The CPR for Feet campaign was launched in April 2014 following an inpatient diabetic foot audit (Stang and Leese 2014) carried out by the Scottish Diabetes Foot Action Group (SDFAG) in November 2013 demonstrating that:
- 2.4% of inpatients with diabetes developed a new foot lesion while in hospital.
- 57% of inpatients reported they had not had their feet checked on admission to hospital.
- 60% of those who were discovered to be at risk of developing a foot ulcer did not have any pressure relief in place.
- 14% had a current foot ulcer, and only 65% of these patients had been referred to a diabetes foot care team.
Resources initially developed to support the campaign were funded by the Scottish Government through the SDFAG and included:
- A Check, Protect, Refer (CPR) for Feet poster for hospital wards (Figure 1).
- A Learnpro (now TURAS) module for staff to raise awareness about the risk of hospital acquired diabetic foot ulceration and its management.
- Training modules for staff to use as an aid and reference for short, ward-based one-to-one and group education.
The National Diabetes Inpatient Audit Scotland 2023
Nearly 10 years after the initial inpatient diabetic foot audit, the Scottish Diabetes Group arranged a national diabetes inpatient audit (NaDIA Scotland, 2023). This included an audit of inpatient diabetes-related foot care. In summary:
- The Scottish Diabetes Group designed a domain which was added to Scotland’s national electronic diabetes patient record (SCI diabetes) to collect data and report hospital inpatient activity to measure standards of care within Scottish hospitals.
- NaDIA Scotland 2023 was a 1 day cross-sectional audit carried out in May/June 2023 with engagement of all 14 health boards in Scotland.
- Data was collected from 2,026 people living with diabetes who were current inpatients in Scottish hospitals.
The foot-related aspects of the NaDIA Scotland 2023 identified:
- 1.5% of inpatients with diabetes developed a new foot lesion while in hospital (unpublished data), a decrease of 37.5% from the previous 2013 audit.
- Approximately 16.5 % of inpatients had documented evidence of their feet being checked within 24 hours of their admission, with a further 16% being checked later in the admission. This was lower than previous audit, where 43% reported that they had their feet checked.
- Of those with active foot disease, 56% had been reviewed by a member of foot multidisciplinary team (MDT) within 24 hours, and 76% had been reviewed by a member of the foot MDT in the 7 days preceding the audit. This is higher than the previous audit (65%, where timing of the review was not collected).
Assessment
The CPR for Feet campaign has been adopted across all boards in Scotland and continues to be championed. With a decreased rate of ulcer development and higher referral rate to the diabetic foot MDT when ulcers have been identified, the campaign can be considered a success. The brief, easy-to-remember name and readily available resources have helped with its implementation and development.
There are several features that have been integral to its success, as follows.
Physical resources
Pressure redistribution devices: A key aspect of the campaign was the securing of national procurement of pressure-relieving devices from TalarMade. This allowed for more value-based, cost-effective interventions to help pressure redistribution for feet in particular heels as well as promote simplicity and consistency of messaging. In addition, ongoing support from TalarMade has been vital for education of staff, driving forward the campaign, supporting consistency of messaging and sharing of good practice across all Scottish health boards.
CPR for Feet poster for hospital wards: To help promote visibility and ease of referral when needed, editable posters were made available for boards to use in inpatient settings (Figure 1).
Mirror and CPR for feet badge: Small cards to fit beside healthcare professional name cards were developed and shared at educational events across Scotland. A mirror on one side of the card facilitates visibility of the harder-to-reach area of the foot, such as the heel. There is a summary of the CPR for feet Campaign on the reverse (Figure 2).
Other initiatives developed by SDFAG group members
Ward packs: A4 folders with packs of information have also been made used to help ensure ward based staff can access appropriate referral pathways and information as easily as possible.
Magnets: To increase awareness of those at risk in the inpatient setting, a red ‘Relieve the Heel’ magnet has been developed with its use being promoted to easily identify at the bedside those people at risk of static pressure related foot harm. Improving the identification of those people at risk, preventative methods can be implemented.
