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Foot Complications in People with Diabetes Prevention and Management Of Group arrangements: Salford Royal NHS Foundation Trust (SRFT) Pennine Acute Hospitals NHS Trust (PAT) Foot Complications in People with Diabetes Prevention and Management of Lead Author: Samantha Haycocks Consultant Podiatrist Additional author(s) Dr Adam Robinson Consultant Diabetologist Division/ Department:: CSS&TM Applies to: Salford Royal Care Organisation Approving Committee Diabetes Foot Steering Group Date approved: September 2019 Expiry date: September 2022 Contents Contents Section Page 1 Overview 2 2 Scope & Associated Documents 3 3 Background 3 4 What is new in this version? 4 5 Policy 4 5.1 ACTIVE FOOT DISEASE 5 6 Roles and responsibilities 12 7 Monitoring document effectiveness 12 8 Abbreviations and definitions 12 9 References 12 10 Appendices 13 Appendix 1 Guide to foot screening 14 Appendix 2 Critical limb ischaemia 17 Appendix 3 Community emergency clinic contact details 19 11 Document Control Information 20 12 Equality Impact Assessment (EqIA) screening tool 21 Foot Complications in People with Diabetes Prevention and Management of Reference Number TWCG29(14) Version 3 Issue Date: 18/10/2019 Page 1 of 22 1. Overview (What is this policy about?) A. All people in Salford with diabetes who are not at increased risk of active foot disease e.g neuropathy or peripheral arterial disease, foot deformity or previous foot disease should have an annual foot screen in primary care (see appendix 1) B. Any person with diabetes who is identified as having an increased risk of developing diabetic foot disease should be offered access to the foot protection service. C. If a person has a limb-threatening or life-threatening diabetic foot problem, refer them immediately to acute services and inform the multidisciplinary foot care service, so they can be assessed and an individualised treatment plan put in place. Patients who attend Salford Royal NHS Foundation Trust Emergency department should be booked into the podiatry department the next working day. If the patient has critical limb ischaemia they should be referred to the Vascular team at Manchester Foundation Trust as per PAD pathway. Examples of limb-threatening and life-threatening diabetic foot problems include the following: o Ulceration with fever or any signs of sepsis. http://intranet.srht.nhs.uk/policies-resources/trust-policy- documents/directorate-department-clinical/ag/144tdc25b2/?locale=en o Ulceration with limb ischaemia o Clinical concern that there is a deep-seated soft tissue or bone infection (with or without ulceration) o Gangrene (with or without ulceration). o unexplained hot, red, swollen foot with or without pain o Ischaemic rest pain D -All other active diabetic foot problems, refer the person within 1 working day to the multidisciplinary foot care service or foot protection service for triage within 1 further working day on 0161 206 4710 (NICE 2015) For domiciliary patients contact 0161 206 3842. E- All diabetic patients who attend the Emergency Department with a foot problem even if this does not meet the criteria for a life or limb threatening condition must be referred to the podiatry clinic within 1 working day Emergency access to foot services Salford Royal NHS Foundation Trust runs an emergency foot clinic (Appendix 3) each working day (Monday to Friday) in the community see Appendix 3 for contact details. If in doubt about a proposed course of action ring 0161 206 4710 (9- 5 Monday to Friday) for advice about what action to take. Out of office and public holidays if the problem is felt to be limb or life threatening attend the Emergency Department at Salford Royal NHS Foundation Trust unless the crisis is felt to be ischaemic in origin i.e. critical limb ischaemia then they should attends Emergency Department at Manchester Royal Infirmary. Foot Complications in People with Diabetes Prevention and Management of Reference Number TWCG29(14) Version 3 Issue Date: 18/10/2019 Page 2 of 22 2. Scope (Where will this document be used?) This document is aimed at all staff managing patients with diabetes. Associated Documents: 144TD(C)25(B2) Diabetic Foot Infections Antibiotic Guidelines Last Modified: 10/12/2018 TWCG6(11)QRG Feet First Preventing avoidable foot complications in hospital QRG review date: July 2021 Neuropathic Pain Management in a Specialist setting PAIN TEAM and Neurology TWCG39(12) 3. Background (Why is this document important?) Around 7,000 people with diabetes undergo leg, foot or toe amputation each year in England. Many of these amputations are avoidable. The risk of lower extremity amputation for people with diabetes is 23 times that of people without diabetes. Around 68,000 people with diabetes are thought to have foot ulcers at any given time, approximately 2.5% of the diabetes population. Ulceration and amputation substantially reduce quality of life, and are associated with high mortality. Studies suggest that only 50% of patients with diabetes who have had an amputation survive for a further two years. Even without amputation, the