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. Assess circulation. Any patient who has symptoms of critical limb ischemia should be referred to Vascular Team on call as per PAD pathway (below) 5. Refer to Multidisciplinary Foot Care Team (MDFT) within one working day as per NICE (2015) guidelines. If felt to be life or limb threatening e.g. ulceration with fever or any signs of sepsis or ulceration with limb ischaemia refer urgently to acute services. 6. Consider referral to Community nurse as per combined care protocol. 7. Select dressing regime appropriate to state of ulcer (see wound care formulary). 8. Provide appropriate pressure relief and footwear (see below).
Foot Complications in People with Diabetes Prevention and Management of Reference Number TWCG29(14) Version 3 Issue Date: 18/10/2019 Page 5 of 22
9. Inform patient / carer regarding care of ulcer: issue guide to foot ulcer leaflet (pod10). 10. Ascertain when patient last had diabetes annual review and most recent HbA1c, blood pressure, lipids (see Salford Integrated Care Record on EPR.) Consider liaising with others to optimise metabolic control and cardiovascular risk factors (e.g. GP or Diabetes Specialist Nurse). 11. When ulcer healed, close-down (inactivate the episode) ulcer form on EPR. Assess future podiatric needs and implement a plan to prevent further ulceration (e.g. increase frequency of review, consider biomechanical / footwear referral, education). 12. Review within one month of healing as a minimum, 13. If a person undergoes an amputation, they should be referred back to podiatry immediately post-operatively.
PRESSURE REDISTRIBUTION GUIDELINES FOR DIABETIC FOOT ULCERATION
The choice of pressure redistribution method will be dependent upon various factors including: o Vascular and neurological status of the patient. o Presence of infection. o Presence of oedema and the viability of the skin o Dressing choice. o Pain. o Foot function including biomechanical assessment. o Mobility of the patient. o Normal activities that the patient will be performing. o Quality of life.
Remember that rest is one of the most effective methods of relieving pressure. This includes removing footwear when at rest. It is important to negotiate, with the patient, what levels of activity will be pursued whilst there is an active ulceration.
It is important to note: that below knee (BK) casts, both removable and non-removable, and slipper casts should be considered for plantar ulcerations but are not recommended for use in the presence of severe PAD. transferring from chair to bed will create pressure on the foot, especially on the plantar aspect. when redistributing pressure, that excess pressure is not positioned over a vulnerable site. that removable padding is only a temporary first aid measure and should NEVER be placed directly onto the skin. It can be placed over a dressing or a bandage. bulky dressings might be necessary at some points of the ulcer episode, but they will not provide pressure relief as they ‘flatten’ with pressure and do not have effective cushioning properties. Dressings can make it difficult to achieve an intimate relationship between the foot and the appropriate pressure redistribution device. specialist therapeutic footwear can be considered during active ulceration in a small number of complex cases.
Foot Complications in People with Diabetes Prevention and Management of Reference Number TWCG29(14) Version 3 Issue Date: 18/10/2019 Page 6 of 22
The following is a guide to the range of measures that can be taken to redistribute or relieve pressure. The guidance is based on available evidence-based guidance and expert opinion.
