DIABETIC FOOT COMPLICATIONS: CLINICAL PRACTICE GUIDELINES FOR THE PREVENTION AND MANAGEMENT OF

Transcription

1 Title: Directorate: Responsible for review: Ratified by: Applicability: DIABETIC FOOT COMPLICATIONS: CLINICAL PRACTICE GUIDELINES FOR THE PREVENTION AND MANAGEMENT OF Organisation Wide Lead Diabetes Podiatrist Care and Clinical Policies Sub Group Chief Nurse Medical Director All Staff Ref No: 2162 Version 1 Classification: Guideline Due for Review: Document Control TABLE OF CONTENTS Purpose.. 2 Policy statement. 2 Roles and Responsibilities.. 2 Introduction. 2 Preface. 3 Prevention and Education 3 Optimal diabetes management. 4 Patient self-management of the feet.. 4 The Warning Signs of Foot Ulceration 4 Patient and family Education 5 Screening...6 Management of the Diabetic Foot at Low Risk.. 6 Management of the Diabetic Foot at Increased/High Risk. 6 Management of the Ulcerated Foot 7 Assessment of a New Diabetic Foot Ulcer.9 Treatment of Infection...12 Treatment of Osteomyelitis Assessment of Peripheral Arterial Disease...13 Management of Peripheral Arterial Disease.. 14 Management of the Healed Foot. 15 Painful Neuropathy.. 16 Deformities in the Diabetic Foot Charcot Foot.. 17 Appendices Diabetic Foot Complications: Clinical Practice Guidelines for the Page 1 of 19

2 1.0 Purpose 1.1 The purpose of this document is to provide a practical, evidence based set of guidelines for all primary care health workers in the management of the diabetic foot and its associated problems. 2.0 Policy Statement 2.1 The objective of this document is to provide consistency of care and best practice for the screening of the diabetic foot and the management of diabetic foot ulceration and other diabetic related foot problems, throughout the South Devon Area and by all Health Professionals that routinely come into contact with patients with diabetes. 3.0 Roles and responsibilities 3.1 This guideline will apply to all health professionals; both registered and unregistered who as part of their daily routine come into contact with patients who have either type 1 or type 2 diabetes. 4.0 Introduction 4.1 Below is a list of the essential requirements of a foot care service to prevent and manage diabetic foot problems. This is best delivered when it is provided by a multi-disciplinary team. 1 This should closely involve the person with diabetes and his or her family, along with health care professionals from different specialities: Annual foot inspection/risk assessment. Classification of the foot as either low/medium/high risk or ulcerated foot. Regular podiatry and targeted education for those at risk. Assessment of footwear and provision of specialised footwear if required. Rapid access to a multidisciplinary foot protection team if a foot ulcer or Charcot foot arises. 4.2 Only through a multidisciplinary team approach, addressing the diversity of possible foot problems in people with diabetes, can the desired reduction in amputation rates be achieved. Appendix 1 The Multidisciplinary Diabetic Foot Team 4.3 These guidelines reflect NICE guidelines CG10 which the Podiatry Service is currently commissioned to provide. In 2015 the NICE guidelines for the Diabetic foot changed to NG19 which the Podiatry Service is not commissioned to provide. These guidelines will be updated if the Podiatry Service is commissioned to provide NG19. Diabetic Foot Complications: Clinical Practice Guidelines for the Page 2 of 19

