herbal topical therapy but getting worse, the condition of
the wound is 100% necrotic. Bates jansen examination wound: wound size: 4, wound
depth: 5, wound edge: 4, cave: 1, Exudate type: 4, Exudates amount: 3, Skin Color
surrounding skin: 4, Peripheral tissue edema: 4, Granulation tissue: 4, Epithelization: 5,
total score 39. Wound care : washing the wound using wound soap and Mineral Water,
then mechanical debridement using conservative wound debridement to remove the
necrotic and slough tissue, next giving antimicrobial dressing with cadexomer iodine,
wound salf metcovazin® as topical therapy and hydrogel: intrastiegel® to support the
autolysis debridement , and absorbent dressing, fixation with gauze and crepe bandage.
The wound care for 4 weeks, showed a better condition, where there is no necrotic and
slough tissue but 100 granulation tissue, and it can seen by wound care examination
which are: wound size: 4, wound depth: 3, wound edge: 2, cave: 1, Exudate type: 1,
Exudate amount: 2, Skin Color surrounding skin: 1, Peripheral tissue edema: 1,
Granulation tissue: 1, Epithelization: 5, total score 21.
Case 3.
Mrs. FN Male 45 years old, has DM and diabetic foot ulcer, there was wound in the left
side because of abscess, the condition of the wound is 80% slough, necrotic10% and
granulation 10%. Bates Jansen examination wound: wound size: 4, wound depth: 5,
wound edge: 4, cave: 1, Exudate type: 5, Exudate amount: 5, Skin Color surrounding
skin: 4, Peripheral tissue edema: 4, Granulation tissue: 4, Epithelization: 5, total score
41. Wound care: washing the wound using wound soap and NaCl, then mechanical
debridement using conservative wound debridement to remove the necrotic and slough
tissue, next giving antimicrobial dressing with cadexomer iodine, wound paste
metcovazin® as topical therapy and hydrogel: intrasite gel® to support the autolysis
debridement , and high absorbent dressing, fixation with gauze and crepe bandage.
The wound care for 12 showed a good condition, where there is no necrotic and slough
tissue but 100 granulation epithelization tissue, and it can seen by wound care
examination which are: wound size: 2, wound depth: 2, wound edge: 2, cave: 1, Exudate
type: 1, Exudate amount: 1, Skin Color surrounding skin: 1, Peripheral tissue edema: 1,
Granulation tissue: 1, Epithelization: 2, total score 14. The lysis of several tendons cannot
be prevented.

Future Innovation
Despite of all limitations found in Indonesia, there is a high potency to refine the practice
of diabetic ulcer management. In this article the highlighted innovation is the nurse-led
private wound centers. The enactment of the nursing law in 2014xviii has bring a new light
in wound clinician practices, as it provides a stronger legal standing for nurses who wish
to have a private practice, either individual or in group. However, the manual of the
nursing law has not been established until now. This creates a status quo among nurses
whether they should comply or not, because without the manual then the law itself is not
technically applicable. Consequently, until recently the applicable regulation remains the
old one which is the ministry of health’s statute number 148/2013. As a response to this
situation the InWCCA and Wocare have built a task force with the ministry of health,
especially the health care facility bureau to develop a manual standard for private nursing
practice. The draft of has been presented in the 7th APETNA conference in Bogor,
Indonesia on April 2017 along with the hard copy of the document. Expectedly the final
version would be published this year, therefore more than 8000 certified wound clinicians
that have been trained by the InWCCA and Wocare will have a clear and applicable
manual standard to develop their private wound practice.
Conclusion
There are many opportunities to improve the prevention and management of diabetic foot
ulcer. Indonesian wound care clinician association and wocare center try to improve the
diabetic foot ulcer prevention and management by using several treatments to provide the
wound healing and wound prevention.

References

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Professional. 4rd Edition. Lippincott Wiliams&Wilkins.2012

4. iv Gitarja W.S. Manual Book of Wound Care Management. 2015; 2nd Edition. Wocare

Publishing, Indonesia.
5. v WHO – Diabetes country profiles, 2016

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for the advancement of wound care, Philadelphia. 2014

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literature review. Global Health; 9: 63.Published online 2013 Dec 3.doi: 10.1186/1744-8603-9-
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Widasari Sri Gitarja
Enterostomal Therapy Nurse
Wocare Indonesian Foundation
Wocare Center-private practice
Bogor, West Java - Indonesia
Email: srigitarja@yahoo.com or srigitarja@wocare.org
Phone:+628158843528

Carmen George
Enterostomal Therapy Nurse
St.Andrew Hospital-WOC clinic
Melbourne – Australia
Email: carmensmith@adam.com.au
Phone: +61 410 370 210⁠

Ahmad Jamaluddin
Enterostomal Therapy Nurse
GOcare-private practice
Sulawesi - Indonesia
Email: ns.ahmadh@yahoo.co.id
Phone: +6285242230191

Ahmad Hasyim Wibisono
Certified Wound Care Clinician
School of nursing, Brawijaya University
And Pedis care center-private practice
Malang-East Java - Indonesia
Email: ahasyimw@gmail.com
Phone: +6285646333305

Vonny Nurmalya Megawati
Certified Wound Care Clinician
School of Nursing, Majapahit University
Mojokerto, East Java - Indonesia
Email: ners_ivon@yahoo.com
Phone: +62811310436