SITE FIRST AID AT WALKING SPECIALIST AT REST/ INITIAL AIDS INTERVENTION IN BED PRESENTATION Dorsal toes and cut a hole in darby sandal otoform remove subungual slipper or or darco boot crescent footwear (beneath the footwear with padding remove nail bed cage nail) use sandal (ideally including 7mm poron insole) Dorsal foot use sandal as above as above slippers Apical toes use sandal as above otoform prop as above crutches, TCI/functional walking frame, orthosis wheelchair Interdigital (i.e. as above as above otoform as above between the foam dressing wedge toes) functional orthosis
Lateral or medial cut a hole in as above ‘Softcast’ or as above metatarsal slipper or slipper cast pillow to raise heads footwear (FRC) foot off bed use sandal permalux removable bootee padding specialist mattress Lateral border of use sandal as above as above as above foot Medial border of as above as above TCI/functional as above foot and inner rocker-soled orthoses longitudinal arch sandal (ideally removable with 7 mm slipper cast poron insole) with 3mm poron liner removable or non- removable BK cast with TCI BK/short walker & TCI Plantar heel removable as above as above remove padding footwear Plantar forefoot as above as above as above as above forefoot off- loader with 7mm poron liner or TCI Plantar hallux as above as above as above as above stiff-soled shoe with TCI
Foot Complications in People with Diabetes Prevention and Management of Reference Number TWCG29(14) Version 3 Issue Date: 18/10/2019 Page 7 of 22
REVIEW BY PODIATRY ORTHOTICS TEAM
i. If pressure re-distribution initiated and no response in wound size over 4 weeks. Please ensure orthotics review (Band 7/8 Bio team). ii. If pressure re-distribution initiated and no response in red, hot swollen joint, foot or ankle in 2 weeks. Please ensure urgent review Band 7/8
REVIEW BY PODIATRY HIGH RISK TEAM
i. Failure to improve within any two weeks of treatment (e.g. size, depth, infection, pain). ii. Diagnostic uncertainty. iii. Non-urgent, ischaemic ulceration. iv. Deteriorating claudication and/or rest pain (see Critical Limb Ischaemia pathway Appendix 2). v. New swelling or discolouration or pain or discharge. vi. Antibiotics required beyond initial two-week period.
PERIPHERAL ARTERIAL DISEASE
People with suspected peripheral arterial disease should be referred to the Vascular Triage team (enquiries on 0161-206 3842) and see flow sheet below. People with suspected critical limb ischemia should be referred urgently to the MDT/Vascular Unit (see Critical Limb Ischaemia pathway Appendix 2)
Foot Complications in People with Diabetes Prevention and Management of Reference Number TWCG29(14) Version 3 Issue Date: 18/10/2019 Page 8 of 22
Peripheral Arterial Disease (PAD) Integrated Care Pathway
Patient has a lower limb assessment by: GP, Nurse or Allied Health Professional
Baseline peripheral arterial assessment
Modifiable cardiovascular risks Foot pulses Leg symptoms Doppler signals
No PAD Suspected PAD Severe / critical limb ischaemia •Foot pulses palpable •Foot pulses non-palpable •Foot pulses absent / not palpable OR •No intermittent claudication •Symptoms of intermittent claudication •Doppler signals monophasic / absent
•Doppler signals tri / bi phasic •Doppler signals monophasic PLUS any of the following •No ischaemic rest pain •Clinical signs eg skin / nail atrophy, Ischaemic rest pain (toes / feet) •No clinical signs of PAD cyanosed / pale cold feet, chronic New gangrene or necrosis wound, slow capillary refill time Ankle systolic < 50mmHg Consider differential diagnosis •Sub-optimally managed existing PAD Toe systolic < 30 mmHg
Refer to the Leg Circulation Service for non-invasive lower limb vascular Refer urgently to Hospital Vascular assessment, diagnosis / exclusion of PAD and an individually agreed management Team by contacting the Vascular Team or plan: education, lifestyle change, medicines, surgical options the on-call Vascular Registrar, if it appears urgent & limb threatening.
Non -surgical management Refer for surgical opinion Follow up within 1 working day to ensure •Early – moderate or stable PAD •Severe / critical or worsening PAD that Hospital Vascular Team has received •Individual management plan •Severe lifestyle impacting symptoms and triaged the referral. Document this •Review in 3 – 12 months, or if •Ankle brachial pressure index < 0.4 clearly in clinical notes. lower limb symptoms worsen •Ankle < 50mmHg or toe < 30 mmHg • •
All patients with a confirmed diagnosis of PAD should have an individually agreed management plan, which is to be reviewed periodically with their GP, the Leg Circulation Service or the Hospital Vascular Team.