3 Diabetic Foot Complications 5.0 PREFACE 5.1 The most important factors related to the development of foot ulcers are peripheral neuropathy, foot deformity and peripheral arterial disease. Loss of protective sensation is a major component of nearly all diabetic foot ulcers and is associated with a 7 fold increase in risk of ulceration The development of Peripheral Arterial Disease (PAD) is a key risk factor for lower extremity amputation 3. People with diabetes are twice as likely to have PAD as those without diabetes Peripheral neuropathy is a common component of ulceration and will be discussed as three categories; motor, autonomic and sensory. 5.4 Peripheral motor neuropathy is highlighted by a change in joint mobility and a loss of tone in intrinsic foot muscles. Changes to the musculature of the foot result in hammer toes, hallux valgus and callus production. A reduction in ankle and toe joint mobility related to glycosylation of collagen within the joint structure alters pressure on the plantar surface of the foot and increases the likelihood of tissue breakdown. 5.5 Peripheral autonomic neuropathy causes the formation of arterio-venous shunting. Shunt formation results in the inhibition of temperature regulation to the foot and is demonstrated by a warm foot with bounding pulses. These foot tissues have a reduced ability to sweat resulting in dry skin, skin cracks and fissures. Openings in the skin can be a portal for bacterial invasion and, if unnoticed because of sensory loss, can result in ulceration. 5.6 In summary, structural changes resulting from peripheral neuropathy alter the pressure to the walking surface of the foot. Tissues are less able to tolerate the increased plantar pressures and shear as a result of decreased elasticity because of tissue glycosylation. Lack of protective sensation leads to a lack of awareness on the part of the individual and the person continues to ambulate. Repetitive high pressures to the sole of the foot as a result of walking, cause callus formation, and tissue breakdown at these pressure points and can result in bleeding and ulceration. Neuropathic foot complications in people with diabetes can be reduced by preventative measures like good glucose control, diabetes education and selfmanagement, smoking cessation, sensation testing, appropriately fitted foot wear, routine foot examination and professional nail and callus care. 6.0 Prevention and education 6.1 The prevention of diabetic foot complications requires a proactive approach involving the person with diabetes, family/care givers and a multidisciplinary team of health care providers. Education is an essential element in the empowerment of people with diabetes, helping to develop an effective partnership between healthcare professionals and the individual, which is key to achieving effective care. Critical aspects for prevention of diabetic foot complications are: optimal diabetes management, daily foot care, education for the person with diabetes and their family, screening and risk assessment by trained care providers Diabetic Foot Complications: Clinical Practice Guidelines for the Page 3 of 19

4 6.2 Optimal diabetes management Prevention needs good overall diabetes management as well as specific foot care. Patients with newly diagnosed type 2 diabetes should be referred to their local group for a series of education sessions which include healthy eating and lifestyle choices as well as foot care education. The Lifestyles team Health Promotion Devon St Edmunds Culm Valley Integrated Centre for Health 2 nd Floor Willand Rd, Victoria Park Rd Collumpton, Torquay EX15 1FE TQ1 3QH Tel: Diabetes UK have listed the 15 healthcare essentials that all people with diabetes have the right to expect: Blood glucose monitoring Blood pressure checks Blood fat checks Retinal screening Foot screening Kidney function monitoring Weight check Advice to stop smoking Individualised care planning The opportunity to attend a local education group Paediatric care if you are a child or young person High quality care if admitted to hospital Information and specialist care if you are planning a baby Access to appropriately trained specialists Emotional and psychological support For further information regarding diabetes management see NICE Quality Standards 6 - Diabetes, (March 2011) 6.4 Patient self-management of the feet Basic foot care should be considered an important part of self-care in people with diabetes, and as much a part of a self-care routine as blood glucose control or meal planning. Patients should be encouraged to inspect their feet every day, searching for the warning signs of foot ulceration: 6.5 The Warning Signs of Foot Ulceration Bleeding or weeping from any part of the foot Callus with bleeding, this may look like an area of hard skin with dark streaks or speckles Sinister blisters containing blood or pus Areas of discolouration or swelling Hot spots Diabetic Foot Complications: Clinical Practice Guidelines for the Page 4 of 19

5 If any of the above warning signs or active ulceration are discovered the patient should alert a health care professional immediately. 6.6 Patient and family education Education about foot care should be provided to all people with diabetes and their families/caregivers. Patient education should be tailored to meet each individual s needs and risk factors, using the principles of adult education. Education should be provided in several sessions over time, using a variety of teaching methods. It is essential to evaluate whether the patient has understood the message, is motivated to act and has sufficient self-care skills. A person with diabetes should expect to be offered information about the following: Self-care and monitoring of diabetes The potential impact of diabetes on the feet A daily foot inspection searching for the warning signs of foot ulceration Implications of loss of protective sensation Possible consequences of neglecting the feet Methods to help self-examination/monitoring (for example, the use of mirrors if mobility is limited) Hygiene (daily washing and careful drying) Skin care (moisturiser use) Nail care Dangers associated with inappropriate mechanical and chemical skin removal Footwear (the importance of well-fitting shoes and hosiery) Injury prevention and the importance of not walking barefoot when reduced sensation is present Annual foot exam by trained professional to assess for neuropathy and vascular disease Prompt detection and management of any problems are important, thus the importance of seeking help as soon as possible The Telephone Number of the Podiatry Appointments Office: The Podiatry Department has produced several information leaflets for patients covering all aspects of foot care as well as specific leaflets tailored to the diabetic foot risk levels. These leaflets are available to download free of charge on the Torbay and South Devon NHS foundation Trust intranet, ICON. A series of health videos have been produced by the health videos team and can be accessed at the link below: (Date last accessed ) Diabetic Foot Complications: Clinical Practice Guidelines for the Page 5 of 19