Broad-reaching relevance of CPR for Feet campaign
Beyond Diabetes.
Not long after the launch of the campaign it was recognised that there are many people who do not have diabetes, but who are also at risk of static pressure-related foot harm. Therefore, the materials developed included other risk factors, such as frailty and other causes of neuropathy, in addition to diabetes. This emphasises the need to implement CPR for feet to wider populations.
Community setting
While initially developed for inpatient settings it has been recognised that the CPR for Feet campaign has relevance and benefit in community settings such as care homes. Recognising the wider relevance into social as well as health services, a training module known as an “Open Badge” is available on the Scottish Social Services Council’s MyLearning website (https://www.mylearning.scot/badges/cpr-for-feet). The website notes it is “intended for people in a variety of care settings and focuses on supportive foot care and monitoring for people who have a medical and / or foot condition which puts their feet at high risk of ulceration”.
Staff education resources
The campaign was initially rolled out through the SDFAG in 2014. The campaign was championed by the National Diabetic Foot Coordinator at the time, by raising awareness, highlighting electronic teaching resources on the NHS Education for Scotland Staff education platform and sharing the physical resources at educational and other health care related events.
All educational resources produced by the SDFAG and TalarMade can be found on the Diabetes in Scotland website (https://www.diabetesinscotland.org.uk/resources). TalarMade is the company that was awarded the national contract for pressure redistribution/relief devices to support the CPR for Feet campaign.
A more recent resource developed to complement the current resources includes a video and song available through YouTube (NHS Scotland, 2023). This popular, easily accessible, memorable and time-efficient resource makes it easy for staff to increase awareness either as part of a more in depth education session or in isolation.
Other locally based initiatives include links to CPR for Feet resources on electronic patient record and using electronic alerts on individuals’ records to highlight the risk, but these have not been formally evaluated.
Quality improvement
As a national campaign, local boards have also used the CPR for Feet principles as a basis for quality improvement initiatives. This was demonstrated by Regan et al (2018) in Greater Glasgow and Clyde who demonstrated that the use of a CPR for Feet bundle improved the assessment of feet in the inpatient setting in those with diabetes. Other quality improvement work and strategies around CPR for Feet has been shared informally at the regular meetings of the SDFAG. These include inclusion of the CPR for Feet campaign on admission paperwork, electronic patient records and prescription documentation.
Cost effectiveness
Diabetic foot ulceration costs the NHS significant amounts of money; therefore, prevention of any avoidable ulcer is crucial for the individuals at risk as well as health budgets. The 2013 audit indicated 24 per 1,000 people with diabetes in inpatient settings had developed ulceration compared to 15 per 1,000 in the 2023 audit – 9 per 1,000 fewer ulcers in 2023 compared to 2013.
If 20% of inpatients have diabetes, this equates to approximately 115,000 diabetes inpatients in Scotland at any one time (Public Health Scotland, 2024). The difference in the number of inpatient ulcers developed between 2013 and 2023 was 920 (2,760 and 1,840, respectively). Therefore, it is reasonable to consider that 920 ulcers have been avoided.
The range of extra inpatient days being required following the development of a foot ulcer in hospital is estimated to be from 8 days (Kerr et al, 2019) to 13 days (Stang and Leese, 2014) in the acute inpatient setting.
The costs of acute inpatient beds range from around £550 to £1071 per night (NHS Grampian Data).
The conservative estimate of savings are from £4,048,000 (8 days at £550 × 920 ulcers) ranging to upper limit estimate of £12,809,160 (13 days at £1,071 × 920 ulcers) for the extra inpatient stay following the development of a potentially avoidable ulcer.
Cost of ulcer care in the outpatient setting has been estimated to be £7,800 per ulcer (Guest et al, 2018) this equates to £7,176,000 for 920 ulcers.
The NaDIA Scotland 2023 only occurred in the hospital setting, so it is likely that more ulcers would have been prevented due to the implementation of the CPR for Feet campaign in community settings, and thus the costs are likely underestimated.