The management plan will include discussing cardiovascular & limb risks and negotiating treatment options (lifestyle, medicines, surgery), to be reinforced by all health professionals involved in management of the lower limb
PAD / CV risk management Target Source •Antiplatelet therapy Initiate for all with established PAD NICE CG 147 (2018) •Lipid lowering therapy Initiate for all with established PAD NICE CG 147 (2018) •Hypertension BP < 140/90 mmHg NICE CG 127 (2016) •Smokin g Aim for quit NICE CG 147 (2018) •Obesity BMI < 30 NICE CG 189 (2014)
•Moderate cardiovascular exercise 30 minutes, 5 times per week NICE PH 44 (2013) •Glycaemic control (if has diabetes) HbA1c < 7.0 % or < 53 mmol/mol NICE NG 28 (2017)
This pathway is based on PAD consensus from NICE, TASC II, diabetes systematic reviews & local expert opinion
Foot Complications in People with Diabetes Prevention and Management of Reference Number TWCG29(14) Version 3 Issue Date: 18/10/2019 Page 9 of 22
CHARCOT FOOT
People who develop unexplained warmth and swelling in their foot should be referred urgently to the MDT (0161-206-4710). They should be told to non-weight bear until they have been seen (see flow sheet below)
Salford Royal Foundation Trust Management of CHARCOT NEUROARTHROPATHY
Charcot Foot is an acute inflammatory condition of the foot. Untreated it leads to dislocation and/or fracture and disorganisation of foot architecture. The condition is associated with osteopenia. (SIGN 2001). It is commonly misdiagnosed as a sprain or as cellulitis.
The cause is not known but the majority of cases are preceded by some minor injury, preceding ulcer or other cause of inflammation. It has been suggested that inflammation is the pivotal trigger (Jeffcoate 2005). Differentiation from osteomyelitis may be impossible in people in whom the overlying skin is ulcerated. Acute Charcot foot and osteomyelitis may coexist. (Frykberg et al 2000; Jeffcoate et al 2000). Charcot Neuroarthropathy most commonly occurs in people with diabetic neuropathy, but can occur in any severe peripheral neuropathy. Any person with suspected Charcot foot should be referred for urgent assessment by a specialised foot care team: suspected and confirmed cases should be managed by weight sparing to minimise the extent of bone damage. Secondary ulceration occurs in one third, and one fifth has bilateral disease. (NICE 2004)
Diagnosis should be made by clinical examination, X-ray, MR Scan & exclusion of infection when necessary. The activity of the disease may be monitored by comparing skin temperature with the non-affected side. Suspected foot fractures in diabetic patients should be managed using the following guidelines.
Foot Complications in People with Diabetes Prevention and Management of Reference Number TWCG29(14) Version 3 Issue Date: 18/10/2019 Page 10 of 22
Guidelines for assessment and treatment of Charcot Neuroarthropathy
Clinical features and History Red, oedematous, warm and possibly painful foot. History of trauma to limb may be present, but not essential
Differential Diagnosis - Charcot Neuroarthropathy,
Infection, Gout, Soft Tissue Injury Fracture or any cause of foot inflammation such as arthritis.
Refer to specialist foot care team Undertake neurological and vascular assessment. Confirm or exclude infection, if possible. Assess and if possible record heat difference between limbs – affected limb usually >2oC higher than contralateral foot, when tested with thermography. Blood tests – include HBA1c, ESR, C-reactive protein, Alkaline Phosphatase, Renal function, Urate, Full Blood Count.
X-Ray as a baseline and to exclude diabetic neuropathic fracture – although X-ray may be normal (use weight bearing views) If Charcot foot is suspected but X-Ray is inconclusive, consider MRI
Immediate Management
1. Immobilisation of the foot is urgently required. Non-removable below knee total contact cast is the method of choice, but following holistic assessment, may not appropriate. Casting should be continued until all signs of inflammation regress – which may not be for many months (SIGN 2001). 2. Non-weight bearing. 3. Education on the causes and management of Charcot foot and advice on prevention of complications. 4. There is insufficient evidence to support the routine use of bisphosphonates in the acute phase (SIGN 2001) although there are a small number of studies which suggest that bisphosphonates may be beneficial in some patients (Anderson 2004, Jude 2001). 5. Optimise glucose control.
Medium Term Management 1. 6. Regular clinical examination and imaging to monitor progress. 2. 7 . During post-acute phase consider use of removable below knee cast. 3. 8. Begin staged return to weight bearing, in cast, when foot temperature is equal and imaging indicates condition has 4. reached non-destructive phase. 5. 9 . If foot remains stable & whilst still using cast, follow with staged introduction of appropriate orthotic device (e.g. 6. boots and foot orthoses),. 10. 10 . Consider referral to an Orthopaedic surgeon for assessment and discussion of surgical remodelling.
