In a person with diabetes and a foot ulcer, as a minimum, use the SINBAD wound classification system for communication among health professionals about the characteristics of the ulcer.
The panel decided to adapt this recommendation after full assessment, based on minor differences in some judgements to the IWGDF, particularly regarding acceptability and feasibility in an Australian context (see Table 2
). As a result, wording changes to the original IWGDF recommendation were made, with the insertion of ‘as a minimum’ to indicate the use of the SINBAD wound classification system as a minimum standard for wound classification for the purposes of communication among health professionals.
The panel agreed with the IWGDF evaluation of the strength of the evidence (moderate) and that health providers would place importance on the effective communication of information to facilitate appropriate referral and patient assessment. Although most patients are probably unaware of specific wound classification systems, it was also agreed that patients would likely place importance on effective communication of clinical information that would facilitate appropriate triage of referrals for DFU asessment and management. There were some minor differences in comparison to the IWGDF judgement for this recommendation, with partial agreement with IWGDF in regard to acceptability and feasability in an Australian context, due to existing guidelines and recommendations for use of WIfI and/ or University of Texas wound classification systems in specialist settings such as iHRFS, as well as current lack of widespread familiarity with the SINBAD wound classification system in Australia [42
]. The detailed justifications for our full assessment are described in Appendix 1 of the Supplementary Material.
The panel agreed that the use of the additional text ‘as a minimum’ in the recommendation for the Australian Guidelines provides two additional strengths. Firstly, it recognises that SINBAD is the minimum acceptable method for wound classification, suitable for communication between health professionals, for example to and from primary care settings. Secondly, it highlights for communication between other health care providers, such as within and between iHRFS, use of an additional, more detailed wound classification system is desirable such as WIfI or University of Texas. Given the simplicity and lack of need for specialised equipment, there should be no significant barriers to implementation of the use of SINBAD in Australia. In agreement with IWGDF, it is important the individual components of SINBAD (rather than the total score) are used for the purposes of communication between health professionals. It is likely in Australia that additional educational measures will be required to support more widespread familiarity and use of SINBAD across diverse clinical settings.
Geographical remote people.
The panel agreed with the IWGDF, that SINBAD would be acceptable for use in remote locations, given the simplicity, reliability and no requirement for specialised clinical equipment.
Aboriginal and Torres Strait Islander people.
The SINBAD wound classification system would likely be well accepted and utilised in health settings where Aboriginal and Torres Strait Islander populations are managed, especially given the simplicity, reliability and no requirement for specialised clinical equipment.
Other subgroup considerations.
No other subgroup considerations.
As SINBAD is not currently widely used in Australia the panel determined that it would be useful to monitor use of SINBAD across clinical care settings in the future. This may be possible via updates inclusive of SINBAD, for the DFA minimum dataset reporting, NADC iHRFS data collection, and benchmarking or via individual primary care or hospital audits. Furthermore, the panel felt that it would be helpful to monitor how SINBAD is being used, either as a total score only, or with reporting of individual components. The effectiveness of SINBAD as a communication and triage tool depends on widespread adoption and use by health professionals across the care spectrum, so the panel felt it was important to monitor the use of SINBAD subsequent to the release of these recommendations.
Future research considerations.
The critical review of diabetic foot ulcer classification systems recently conducted by the IWGDF identified eight important prognostic features of a DFU, however no existing wound classification system includes all of these variables [18
]. In agreement with the IWGDF, future research should investigate whether the addition of more complexity to existing wound classification systems can improve clinical and prognostic utility without compromising reliability and/ or simplicity of use [19
]. Furthermore, there may be uniquely Australian considerations when evaluating prognostic utility of a wound classification system in an Australian setting - Aboriginal and Torres Strait Islander people and people living in rural and remote locations experience a higher rate of LEA [9
] however these important patient-related factors are not included in any existing wound classification or scoring system.
As per the panel’s recommendations for monitoring of this recommendation, future research should also address the clinical uptake and usage of SINBAD in Australia across the spectrum of care settings. This may include quantitative and qualitative surveys conducted by specialist societies (e.g. RACGP, AWTRS, APP), to target groups such as general practitioners, practice nurses, nurse practitioners, orthotists/prosthetists, and podiatrists as well as via accreditation, benchmarking and reporting processes for iHRFS.