Your web browser is out of date.

For your security and improved experience online, please update your browser.

This site is intended for healthcare professionals only
×
Share this article
Share on facebook
Facebook
Share on twitter
Twitter
Share on linkedin
LinkedIn
Share on email
Email
Share on print
Print

ACT NOW! Reducing amputations during the COVID-19 pandemic and beyond

Amputation is one of the most feared complications of diabetes (Wukich et al, 2018). There were 7,545 major amputations in people with diabetes (PwD) in England between 2015 and 2018 (Public Health England, 2019). It is important to note that 84% of lower-extremity amputations are preceded by a foot ulcer (Pecoraro et al, 1990). With one in three people diagnosed with diabetes experiencing a foot ulcer during their lifetime (Armstrong et al, 2017; Edmonds et al, 2020), it is suggested that these amputations could be avoided if foot ulcers are effectively detected, assessed, referred and rapidly treated, in order to optimise healing (Boulton et al, 2015; Phillips and Mehl, 2015).

In response, the iDEAL (Insights for Diabetes Excellence, Access and Learning) Group has made recommendations to improve foot care and education, promote effective and timely referral, and to reduce the unacceptable numbers of major amputations in people with diabetes (iDEAL, 2020). This is especially timely. The COVID-19  pandemic  has caused  major disruption to many healthcare services, including  hospital and community services, and has resulted  in delayed assessment and treatment for many patients (Chadwick et al, 2020). There has been an increase in avoidable late referrals into multidisciplinary diabetes footcare teams (MDFT) and foot examinations have not been routinely undertaken (Rogers et al, 2020).

One of the major problems during the COVID-19 pandemic, with increasing numbers of remote/virtual consultations becoming the norm in diabetes care, is that potentially serious and limb-threatening foot problems can be missed. This is especially relevant if individuals cannot check their own feet or do not know how to undertake a foot check or know what they should be looking for, in order to initiate reporting for further assessment (Phillips et al, 2020). Practitioners cannot assume people with diabetes (PwD) know what to look for or what foot checks to do daily, especially if they have poor eyesight or cannot reach their feet.

A foot ulcer is defined as a full-thickness wound of any duration, below the ankle, in a person with diabetes (International Working Group on the Diabetic Foot [IWGDF], 2019) and affects between 15% and 25% of people with diabetes at some point during their lifetime (Dorresteijn and Valk 2012).  The pathway to ulceration and, therefore, amputation is often complex and multifactorial (Figure 1), and it is now generally agreed that there is no single, magic bullet for long-term prevention of foot ulceration and amputation in diabetes.

Even when immediate and intensive treatment is provided, these wounds may take weeks or months to heal or may not heal at all. This not only leads to physical disability and marked reduction of quality of life, but also precedes the majority of lower-extremity amputations. In addition, patients with neuropathic foot ulceration have a 7% risk of amputation in the next 10 years (Margolis et al, 2005; Dorresteijn and Valk, 2012) and 70% of foot ulcer patients have recurrent lesions within 5 years after the initial treatment (Dorresteijn and Valk, 2012).

Treatment of diabetic foot ulceration is, therefore, challenging and often needs to be of long duration. It requires not only expert attention, appliances and antimicrobial drugs, but also costly topical dressings, oral antibiotics and frequently results in extended hospital admissions for inpatient care. Delays in reaching specialist care can take place in three locations along the person’s healthcare journey:

  1. Delay by the PwD in seeking and reaching specialist care.
  2. Delay by HCPs in referring to specialist care.
  3. Delay in actually accessing care from the MDFT

Poor symptom recognition and a lack of knowledge, or failure to understand the severity of a foot problem in a PwD can lead to a lack of urgency. Both PwD and healthcare professionals (HCPs) may not appreciate the warning signs that precede the need for an amputation thereby reinforcing the requirement for foot problems to receive urgent attention (Pankhurst and Edmonds, 2018). Even after PwDs have reached an HCP, there may be delay in referring to specialised care because of a failure to make a diagnosis. HCPs may fail to recognise infection or ischaemia in the absence of pain due to concomitant neuropathy and even after recognition of the seriousness of foot disease, the importance of specialised care may not be appreciated by some HCPs due to inaccurate healthcare assessments (Pankhurst and Edmonds, 2018).