Long Term Management 11. Pressure relief with footwear and orthotic therapy as appropriate, via specialist podiatrist. 12. Classify patient as high current risk and review regularly in podiatry for signs of long –term complications. Foot(NICE Complications 2015) in People with Diabetes Prevention and Management of Reference Number TWCG29(14) Version 3 Issue Date: 18/10/2019 Page 11 of 22
Painful Peripheral Neuropathy See guidelines: Commencing Neuropathic Pain medications in a non-specialist setting guidelines TWCG25(14) - Issue number: 2
6. Roles and Responsibilities
It is the responsibility of all staff who work with people with diabetes to have read and act in line with this guideline. The guideline will be monitored by the diabetic foot steering group to ensure it is kept up to date and in line with the best available evidence.
7. Monitoring document effectiveness
The service for patients with diabetes and foot complications is under constant review. There are ongoing audits to monitor compliance with national standards. These include: Diabetic Foot Ulcer audit Critical Event analysis of lower limb amputations Feet First Audit Salford Royal NHS Foundation Trust and Salford CCG also sign up to external audits which monitor performance of foot services against National Standards including: National Diabetes Audit (NDA) National Foot ulcer Audit (NDFA) National In-patient Diabetes Audit (NaDIA) Quality Outcomes Framework
The results of the audits are presented at Salford Diabetes Care and the Foot Steering Group and action plans are developed. There is an annual audit event to disseminate information to all staff and public
8. Abbreviations and definitions
NCA Northern Care Alliance NICE National Institute for Health and Care Excellence LocSSIPs Local Safety Standards for Invasive Procedures
9. References
SRFT Feet First Policy (2018) http://intranet.srht.nhs.uk/policies-resources/trust-policy- documents/trust-wide-clinical/gen/twcg611/?locale=en
SRFT Management of diabetic foot infection (2018). http://intranet.srht.nhs.uk/policies- resources/trust-policy-documents/directorate-department-clinical/ag/144tdc25b2/?locale=en Lipsky B, Berendt A, Cornia PB. Infectious Diseases Society of America clinical practice guideline for the diagnosis and treatment of diabetic foot infections. IDSA guidelines. Clin Infect Dis 2012; 54(12): p132-73
Kerr M. Foot care for people with diabetes: the economic case for change. NHSDiabetes, Newcastle-upon-Tyne, 2017. Available at: . NICE (2015) https://www.nice.org.uk/guidance/ng19 accessed 06/08/2019
Foot Complications in People with Diabetes Prevention and Management of Reference Number TWCG29(14) Version 3 Issue Date: 18/10/2019 Page 12 of 22
International Working Group of the Diabetic Foot (2019). K. Bakker J. Apelqvist N. C. Schaper et al Practical guidelines on the management and prevention of the diabetic foot. https://iwgdfguidelines.org/wp-content/uploads/2019/05/IWGDF-Guidelines-2019.pdf accessed 06/08/2019
Diabetes UK. Putting feet first: national minimum skills framework. Joint initiative from Diabetes UK, Foot in Diabetes UK, NHS Diabetes, the Association of British Clinical Diabetologists, the Primary Care,Diabetes Society, the Society of Chiropodists and Podiatrists. London: Diabetes UK, 2011. http://diabetes.org.uk/putting-feetfirst.
TRIEPodD-UK. Podiatry competency framework for integrated diabetic foot care — a user’s guide. London: TRIEpodD-UK, 2012.
Anderson (2004). Bisphosphonates for the treatment of Charcot neuroarthropathy. J Foot and Ankle Surg, 43 (5), 285-9.
Fryberg RG and Mendeleeson E (2000).Management of the Diabetic Charcot foot. Diabetes Metab Res Rev, 16, S59-65
Jeffcoate W.J, Lima J., Nobrega L. (2000).The Charcot foot. Diab Med; 17: 253-8
Jeffcoate WJ (2005). The role of pro-inflammatory cytokines in the cause of neuropathic osteoarthopathy (acute Charcot foot) in diabetes. The Lancet
Jude E (2001). Bisphosphonates in the treatment of Charcot neuroarthropathy: a double-blind randomised controlled trial. Diabetiologia, 44 (11), 2032-7.
