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Best practice pathway of care for people with diabetic foot problems. Part 2: The pre-ulcerated foot

A report from a roundtable discussion held on Sunday 8 October 2006 in London. The meeting was supported by an unrestricted educational grant from KCI Medical.

In the first of the roundtable discussions published in the last issue of The Diabetic Foot journal those present discussed the differences in care provided to the person with diabetic foot problems. They proposed a new diabetic foot risk classification system (Appendix 2; Table 1 shows the modified version following from this discussion. It will be further modified according to the discussion during the following two meetings.) They also introduced a framework for a pathway of care that includes specifying which healthcare professional should be involved, what they should be doing and when. This has already been adopted by the Foot in Diabetes UK (FDUK) group as the basis of its competency document (available from: Diabetes UK, 2006). This in turn has been adopted by various groups, including Diabetes UK, to form the basis of commissioning for diabetic foot services in England and Wales. In this, the second roundtable discussion, those present revisited the first roundtable and further modified the pathway of care by:

  • defining and classifying ulcers
  • debating what mechanisms should exist to ensure prompt review of the person with the diabetic foot and how soon is ‘prompt’
  • discussing where care should be provided and first aid principles for the non-specialist
  • examining whether any interventions for the diabetic foot are evidence based.

Present at this roundtable discussion were:

  • Paul Chadwick (Principal Podiatrist, Salford)
  • Mike Edmonds (Consultant Physician, London)
  • Joanne McCardle (Podiatrist, Edinburgh)
  • Duncan Stang (Chief Podiatrist, Lanarkshire)
  • Lynne Watret (Tissue Viability Nurse, Glasgow)
  • Matthew Young (Consultant Physician, Edinburgh, Associate Editor of The Diabetic Foot, and Chair of session).

This roundtable discussion, the second of four, focused upon the following key aspects of the ulcerated diabetic foot:

  • Preventative care.
  • Defining a diabetic foot ulcer.
  • Mechanisms for prompt review for the person with an ulcerated diabetic foot.
  • Where the care of such an individual should be provided.
  • First aid for the non-specialist who encounters the person with an ulcerated diabetic foot.
  • Whether any intervention for the ulcerated diabetic foot is evidence based.

Management of the high-risk foot
The panel agreed that despite a paucity of evidence for ulcer prevention it remains clear from extrapolation of numerous small studies that this should include preventative podiatric care, particularly callus debridement and biomechanical assessment which would lead to the provision of prescription footwear, orthoses or both. There was a general consensus among the group that not all high-risk patients require NHS shoes if their feet are not significantly deformed or clawed. As yet there is no clear evidence for total contact insoles being better than flat sheet materials in preventing ulceration where insoles are required.

Education strategies for high-risk people continue to be controversial. While everyone agrees that informing individuals that they have high-risk feet and should perform self-care is vital, the detail of this message varies from area to area and the effects are not proven. As a minimum, all high-risk patients should be advised to report any suspicious foot lesions to their carer(s) as soon as possible. The specialist footcare service should then be able to respond urgently as described below.

Defining a diabetic foot ulcer
The Collins Concise Dictionary definition of an ulcer is ‘a disintegration of the surface of the skin or a mucous membrane resulting in an open sore that heals very slowly’ (‘ulcer’, Collins Concise Dictionary, 1999). The only differentiating factor between such a defined ulcer and a diabetic foot ulcer is that the latter occur in people with diabetes and is a consequence of co-morbid conditions. However, from a practical standpoint, ulceration, Charcot neuroarthropathy and other foot pathologies are often treated differently across the NHS.

In some areas, for service reasons, foot ulcers are not referred on until they are present for a few weeks or become static. This group believes that if a healthcare practitioner or patient believes they have a problem they should be referred or be able to refer immediately to a multidisciplinary footcare team – and the problem of what an ulcer is can be decided later.

Ensuring a prompt referral
Those involved in the care of people with diabetic feet should be trained as to when, how and whom to refer to. If any healthcare professional is unable to deal with a certain aspect of an individual’s condition, they should seek appropriate referral especially as diabetic foot problems can deteriorate at an exponential rate. Reaching a consensus on how to ensure that an individual is seen quickly and appropriately is difficult.

A simple phone call, as opposed to a letter, will speed the process up immeasurably but many services cannot respond without letters of referral. Another method agreed by the panel is that a telephone triage could be adopted. However, there should be a ‘gatekeeper’ for all referral contacts, telephone triages and so on. This person should, in the panellists’ opinion, be the diabetes specialist podiatrist.

Another important person to educate is the person with diabetic foot problems: for example, to get him or her to call the relevant out-of-hours service when necessary. Signs such as recognising increasing redness, malodour, pain and warmth in their feet are, in the panellists opinion, relatively easy to do and educating this population on recognising and reporting these symptoms is relatively straight forward.

The Scottish Intercollegiate Guidelines Network (SIGN) and NICE both suggest that urgent cases are seen within one working day. The roundtable attendees suggested that perhaps NHS care trusts should pay for diabetes specialist podiatrists to work a 7-day week, similar to the emergency physiotherapy service. The cost of doing so would be offset by reductions in bed-days or reduced amputations by treating the infected ulcerated diabetic foot out-of-hours quickly and efficiently. More importantly, such a service would greatly improve the individual’s quality of life.