The National Diabetic Footcare Audit (NHS Digital, 2019) noted that there is a direct relationship between the time between first presentation to a HCP and being assessed by a specialist clinician and the severity of the ulcer at presentation to that specialist. The longer the time to expert assessment, the more likely the ulcer is to be judged ‘severe’ using the SINBAD classification, (Jeffcoate et al, 2020). These difficulties in accessing specialised services are strongly linked with worse outcomes, lower rates of healing, higher rates of major amputations and a higher mortality risk, (NDFA Quality Improvement Collaborative, 2020). Even after appreciation of the need for specialised care, the pathway to treatment may be compromised due to poor communication, difficulty in referral between HCPs in primary and secondary care, and reduced access to specialised care because of actual lack of multidisciplinary foot teams (MDFTs) (Pankhurst and Edmonds, 2018). An association has also been noted between the number of HCPs in the referral pathway and increased delays in PwD reaching specialised care. The more complex the referral pathway, the greater the delay (Sanders, 2013).

The importance of early referral has been highlighted by the NHS England Diabetes Programme (2020). Such prompt referral should lead to ulcers being less severe on presentation and, thereby, result in better outcomes (NDFA Quality Improvement Collaborative, 2020). In order to promote this, the iDEAL group (a multidisciplinary team of specialists with a key interest in improving diabetes care outcomes across the UK) has devised the acronym ACT NOW! with direct input from a PwD, for PwD and their carers to recognise the warning signs, which may result in amputation (Figure 2)
The identification of such signs as indicated in Figure 2 should give PwDs permission and confidence to seek urgent help and to activate rapid  referral to specialised care. It has been designed to be easy to use, effective and reliable, and is particularly relevant during these times of remote digital consultations, social distancing and with reduced numbers of diabetes foot care checks being undertaken. It has also been devised to be similar to the acronyms STOP and FAST, which were successfully associated with the campaigns to inform the public of the early warning signs of heart attack and stroke.  Like stroke, diabetes foot disease and foot infection are time sensitive and can lead to rapid destruction of tissue, which often regrettably necessitates hospital admission for surgical intervention and amputation (Figure 3).

It is, therefore, important that HCPs should be aware of the ACT NOW! tool. This consists of the ACT NOW! acronym and also a checklist (Figure 4), which enables PwD, their carers and HCPs to enquire and document the ACT NOW! symptoms or signs and to take possible further information, such as a digital photo. The checklist can then be used as a referral document to specialist care. Alternatively, the checklist can be used when PwDs present for routine assessment with their HCPs. The iDEAL group suggests that if ACT NOW! becomes routine in clinical practice a 50% reduction in major amputations could be achieved among people with diabetes within 5 years (Edmonds et al, 2020).

So, how may this 50% reduction in amputations be achieved? There are four main strategies:

  1. To heal ulcers as rapidly as possible — the primary aim is to prevent unnecessary amputations, by healing ulcers as quickly as possible, and to prevent infection or ischaemia leading to gangrene
  2. To prevent the development of ulcers — diabetes-related foot disease should be prevented by optimising risk factors for neuropathy and vascular disease such as raised glucose levels, blood pressure and lipids
  3. To educate people living with diabetes — HCPs and all members of MDFTs. There should be increased access to education in foot assessment and urgent referral for all HCPs working with people with diabetes. Improved foot care knowledge with practical practice-facing useful information are essential.
  4. To maintain a sufficient, sustainable and supported workforce — improvement of foot care and foot assessment in people living with diabetes is dependent on well-informed and educated HCPs who recognise the importance of foot care from diagnosis and at every diabetes review (Edmonds et al, 2020).