Scottish Intercollegiate Guideline Network (SIGN) (2001) Guideline 55 section 7: Management of diabetes foot disease
North West Podiatry Services Clinical Effectiveness Group for Diabetes. Guidelines for the Prevention and Management of Foot Problems for People with Diabetes 2014, Available from: http://www.diabetesonthenet.com/media/fduk/NORTH_WEST_GUIDELINES
10. Appendices
Appendix 1 Guide to foot screening
Appendix 2 Critical limb ischaemia
Appendix 3 Community emergency clinic contact details
Foot Complications in People with Diabetes Prevention and Management of Reference Number TWCG29(14) Version 3 Issue Date: 18/10/2019 Page 13 of 22
Appendix 1
PATIENT NAME NHS number:
ADDRESS POSTCODE:
D.O.B
GP PRACTICE
Clinical Assessment Right foot Left foot 1. Has pt had a previous ulceration Yes No Yes No 2. Has pt had an amputation Yes No Yes No 3. Does pt have Absent foot pulses Yes No Yes No (A YES answer requires absence of both dorsalis pedis and posterior tibial pulses) 4. Does pt complain of intermittent Yes No Yes No claudication? Complete Edinburgh questionnaire if necessary to aid questioning (see reverse) 5. Does pt have a history of vascular Yes No Yes No surgery to the lower limb? NEUROPATHY testing Using 10g Monofilament 6. Loss of sensation plantar 1st toe Yes No Yes No 7. Loss of sensation plantar 1st metatarsal Yes No Yes No 8. Loss of sensation plantar 5th Metatarsal Yes No Yes No 9. Does pt have chronic kidney disease Yes No CKD 4 or 5 PLAN:
NEGATIVE SCREEN: results when there are all ‘NO’ responses. Patient LOW RISK. No referral to podiatry required. Educate patient and provide with details of Podiatry emergency access. Arrange annual foot screen in 12 months within your practice.
POSITIVE SCREEN: results when there are one or more ‘YES’ responses. Use the guidance attached to classify risk. REFER TO PODIATRY FOR SECOND FOOT SCREEN if applicable.
PLEASE INDICATE HERE PATIENT IS AWARE OF REFERRAL AND WILL ATTEND PODIATRY
Once foot examination taken place you will be sent details of patient’s risk factor for you to enter onto your system.
PLEASE PROVIDE CLEAR DETAILS OF WHO TO RETURN 2nd SCREEN RESULTS TO
Si Signed: ______Printed: ______Designation: ______
Foot Complications in People with Diabetes Prevention and Management of Reference Number TWCG29(14) Version 3 Issue Date: 18/10/2019 Page 14 of 22
ADDITIONAL COMMENTS / REASON FOR REFERRAL
Guidance for completing foot screening tool: Q 1 ‘Yes’, if patient has ever had a foot ulcer Q 2 ‘Yes’ , if previous amputation of a toe, foot or limb is observed Q 3 ‘Yes’, palpate both dorsalis pedis and posterior tibialis pulse. A YES response requires the absence of both foot pulses. If only one pulse is palpable the response to this question is ‘NO’. Q 4 ‘Yes’ use the ‘Edinburgh questionnaire’ below to assist diagnosis of possible intermittent claudication. Boxes in red indicate where a ‘Yes’ response would be recorded on the screening tool Q1 Do you get pain or discomfort in your YES NO leg(s) when you walk? Continue questioning If the answer is NO, you need not continue questioning.