Conversely, the market cost of more expensive safety devices is approximately £139 per individual on the TalarMade website. This equates to outgoings of under £130,000 for 920 patients. However, due to national procurement, the costs of devices are approximately 25% less than this.
Thus it is safe to say that between the two audit periods, approximately 920 ulcers per year have been prevented, avoiding approximately £4 million– £12 million per year of healthcare costs.
Limitations
In regards to the rate of ulcer development it is worth considering other factors. It is likely that other pressure off loading equipment may also be used and, while this may have contributed in part to the improvements, awareness of risk of ulceration, is still required and it is unlikely that the use of pressure off loading mattresses is universal. In addition, as hospital settings become busier, it is likely that the length of stay is decreased for many people when able to be discharged safely or people are treated on an outpatient basis. For example initiatives such as hospital at home or outpatient parenteral antibiotic therapy services. This may have contributed to preventing the development of harm as an inpatient. Conversely, the length of stay for those who do have a delayed discharge remains high (Public Health Scotland, 2025); therefore, adding to the risks of inpatient care in those who no longer require hospital-based care, but are not safe to be discharged home. Often living with frailty, these people will be at particularly high risk of static pressure-related harm and ulcers, likely offsetting the benefits of those being cared for outpatient based services.
We should also consider the differences between the two audits regarding the methods of data collection. For example, in the 2013 audit, assessing whether feet had been checked included asking people directly; whereas in the 2023 audit, only evidence documented in patient notes was included. This may explain the apparent drop in number of feet being checked.
Another aspect that has been a challenge in the last decade and that will have contributed to this difference is the change from paper to electronic notes. The NHS boards with more people documented having had their feet checked were using paper to document the “CPR for Feet assessment”. This possibly represents the pathways having been in a consistent format for longer, with the transition from paper to electronic being a challenge to maintain awareness of safety initiatives, including CPR for Feet. As electronic notes become the norm, it is key to ensure these are embedded electronically.
Ongoing challenges and future considerations
With the increasing prevalence of frailty and diabetes, the risk of individuals developing avoidable harm from static pressure will continue for the foreseeable future. Continuing to implement the CPR for Feet campaign is crucial to avoid this harm, where possible.
Key aspects of the campaign’s success have included:
- High-level support from the Scottish Government, with associated funding.
- Dedication from frontline healthcare professionals as part of the SDFAG and across NHS Scotland.
- Tireless support from TalarMade in providing ward-based staff education.
As health budgets become more constrained and staffing levels continue to be a challenge, the funds for promotional materials and personnel to champion this campaign are likely to become less available. Thus, support from industry to provide awareness and education will be increasingly more important.
One of the challenges expressed by staff when using the recommended pressure offloading devices is that in some cases patient tolerance of the FootSafe boot is not good. Some users can find them uncomfortable and are often unable to tolerate wearing them. Newer equipment is available, such as the HeelPro Advance heel protector boot, which is a more comfortable and user-friendly alternative, as well as still being cost effective (Hodgson, 2025)
While steps have been made to prevent static pressure-related ulcers in the hospital and community settings, we need to ensure harm is prevented across the whole patient journey, including in the ambulance and while being cared for at home. Members of the SDFAG are exploring these opportunities.
With electronic patient records now the norm across Scotland, there are potential opportunities for automated alerts for those with high-risk feet to help facilitate awareness to frontline staff and ensure the CPR for Feet principles are carried out.
Conclusion
The CPR for Feet campaign has been instrumental in reducing rates of iatrogenic static pressure related ulceration over the last 9 years.
Raising awareness of foot risk and having well-resourced and accessible pathways to the correct professionals is key to prevention and early intervention of pressure related harm to the feet. With costs of iatrogenic foot ulceration estimated to be between £4 million and £12 million per year for NHS Scotland, continuation and development of the CPR for Feet campaign will prevent unnecessary future costs to NHS budgets, but – more importantly – prevent significant morbidity and mortality to individuals.