prognosis is poor. Only just over half of people with diabetes who have had ulcers survive for five years, a much worse prognosis than for many cancers. In 2014-2015, the NHS in England spent an estimated £972 million - £1.13 billion million, 0.6– 0.7% of its budget, on diabetic foot ulceration and amputation Kerr 2017 National guidance to address disparity in care across England culminated in the Putting Feet First Document (Diabetes UK 2012). The guidelines that follow, reflects Putting Feet First (2012) in the context of the foot care services of Salford for clarity within Salford the whole Podiatry team is part of Multidisciplinary Foot care Team (MDFT). This is an integrated team across primary and secondary care. Further, the foot protection service (FPS) is a service which is provided in the community care setting. (See Diagram 1) Pressure combines with peripheral neuropathy and/or peripheral vascular disease to cause ulcers. Redistribution of this pressure, away from the ulcer site, or relief of the pressure over the ulcer site are an important part of care. Pressure should be assessed at initial presentation of the ulcer, and appropriate care given or initiated. Pressure should also be re-assessed throughout the period of ulceration, especially if the ulcer deteriorates or fails to progress. Outline why this policy is important or necessary. For example, patient harm has been associated with this intervention, there is evidence that outcomes are improved by standardised practice in this area, national guidance exists, etc. Foot Complications in People with Diabetes Prevention and Management of Reference Number TWCG29(14) Version 3 Issue Date: 18/10/2019 Page 3 of 22 Multidisciplinary Foot Clinic (C+D above) - Multidisciplinary Team (D Above) - Hospital Clinic - Community Clinic - Ward Visit -Domicilliary Visits Foot Protection Service (B above) Foot Screening ( A Above) Diagram 1 4. What is new in this version? This is an update of a previous version of references and data. The document has been transferred onto a new template format. 5. Policy The management and prevention of foot complications in diabetes can be divided into five areas: 1. Management of people currently low risk for foot ulceration: All people in this category should have an annual foot screen carried out in primary care as per Salford Diabetes Foot Screening guidelines (appendix 1) All people identified at their screen as increased risk should be offered a referral to the Foot Protection Service(FPS), contact 0161 206-3842 for details of local clinics. All people with diabetes should be given a leaflet advising them of their risk status and how to access foot services urgently if they develop a problem. Foot Complications in People with Diabetes Prevention and Management of Reference Number TWCG29(14) Version 3 Issue Date: 18/10/2019 Page 4 of 22 2. Prevention of active disease of the foot in those at increased risk Patients with increased risk should be advised of their risk and offered a referral to the Foot Protection Service (FPS). There Patients should have: - Regular podiatric review in-line with their clinical need. - Assessment of their footwear, foot function and appropriate referral for footwear and/or biomechanical intervention. - Education relevant and tailored to the individual and advice on how to access foot service urgently if they develop a problem. - Review of their cardiovascular and peripheral arterial disease risk and signposting to the appropriate service for example: community lower limb vascular assessment service (0161 206 3842) smoking cessation; and best medical therapy. 3. Active Foot Disease: a) Ulceration, b) Peripheral Arterial Disease, c) Charcot neuroarthropathy, d) Painful diabetic neuropathy (see below 5.1). 4. Treatment of a person’s foot disease that is in remission. The person who has an episode of foot disease has a 40% chance of a second episode within 12 months. They should: a) Remain under close observation in the Foot Protection Service. b) Have intensive cardiovascular risk modification c) Have tailored education and reinforcement of key messages and key actions for the individual should there be a newly occurring problem. 5. All Patients with diabetes admitted to Salford Royal NHS Foundation Trust hospital for any reason. All patients with diabetes on admission to hospital should have their feet examined as part of their Waterlow assessment- see Feet First Policy. http://intranet.srht.nhs.uk/policies- resources/trust-policy-documents/trust-wide-clinical/gen 5.1 ACTIVE FOOT DISEASE ULCERATION 1. Commence Salford Diabetic Foot Ulcer forms and complete National Diabetic Foot Ulcer form (NDFA). The new ulceration recorded on health issues and check the risk factor is correct 2. Identify and remove any physical cause (e.g. tight footwear; hot water bottle; inappropriate self-treatment). 3. Assess for infection refer to “Management of diabetic foot infection guideline”. http://intranet/policies-resources/trust-policy-documents/directorate-department- clinical/ag/144tdc25b2/?locale=en 4.
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