Q2 Does the pain ever begin when you are YES NO standing still or sitting? NOT CLAUDICATION Continue questioning
Q3 Do you get this pain if you walk uphill or YES NO when you are in a hurry? Claudication Continue questioning Q4 Do you get this pain when you walk at an YES NO ordinary pace on the level? Claudication Grade 2 Claudication Grade 1 What happens to this pain if you rest? Q5 Usually continues for more than YES NO 10 minutes NOT claudication Usually disappears in 10 minutes YES NO or less CLAUDICATION Definition of positive claudication requires all the following responses: YES to Q1; NO to Q2: YES to Q3; NO to Q4 = Grade 1 YES to Q4 = Grade2; Usually disappears in 10 minutes or less to Q5. Q 5 ‘Yes’, if patient has ever had previous revascularisation to their lower limb. This includes angioplasty or lower limb artery bypass. This does not include patients who have had heart bypass surgery, in this instance the response would be ‘No’ Q 6 10g MONOFILAMENT test Q 7 Q 8 Test 3 sites*: Plantar surface of the hallux , 1st metatarsal area and 5th metatarsal area Apply the filament to a sensitive area of skin (e.g. the forearm) so that the patient is aware of the sensation they are supposed to feel. Ask the patient to close their eyes and say ‘yes’ every time that they feel you touch the skin on the foot Place the monofilament at 90° to the skin surface. Slowly push the monofilament until it has bent approx 1cm (don’t jab) Hold the monofilament in this position for 1-2 seconds, then slowly release the pressure. Repeat for all testing sites. If the patient does not respond, repeat the test at the site twice. If there is still no response, record as a ‘Yes’ response on the screening tool. *If callus (hard skin) is present at any of the sites then test at the nearest non-calloused area Q 9 ‘Yes’ if the patient has an eGFR of 29 or below.
Foot Complications in People with Diabetes Prevention and Management of Reference Number TWCG29(14) Version 3 Issue Date: 18/10/2019 Page 15 of 22
Description of risk
LOW RISK All responses to screening tool are ‘NO’ indicates patient is low risk INCREASED RISK Patient has neuropathy in either foot. Patient has CKD 4 or 5. HIGH RISK Patient has had a previous foot ulcer or an amputation of a toe, foot or limb related to diabetes or poor circulation Patient has absent foot pulses. ULCERATED Patient has a current foot ulcer or has had a foot ulcer in the past year
Foot Complications in People with Diabetes Prevention and Management of Reference Number TWCG29(14) Version 3 Issue Date: 18/10/2019 Page 16 of 22
Appendix 2
TTCRITICAL LIMB ISCHAEMIA 5 MINUTE ASSESSMENT. Symptoms of rest pain
Unremitting pain in the foot (often in the toes). May not be present in neuropathic patients. Often patients report the pain is worse when the foot is elevated and / or covered by socks or bedclothes and patients will often hang the foot down to try and achieve some relief.
Non palpable foot pulses.
Doppler signals will be monophasic and dampened or absent all together. Ankle systolic pressure < 50 mmHg or < 70 mmHg in the presence of tissue loss or ulceration. Be aware calcification may give an unreliable result, especially in diabetic and renal patients.
If clinician is not confident in the use of the Doppler complete all other aspects of the 5 minute assessment and discuss with the High Risk team, or if no one is available and you consider it urgent, the vascular registrar on call.
Temperature difference between the symptomatic and asymptomatic foot.
Colour of foot. May be cyanosed with mottling at apex of toes or around the heel, white, reticular pattern.
Areas of ulceration / necrosis may be present as new lesions or deterioration of existing wounds.
Endorsed by Mr Vince Smyth. Consultant vascular surgeon. Central Manchester foundation trust 29/01/14 Endorsed by Mr David Murray. Consultant vascular surgeon. Central Manchester foundation trust 10/02/14 Endorsed by Dr Bob Young. Consultant Diabetologist. Salford Royal Foundation Trust 12/02/14 Endorsed by Dr Angela Paisley. Consultant Diabetologist. Salford Royal Foundation Trust. 03/03/14 Endorsed by Dr Paul Chadwick. Consultant Podiatrist .Salford Royal Foundation Trust. 01/04/14
INFORMATION REQUIRED BY THE VASCULAR TEAM WHEN DISCUSSING PATIENTS WITH CRITICAL LIMB ISCHAEMIA. 1. General information about the patient including their medical history, previous vascular history/ intervention, their co morbidities and mobility.
2. Pattern of pain symptoms. Does it require analgesia? Is the pain tolerable/controlled? Is the
Foot Complications in People with Diabetes Prevention and Management of Reference Number TWCG29(14) Version 3 Issue Date: 18/10/2019 Page 17 of 22
pain relieved by hanging the foot down?