The iDEAL group, therefore, recommends that the ACT NOW! assessment tool is used for everyone with diabetes presenting with any type of foot problem and by all HCPs in all locations when assessing an individual with diabetes to promote effective and urgent referral and, ultimately, to save limbs and avoid unnecessary amputations (Edmonds et al, 2020; iDEAL Group, 2020).

The ACT NOW! acronym and checklist are  designed to be simple to use and to empower PwD, their carers or healthcare professionals with the skills to ACT NOW! (Robbie, 2021). Improved foot care knowledge, assessment and urgent referral with practical information are essential and the ACT NOW! acronym provides resilient safety netting for high-risk PwD by reducing delays, which may result in poor morbidity outcomes (in terms of ulcer healing and amputations) for this patient cohort. The adoption and regular use of the ACT NOW! tool can keep a focus on the vital nature of assessment and the need for education, knowledge, awareness to expedite timely referral to save limbs and lives (Phillips et al, 2020).

This practical and innovative approach to encourage people with diabetes and a foot problem  to ACT NOW! has been endorsed by Diabetes UK, the International Diabetes Federation (Europe), D-Foot International, the Royal College of Podiatrists, the Foot in Diabetes UK, the English Diabetes Footcare Network, Diabetic Foot Network Wales, Diabetes Network Northern Ireland, the Juvenile Diabetes Research Foundation and the Primary Care Diabetes Society, who all recognise its valuable contribution to footcare services.

Adopting and using the ACT NOW! acronym and checklist, therefore, have the potential to make a profound impact and to help PwDs to access timely assessment and referral, as ‘delays lead to dire results’ (Robbie et al, 2020). Rapid assessment and treatment of ischaemia, as well as treatment of infection and the recognition of the important role of podiatry, alongside the application of robust protocols, including the ACT NOW! checklist, will achieve better healing rates, as well as reducing hospital admissions for major amputations (Vainieri et al, 2020). This, in turn, can reduce the unacceptably high volume of major amputations (Phillips et al, 2020), which cannot be tolerated.

