Most diabetic foot ulcers are managed in outpatient clinics, but a substantial minority progress to deep infection, ischemia, or tissue loss that requires hospital admission. Admission is a marker of disease severity, and it brings its own risks: prolonged stays, readmission, and a high likelihood of surgery. Understanding what happens to people hospitalized with diabetic foot ulceration helps clarify where care is succeeding and where it is not.
How Long Do Patients Stay, and How Often Do They Return?
Manewell and colleagues (Wound Practice and Research, 2022) analyzed 1,250 admissions for diabetes-related foot ulceration among 749 patients at two tertiary hospitals in Sydney between 2012 and 2017. The median length of stay was 8 to 10 days per admission, and the median cumulative stay per patient was 13 days (interquartile range 7 to 29). About 8% of patients were readmitted within 28 days and 28% within one year. Minor amputation occurred in 43.4% of patients and major amputation in 9.3%.
Several factors were associated with longer cumulative stays: male sex, older age, unplanned admission, revascularization, dialysis (incidence rate ratio 2.30), higher comorbidity burden, and mental health or behavioural disorders. Notably, a greater number of podiatry appointments was associated with a modestly shorter cumulative stay (incidence rate ratio 0.96). As a retrospective observational study, it shows association rather than causation.
Who Reaches the Hospital, and by What Route?
Robbie and colleagues (The Diabetic Foot Journal, 2020) prospectively audited 68 acute admissions of 58 patients sent directly from an outpatient podiatry clinic in Birmingham, United Kingdom. Nearly half of the referrals originated from routine redressing or walk-in appointments, and the mean length of stay was 15.8 days. Most patients had severe soft tissue infection requiring intravenous antimicrobials. Eleven patients (19%) died during the audit period, and almost 89% of those deaths occurred within a year of admission, with cardiovascular disease the most commonly recorded cause. This was a small, single-centre audit without a comparison group, so it describes outcomes but cannot establish what would have changed them.
The audit nonetheless illustrates two points. Routine contacts are an opportunity to recognize deterioration early, and patients who are admitted carry a heavy burden of cardiovascular and renal disease, with 10 of the 58 dependent on dialysis.
Does Team-Based Inpatient Care Change Outcomes?
Choi and colleagues (BMC Health Services Research, 2023) audited 89 inpatient diabetic foot infection admissions at one Australian hospital from 2019 to 2021. Multidisciplinary involvement, defined as two or more specialties, rose from 62.5% to 83.8% over the three years. It was associated with more frequent imaging (78.8% versus 21.3%), but length of stay (median 7.8 versus 4.8 days) and surgical outcomes did not differ significantly. Patients who required major amputation stayed far longer than those managed conservatively (median 24 versus 5.2 days). The authors note that these are associations from a retrospective single-site audit.
At the health-system level, Meza-Torres and colleagues (Acta Diabetologica, 2021) systematically reviewed 57 studies of organizational arrangements such as care pathways, multidisciplinary teams, and combined interventions. In the seven-study meta-analysis, organized care was associated with lower odds of any lower extremity amputation (odds ratio 0.71, 95% CI 0.52 to 0.96) and of major amputation (odds ratio 0.52, 95% CI 0.30 to 0.91). Heterogeneity was substantial, possible publication bias was noted for total amputations, and minor amputations were often unchanged or slightly increased. The authors could not determine which type of arrangement worked best.
When Is Urgent Surgical Input Needed?
The IWGDF/IDSA guideline on diabetes-related foot infections (Senneville et al., Diabetes/Metabolism Research and Reviews, 2024) recommends urgent surgical consultation for severe, and some moderate, infections complicated by extensive gangrene, necrotizing infection, deep abscess, compartment syndrome, or severe limb ischemia. These are situations in which delay can convert a salvageable limb into an amputation.
Clinical Summary
Hospitalization for diabetic foot ulceration typically lasts one to two weeks, is followed by readmission in roughly one in four patients within a year, and frequently involves amputation. Comorbid kidney disease, unplanned presentation, and revascularization are associated with longer stays. Organized, team-based care is associated with fewer major amputations at the system level, although single-hospital audits have not shown shorter stays, and the available evidence is observational and heterogeneous. Hospital admission is best understood as a high-risk point in a longer disease course, and mortality after admission remains substantial.
References
- Manewell SM, Aitken SJ, Nube VL, et al. Length of stay and readmissions in people with diabetes-related foot ulceration admitted to two public tertiary referral hospitals in Australia. Wound Practice and Research. 2022;30(2):82-90.
- Robbie J, Tomkins D, Mitchell L, et al. A 2-year prospective audit of patients admitted into an acute hospital from an outpatient podiatry clinic: trends and outcomes. The Diabetic Foot Journal. 2020;23(4):32.
- Choi T, Osuagwu UL, Tran C, Bulsari K, Simmons D. Impact of multidisciplinary care of diabetic foot infections for inpatients at Campbelltown Hospital. BMC Health Services Research. 2023;23(1):1-9.
- Meza-Torres B, Carinci F, Heiss C, Joy M, de Lusignan S. Health service organisation impact on lower extremity amputations in people with type 2 diabetes with foot ulcers: systematic review and meta-analysis. Acta Diabetologica. 2021;58(6):735-747.
- Senneville É, Albalawi Z, van Asten SA, et al. IWGDF/IDSA guidelines on the diagnosis and treatment of diabetes-related foot infections (IWGDF/IDSA 2023). Diabetes/Metabolism Research and Reviews. 2024;40(3):e3687.
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