For any out-of-hours services to be successful, healthcare professionals with no specialist knowledge of the diabetic foot need to be educated to recognise:

  • the ischaemic foot
  • the neuropathic foot
  • the infected foot.

An analogy a panellist used was that of a patient seeing his or her GP with a sore tooth: the GP would never consider trying to manage it him or herself, they would be sent to a dentist; so, when the GP comes across a ‘sore foot’ why do they not send them to a podiatrist? ‘It is getting the mind-set correct’, they agreed. Therefore, the most important thing that groups of healthcare professionals with an interest in and specialist knowledge of diabetic foot problems and their treatment can do is to raise awareness among their peers.

Where should out-of-hours care be provided?
General practice emergency treatment centres, minor injury units and emergency departments are where patients present after hours. Minor injury units in all hospitals should already have review systems in place to prevent further deterioration of any injury. However, due to the multifactorial nature of diabetic feet, many cases are poorly treated, for example, when decisions are made on intravenous antibiotic treatment regimens for the infected diabetic foot.

The panel suggested that: ‘In order to reduce bed-days, which is very pertinent to the modern NHS, patients with, for example, cellulitis could be treated as an inpatient for their first intravenous antibiotic treatment, then discharged with oral antibiotics with follow-up being carried out in a specialist outpatient clinic.’

An on-call service by a group of diabetes specialist podiatrists should be set up in all areas to attend the person with the diabetic foot. Given the complex needs of the infected foot the best filter point – where the patient is seen by the podiatrist and appropriately referred – would be the emergency department. If an on-call service exists this is where patients should be directed to by NHS Direct or NHS-24.

The panel agreed that there should be a complications escalator that goes up and down as and when required: foot complications that improve may recur at a later date, therefore the person with diabetes may need to be seen by the podiatrist at one point in time, by the vascular surgeon the next, then the podiatrist again for the forseeable future.

In conclusion to the first part of the meeting the Chair, Matthew Young, summarised that ‘all healthcare professionals caring for the person with diabetic foot complications should have relevant and recognised competences in order to reduce the patients’ risk factors for their feet getting worse.’ Also that ‘an extended out-of-hours podiatry service running 7 days a week is justified and will increase the patient’s quality of life.’ He added that ‘patients should, when out of hours, be referred to a service centre that has access to X-ray facilities (in order to check for Charcot feet, infection and other problems such as fractures), and facilities to administer intravenous antibiotics to treat the infected foot.’

First aid principles
If, however, a patient lives in an area where access to an organised service is logistically difficult or in the absence of a 7-day podiatry service, what does he or she do?

It appears that NHS Direct and NHS-24 have algorithms for many other conditions, such as deep vein thrombosis, chest pain and asthma, but not for people with diabetes and related foot problems. The panellists decided that they could present these NHS bodies with a simple algorithm based upon the final outcomes of this series of roundtable discussions. It could start with, for example, ‘is the skin broken?’ and lead to more specific questions regarding pain, redness and the individual’s history of ulceration, if any. Such algorithms will reduce non-urgent referrals to the specialist healthcare professional; therefore allowing them to focus on more problematic cases.

A similar algorithm should be developed for other healthcare professionals, such as those working in nursing homes or residential homes for the disabled. It could also be used by others who consider themselves not to have specialist knowledge in this area. Any such algorithm has to take into account whether a delay in referring onto other specialists may do further harm to the person with diabetic foot problems – a further justification of a 7-day podiatric service, agreed the panel.

Evidence base
The panel unanimously agreed that there is a serious lack in formal published evidence to support any of the practices that thay have and will put forward. But, does all practice within medicine have to be evidence-based? The panel were, again, unanimous in that anecdotal evidence, or that based upon long-term practice, is as valid when treating conditions such as the diabetic foot.

Concluding remarks
The panellists from meeting of the roundtable hopes that, with the further modified progression chart of people with diabetic feet through the healthcare system, the importance of vigilance required when tending to people with diabetes and related foot problems can be appreciated.

The panellists concluded the meeting with the statement: ‘We hope that we have made a good start on this and that the next two meetings will bring together a new wealth of knowledge in order to provide a full flow chart that can be used by GPs, practice nurses, the non-specialist at the emergency department, and any other healthcare professional with no specialist knowledge of the subject’.

REFERENCES:

‘Ulcer’ Collins Concise Dictionary (1999) 4th edition. Collins, Glasgow
Diabetes UK (2006) The National Minimum Skills Framework for Commissioning of Foot Care Services for People with Diabetes. Diabetes UK, London. Available at: http://www.diabetes.org.uk/news/nov06/footcare (accessed 13.12.2006)
Peters EJ, Lavery LA; International Working Group on the Diabetic Foot (2001) Effectiveness of the diabetic foot risk classification system of the International Working Group on the Diabetic Foot. Diabetes Care 24(8): 1442–7

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