Armstrong DG, Boulton AJM, Bus SA (2017) Diabetic Foot Ulcers and Their Recurrence. N Engl J Med 376(24): 2367–75
Boulton A (2015) The Diabetic Foot. Medicine 43(1): 33–7
Burgess EM (1990) Pathways to diabetic limb amputation. Basis for prevention. Diabetes Care 13(5): 513–21
Chadwick P, Ambrose L, Barrow R, Fox M (2020) A commentary on podiatry during the Covid-19 pandemic. J Foot Ankle Res 13(1): 63
Dorresteijn JAN, Valk GD (2012) Patient education for preventing diabetic foot ulceration. Diabetes Metab Res Rev 28(Suppl 1): 101–6
Edmonds ME, Foster AVM (2014) Managing the Diabetic Foot. 3rd edition. Oxford: Blackwell Science
Edmonds M, Phillips A, Holmes P, Odiase C, Robbie J, Grumitt J, Halloum H (2020) To halve the number of major amputations in people living with diabetes, “ACTNOW”. Diabetes & Primary Care 22(6): 1–5
iDEAL group (2020) iDEAL Group Position Statement: ACT NOW!  Diabetes and Foot Care Assessment and Referral. Available at: https://idealdiabetes.com/publications (accessed 30.10.2020)
International Working Group on the Diabetic Foot (2019) IWGDF Guideline on the Diagnosis and Treatment of Foot Infection in Persons with Diabetes. Available at: https://iwgdfguidelines.org/wp-content/uploads/2019/05/05-IWGDF-infection-guideline-2019.pdf (accessed 28.05.2021)
Jeffcoate W, Gooday C, Harrington A et al (2020) The National Diabetes Foot Care Audit of England and Wales: achievements and challenges. The Diabetic Foot Journal 23(1): 70–3
Margolis DJ, Taylor L, Hoffstad OJ, Berlin JA (2005) Diabetic neuropathic foot ulcers and amputation. Wound Repair Regen 13(3): 230–6
NDFA Quality Improvement Collaborative (2020) Report on the  National Diabetes Foot Care Audit (NDFA) Quality Improvement Collaboratives. Available at: https://bit.ly/3vyeV82 (accessed 28.05.2021)
NHS Digital (2019) National Diabetes Foot Care Audit, 2014– 2018. NHS Digital, Leeds. Available at: https://bit.ly/36i2T7J.  (accessed 28.05.2021)
NHS England Diabetes Programme (2020) Diabetes Treatment and Care Programme. Available at: https://www.england.nhs.uk/diabetes/treatment-care/ (accessed 28.05.2021)
Pankhurst CJW, Edmonds ME (2018) Barriers to foot care in patients with diabetes as identified by healthcare professionals. Diabet Med 35(8): 1072–7
Pecoraro RE, Reiber GE, Burgess EM (1990) Pathways to diabetic limb amputation. Basis for prevention. Diabetes Care 13(5): 513–21
Phillips A, Mehl AA (2015) Diabetes mellitus and the increased risk of foot injuries. J Wound Care 24(5 Suppl 2): 4–7
Phillips A, Edmonds M,  Holmes P et al (2020) ACT NOW in diabetes and foot assessments: an essential service. Practice Nursing 31(12): Comment Published Online. Available at: https://bit.ly/3x5VqEl (accessed 08.06.2021)
Public Health England (2019) Diabetes Foot Care ProfilesApril 2019. Available at: https://fingertips.phe.org.uk/profile/ diabetes-ft (accessed 28.05.2021)
Robbie J, Tomkins D, Mitchell L et al (2020) A 2-year prospective audit of patients admitted into an acute hospital from an outpatient podiatry clinic – trends and outcomes. The Diabetic Foot Journal 23(4): 32–5
Robbie J (2021) Managing foot care for people with diabetes. Practice Nursing 32(3): S3–7
Rogers LC, Lavery LA, Joseph WS, Armstrong DG (2020) All feet on deck-the role of podiatry during the COVID-19 pandemic: preventing hospitalizations in an overburdened healthcare system, reducing amputation and death in people with diabetes. J Am Podiatr Med Assoc 10.7547/20051 [Online ahead of print]
Sanders AP, Stoeldraaijers LG, Pero MW et al (2013) Patient and professional delay in the referral trajectory of patients with diabetic foot ulcers. Diabetes Res Clin Pract 102(2): 105–11
Vainieri E, Ahluwalia R, Slim H et al (2020) Outcomes after emergency admission with a diabetic foot attack indicate a high rate of healing and limb salvage but increased mortality: 18-month follow-up study. Exp Clin Endocrinol Diabetes 10.1055/a-1322-4811 [Online ahead of print]
Wukich DK, Raspovic KM, Suder NC (2018) Patients with diabetic foot disease fear major lower-extremity amputation more than death. Foot Ankle Spec 11(1): 17–21

iDEAL has downloadable ACT NOW! resources and educational material, which can be accessed from the website at https://idealdiabetes.com/act-now-education-resources/ Diabetes UK provides steps to prevent foot problems and offers tips for everyday foot care: https://www.diabetes.org.uk/guide-to-diabetes/complications/feet/ taking-care-of-your-feet Diabetes UK shows how people with diabetes can check their feet and recognise a serious foot problem: https://www.diabetes.org.uk/guide-to-diabetes/ complications/feet/serious-foot-problem
Share this article
Share on facebook
Share on twitter
Share on linkedin
Share on email
Share on whatsapp
For the latest news and articles

Sign up to all DiabetesontheNet journals

© Copyright Omniamed Communications. All Rights Reserved​
108 Cannon Street, London, EC4N 6EU. Registered in the United Kingdom​
Omniamed logo white
For the latest news and articles

Sign up to all DiabetesontheNet journals

 

By clicking ‘Subscribe’, you are agreeing that DiabetesontheNet.com are able to email you periodic newsletters. You may unsubscribe from these at any time. Your info is safe with us and we will never sell or trade your details. For information please review our Privacy Policy.

DiabetesontheNet Logo

This website is for UK healthcare professionals only. To continue, please confirm that you are a UK healthcare professional below.