6 6.7 Screening, (Diabetic Foot Risk Assessment) A physical examination of the feet should be performed at least once a year by a trained health care professional to assess risk factors for ulceration/amputation.* *NICE Guideline CG10 Diabetic Foot Care Appendix 2 Torbay and South Devon NHS Foundation Trust: Guidance for Undertaking Diabetic Foot Checks 6.8 A physical examination of the feet should be performed by a trained health care professional at least annually in all people with diabetes. Foot examinations should be performed at more frequent intervals in individuals at high risk for vascular and neuropathic complications of diabetes. 6.9 The physical examination of the feet should include assessment of the blood circulation and the sensation in the foot, and examination for any skin changes (e.g. ulceration) and structural deformities of the foot The patient should then be classified as being at either low risk, increased risk or high risk of developing foot ulcers. Appendix 3 Diabetic Foot Referral Pathway Algorithm The patient should be informed of their risk level and advised appropriately. Patients at increased and high risk should be referred to the podiatry department for regular review, treatment and advice as per NICE guidelines. (CG10 Jan 2004) 6.11 Screening for House Bound Patients Screening should take place more frequently for patients who are unable to get to clinic due to frailty, dementia or disability, usually every 6 months. Screening in this situation is usually carried out by community nursing teams. Assessment of the sensation of the foot can be done using a 10g monofilament or alternatively, the Ipswich Touch Toe Test can be used. Appendix 4 The Ipswich Touch Toe Test 6.12 Screening for Patients Admitted to Hospital All patients with diabetes admitted to either the acute or a community hospital should have their feet screened to assess for the risk of developing an ulcer during their inpatient stay and to alert the podiatry team should the patient have a current ulcerated foot. A screening tool incorporating the Ipswich Touch Toe Test has been developed for this purpose. Appendix 5 Torbay Diabetic Foot Protection Programme Screening Tool 7.0 Management of the Diabetic Foot at Low Risk of Developing a Foot Ulcer Patient should be informed that they are at low risk of developing a foot ulcer Patient should be issued with an information leaflet appropriate to their level of risk. Diabetic Foot Complications: Clinical Practice Guidelines for the Page 6 of 19

7 If newly diagnosed with type 2 diabetes, patient should be invited to attend local education sessions. 8.0 Management of the Diabetic Foot at Increased/High Risk of Developing a Foot Ulcer should expect the following: Patient should be referred to their local podiatry clinic Patients at increased risk should be seen every 3 to 6 months and recalled as appropriate Patients at high risk should be seen every 1 to 3 months and booked ahead by the podiatrist At each visit the following should be carried out: On-going targeted education Review of biomechanical need and appropriate follow up Review of footwear and referral to Orthotist if required Review of vascular status and onward referral if required Search for ulceration or pre-ulcerative state and appropriate follow up Expert treatment of skin and nails (high risk only). 9.0 Management of the Ulcerated Diabetic Foot 9.1 NICE guidance recommends that all diabetic patients presenting in primary care, with a new or deteriorating foot ulcer, should be referred to a foot protection team within 24 hours. 9.2 Any new foot ulcer should be seen within 2 working days by the Podiatry Team. 9.3 If a patient presents with a severely infected foot accompanied by spreading cellulitis, the development of necrotic tissue and systemic symptoms such as a temperature, rigors and out of control blood sugars, the patient should be admitted to hospital urgently for immediate intravenous antibiotics and a surgical review. Whilst in hospital the patient should be reviewed by a member of the multidisciplinary diabetic foot team within 24 hours. 9.4 Heel pressure ulcers should be graded using the European Pressure Ulcer Advisory Panel, (EPUAP) grading tool. All areas of pressure damage must have an incident form completed following identification. All heel pressure ulcers of EPUAP grade 3 or 4 should be referred to the acute tissue viability service, bleep 292, tel: Diabetic Foot Complications: Clinical Practice Guidelines for the Page 7 of 19