3. Non palpable foot pulses.
4. Doppler signals- are they monophasic, dampened, absent?
5. What is the ankle systolic pressure, is it < 50mmHg? Do you suspect calcification?
6. Is there a temperature difference between the problematic and asymptomatic foot?
7. What is the colour of the foot like, is it cyanosed, mottled, white, reticular pattern.
8. Are there any areas of ulceration/ necrosis? If so are these new and/ or deteriorating?
9. Onset of symptoms. Is it a gradual deterioration? Is it an acute episode? Is there infection present?
Foot Complications in People with Diabetes Prevention and Management of Reference Number TWCG29(14) Version 3 Issue Date: 18/10/2019 Page 18 of 22
Appendix 3
Podiatry Emergency ‘Drop-in’ Clinic
The Podiatry department operates a ‘drop-in’ clinic for NHS patients who have a painful foot problem and are unable to wait for a routine appointment. New patients will be seen if they have an infection or a wound.
If you feel you need to attend the Drop-in Clinic please telephone the relevant clinic before 11am on the day you wish to attend. If you are attending Irlam Health Centre please ring from 9am, the drop-in clinic starts at 9:30 am.
Please ensure you report to reception on your arrival
Monday ECCLES GATEWAY, Barton Lane, Eccles, M30 0TU Tel No: 206 3827 1.30 – 3.00 pm.
Monday NEWBURY PLACE (1ST Floor) 55 Rigby Street, M7 4NX Tel No: 206 1772 1.30 – 3.00 pm.
Tuesday SWINTON GATEWAY, 100 Chorley Rd, Swinton, M27 6BP Tel No: 793 3882 1.30 – 3.00 pm
Wednesday WALKDEN GATEWAY, Smith Street, Walkden, M28 3EZ Tel No: 206 2151 1.30 – 3.00 pm
Thursday PENDLETON GATEWAY, 1 Broadwalk, Salford, M6 5FX Tel No: 206 1072 1.30 – 3.00 pm
Thursday ECCLES GATEWAY, Barton Lane, Eccles, M30 0TU Tel No: 206 3827 1.30 – 3.00 pm.
Friday IRLAM HEALTH CENTRE, Macdonald Road, Irlam, M44 5LH Tel No: 206 2160 9.30 – 10.30 am
This clinic will not provide routine nail cutting or full treatments.
These clinics work on a first come first served basis and can be busy, you must therefore be prepared to wait. Patients who come after the times stated above will not be seen on that day, but can attend the next available ‘Drop-in’ Clinic.
Emergency clinics will not run on Bank Holidays.
Yours Faithfully,
Jane Steel Podiatry Manager
Foot Complications in People with Diabetes Prevention and Management of Reference Number TWCG29(14) Version 3 Issue Date: 18/10/2019 Page 19 of 22
11. Document Control Information
All sections must be completed by the author prior to submission for approval
Lead Author: Samantha Haycocks Consultant Podiatrist
Lead author contact 206 4710 [email protected] details: Consultation Name of person or Role / Department / Committee (Care Date List the persons or group Org) groups who have Consultant Diabetologist Salford Care Dr Adam Robinson 21/08/2019 contributed to this Organisation policy. (please state Principal Podiatrist Salford Care 21/08/2019 Matthew Allen which Care Organisation Organisation) Podiatry Manager Salford Care 09/08/2019 Vikki Pestridge Organisation
Endorsement Name of person or Role / Department / Committee (Care Date List the persons or group Org) groups who have Diabetes Foot Steering Salford Care Organisation 21/08/2019 seen given their Group support to this policy. Multidisciplinary Foot Salford Care Organisation 03/09/2019 (please state which Team Care Organisation) Podiatry Vascular Triage Salford Care Organisation 03/09/2019 Team
Keywords / phrases: Diabetic foot, Diabetic foot ulcer, podiatry Communication This policy is already embedded into practice this is an updated version plan: Document review This document will be reviewed by the author, or a nominated person, at least once arrangements: every three years or earlier should a change in legislation, best practice or other change in circumstance dictate.