8 International NPUAP- EPUAP Pressure Ulcer Classification System Please complete a local incident form for all pressure ulcers graded at stage II or above Category/Stage I: Non-blanchable redness of intact skin Intact skin with non-blanchable erythema of a localized area usually over a bony prominence. Discoloration of the skin, warmth, edema, hardness or pain may also be present. Darkly pigmented skin may not have visible blanching. Further description: The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category/Stage I may be difficult to detect in individuals with dark skin tones. May indicate at risk persons. Category/Stage II: Partial thickness skin loss or blister Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or sero-sanginous filled blister. Further description: Presents as a shiny or dry shallow ulcer without slough or bruising. This category/stage should not be used to describe skin tears, tape burns, incontinence associated dermatitis, maceration or excoriation. Category/Stage III: Full thickness skin loss (fat visible) Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Some slough may be present. May include undermining and tunnelling. Further description: The depth of a Category/Stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and Category/Stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage III pressure ulcers. Bone/tendon is not visible or directly palpable. Category/Stage IV: Full thickness tissue loss (muscle/bone visible) Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often include undermining and tunnelling. Further description: The depth of a Category/Stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and these ulcers can be shallow. Category/Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteomyelitis or osteitis likely to occur. Exposed bone/muscle is visible or directly palpable. Appendix 3 Diabetic Foot Referral Pathway Algorithm 9.5 All diabetic foot ulcers assessed by the podiatry team should be classified according to the SINBAD diabetic foot score. 5 Site = Index ulcer Hindfoot? No Yes Ischaemia: Clinical PVD? No Yes Neuropathy: Sensory Loss? No Yes Bacterial infection: Clinical? No Yes Area: 1cm 2 or more? No Yes Depth: to tendon or bone? No Yes Diabetic Foot Complications: Clinical Practice Guidelines for the Page 8 of 19

9 All ulcers with a SINBAD score of 3 or above should be referred immediately to the multidisciplinary diabetic foot team at Torbay Hospital. All ulcers with a SINBAD score of 0 2 should be referred to a community diabetes ulcer specialist podiatrist Assessment of a new Diabetic Foot Ulcer 10.1 The podiatrist should complete a Foot Ulcer Care Pathway form, taking into account the following key points: Appendix 4 Foot Ulcer Care Pathway Diabetes history Type, duration, control General medical history and co-morbidities Social history Smoking, alcohol, work, home circumstances, learning difficulties Full list of medications check for allergies Ulcer history past and present how did the ulcer start? Could it have been prevented? 10.2 A neurovascular assessment should be performed The wound should be classified as either neuropathic, ischaemic or neuro-ischaemic The wound should be debrided in an appropriate way, by a competent practitioner, at a level suitable for the type of wound. The purpose of debridement is to reveal the true size of the wound and expose any hidden sinuses or pockets of tissue damage. It allows the wound to drain more freely, reduces the bacterial burden by removing dead tissue and reduces pressure on the edges of the wound by removal of callus build up In a neuropathic wound with a good blood supply, extensive debridement down to bleeding tissue can take place in the clinic, however, in the presence of a reduced blood supply and intact feeling then debridement needs to be carried out with caution The vascular supply to the foot should always be assessed prior to carrying out debridement Ischaemic foot ulcers with dry eschar need not be debrided if they are stable/unchanging, however they will need to be checked on a regular basis for signs of deterioration/infection Sharp debridement using a scalpel is the usual method of debridement for diabetic foot ulcers. It can only be carried out by a trained health professional Surgical debridement is indicated if there is extensive tissue damage and the presence of an abscess or gas in the tissues. Widespread bone infection may also require surgical debridement or resection. This is usually carried out during an in-patient stay in combination with a course of intravenous antibiotics Autolytic debridement involves using dressings that maintain moisture within the wound bed supporting the body s own ability to cleanse itself. The action of enzymes present in wound fluids will break down necrotic tissue. These dressings have a limited role in the treatment of diabetic foot ulcers and should be used with caution Biological debridement. Increasingly maggots are being used as a safe method of debriding diabetic foot ulcers. The maggots are applied to the wound, covered with a moist layer of Diabetic Foot Complications: Clinical Practice Guidelines for the Page 9 of 19