This section will be completed following committee approval
Policy Approval: Name of Approving Committee: Diabetic Foot Steering Group
Chairperson Samantha Haycocks
Approval date: 03/09/2019
Formal Committee decision (tick) x Chairperson’s approval (tick) x
Foot Complications in People with Diabetes Prevention and Management of Reference Number TWCG29(14) Version 3 Issue Date: 18/10/2019 Page 20 of 22
12. Equality Impact Assessment (EqIA) screening tool
Legislation requires that our documents consider the potential to affect groups differently, and eliminate or minimise this where possible. This process helps to reduce health inequalities by identifying where steps can be taken to ensure the same access, experience and outcomes are achieved across all groups of people. This may require you to do things differently for some groups to reduce any potential differences.
1a) Have you undertaken any consultation/ Yes/No involvement with service users, staff or other Please state: Staff have reviewed the groups in relation to this document? updated content 1b) Have any amendments been made as a Yes/No result? Please Comment: Only update of references 2) Does this policy have the potential to affect any of the groups below differently or negatively? This may be linked to access, how the process/procedure is experienced, and/or intended outcomes. Prompts for consideration are provided, but are not an exhaustive list. Protected Group Yes No Unsure Reasons for decision Age (e.g. are specific age groups excluded? Would the same x process affect age groups in different ways?) Sex (e.g. is gender neutral language used in the way the policy x or information leaflet is written?) Race (e.g. any specific needs identified for certain groups such x Interpretation as dress, diet, individual care needs? Are interpretation and /translation translation services required and do staff know how to book services are these?) needed in some instances Religion & Belief (e.g. Jehovah Witness stance on blood x Certain transfusions; dietary needs that may conflict with medication dressing offered.) containing animal by products Sexual orientation (e.g. is inclusive language used? Are x there different access/prevalence rates?) Pregnancy & Maternity (e.g. are procedures suitable for x Radiology pregnant and/or breastfeeding women?) procedures/ antibiotics Marital status/civil partnership (e.g. would there be any x difference because the individual is/is not married/in a civil partnership?) Gender Reassignment (e.g. are there particular tests related x to gender? Is confidentiality of the patient or staff member maintained?) Human Rights (e.g. does it uphold the principles of Fairness, x Respect, Equality, Dignity and Autonomy?) Carers (e.g. is sufficient notice built in so can take time off work x to attend appointment?) Socio/economic (e.g. would there be any requirement or x
Foot Complications in People with Diabetes Prevention and Management of Reference Number TWCG29(14) Version 3 Issue Date: 18/10/2019 Page 21 of 22
expectation that may not be able to be met by those on low or limited income, such as costs incurred?) Disability (e.g. are information/questionnaires/consent forms x available in different formats upon request? Are waiting areas suitable?) Includes hearing and/or visual impairments, physical disability, neurodevelopmental impairments e.g. autism, mental health conditions, and long term conditions e.g. cancer. Are there any adjustments that need to be made to ensure that x people with disabilities have the same access to and outcomes from the service or employment activities as those without disabilities? (e.g. allow extra time for appointments, allow advocates to be present in the room, having access to visual aids, removing requirement to wait in unsuitable environments, etc.) 3) Where you have identified that there are potential differences, what steps have you taken to mitigate these?
4) Where you have identified adjustments would need to be made for those with disabilities, what action has been taken?
5) Where the policy, procedure, guidelines, patient information leaflet or project impacts on patients how have you ensured that you have met the Accessible Information Standard – please state below:
……………………………………………………………………………………………………………… EDI Team/Champion only: does the above ensure compliance with Accessible Information Standard o Yes o No If no what additional mitigation is required:
Will this policy require a full impact assessment? Yes / No
Please state your rationale for the decision:
(a full impact assessment will be required if you are unsure of the potential to affect a group differently, or if you believe there is a potential for it to affect a group differently and do not know how to mitigate against this - Please contact the Inclusion and Equality team for advice on [email protected])
Author: Type/sign: Samantha Haycocks Date: 03/09/2019
Sign off from Equality Champion: Date:
Foot Complications in People with Diabetes Prevention and Management of Reference Number TWCG29(14) Version 3 Issue Date: 18/10/2019 Page 22 of 22