10 gauze and left in place for 3 to 4 days. Enzymes produced by the maggot s saliva breakdown slough and necrotic tissue, which is then ingested by the maggot. The ordering and application of maggots should be carried out by a trained health professional specialising in wound management, via the tissue viability service The wound should be probed if indicated. The purpose of probing is to gauge the depth of the wound and feel for underlying structures such as tendon, joint capsule and bone. Probing should be carried out carefully so as to prevent further tissue damage The wound should be assessed for the presence of infection and graded as mild, moderate or severe. If infection is suspected a deep wound swab should be taken after first debriding and cleansing the wound. (See Section 11) The vascular status of the limb should be assessed. (See section 13) The wound should be photographed and measured with the patients consent. Wounds should be measured in millimetres and the wound bed described e.g. necrotic, sloughy, granulating etc. along with the estimated percentage of each type of tissue The wound should be dressed with a suitable sterile dressing using an aseptic technique. There is very little evidence to support any particular type of dressing in the management of diabetic foot ulcers. Due to the chronic nature of diabetic foot ulcers and the predisposition to picking up infection it is advised that diabetic foot ulcers should be covered with a clean, sterile dressing at all times. This should be kept dry and only removed when the wound is to be inspected or debrided As diabetic foot wounds can deteriorate rapidly, regular monitoring is essential and in most cases wound dressings will need to be changed at least weekly and according to exudate levels A diabetic foot ulcer needs to be dressed with a dressing that: Can be removed easily and comfortably for the patient Is able to accommodate the pressures of walking and be enclosed in a shoe/off- loading device without disintegrating Is absorbent at a level appropriate to the amount of exudate being produced by the wound The clinician should be guided by the following points: The position of the wound The level of exudate The blood supply to the foot The presence of infection If possible the clinician should be guided by the wound management chapter in the South Devon Joint Formulary. If the clinician wishes to use a dressing not included in the formulary or one that is for specialist care only, this should be discussed with the tissue viability service and the rationale for the dressing choice must be clearly documented in the notes The wound should be off loaded to relieve weight bearing pressure from the wound. Diabetic Foot Complications: Clinical Practice Guidelines for the Page 10 of 19

11 In its simplest form this may be a case of simply advising the patient to change their footwear, however, in most cases some form of temporary shoe or cast will be required These can be either an off the shelf product or an individually made cast. When considering off-loading devices, the following should be taken into consideration: The mobility of the patient. A cast or wedged shoe is a falls risk and should only be issued to patients with good mobility. A stick may be helpful. Does the patient drive? If the patient is unwilling to give up or cut back on driving this will limit the off-loading options available. If using a cast, will it be removable or non-removable? The patient cannot drive in a nonremovable device and will need to be advised appropriately The following are examples of the most commonly used off-loading devices in our clinics: Benefoot post-op shoes These come in a range of sizes. The sole of the shoe is rigid and has a rocker giving some pressure relief. These are very useful for accommodating bulky dressings and are useful for patients with poor mobility who would not be able to cope with a wedge shoe or bulky cast Darko wedge These are very effective for off-loading the forefoot. The patient will need to have good mobility and a full range of motion at the ankle Scotch Cast Boot A custom made slipper cast. Very safe and comfortable. Can be made either removable or non-removable. The cast is usually made by a trained podiatrist or fracture technician. Diabetic Foot Complications: Clinical Practice Guidelines for the Page 11 of 19

12 10.26 Air Cast Boot - This is an off the shelf casting device, very useful for long term use e.g. Charcot Total Contact Cast A non-removable cast applied in the fracture clinic. It is used for the treatment of acute Charcot arthropathy and to off load foot ulcers where other attempts at offloading have not been successful. The cast is changed on a weekly basis A short term and long term treatment plan should be agreed with the patient Treatment of Infection 11.1 Foot infections are a common and serious problem in diabetic foot ulcers. Most diabetic foot ulcers are polymicrobial, with aerobic gram-positive cocci (staphylococci), being the most common causative organism. Aerobic gram-negative bacilli (pseudomonas) are frequently copathogens in infections that are chronic or follow antibiotic treatment. Anaerobes are often copathogens in ischaemic or necrotic wounds Infections should be classified as: Mild - local infection involving only the skin and subcutaneous tissues without involvement of deeper tissues or systemic signs. If erythema, must be >0.5cm to <2cm around ulcer. Moderate - local infection with erythema > 2cm or involving structures deeper than skin and subcutaneous tissues (e.g. abscess, osteomyelitis, septic arthritis, fasciitis) and no systemic inflammatory response. Severe - local infection with signs of SIRS,(systemic inflammatory response signs) i.e. at least 2 of temperature >38 or<36, HR >90bpm, RR >20 breaths/min, WCC >12000 or <4000 ( accompanied by systemic signs). Diabetic Foot Complications: Clinical Practice Guidelines for the Page 12 of 19

13 11.3 For infected wounds a deep wound swab or tissue sample should be taken after the wound has been debrided and cleansed For acutely infected wounds, extending to soft tissues only, a 2 week course of empiric antibiotics is recommended as per local guidelines Patients with chronic ulcers previously treated with antibiotics or severe infections usually require broader spectrum antibiotics for a longer time and treatment should be guided by a Consultant Microbiologist (Telephone ) Patients requiring antibiotics for longer than 2 weeks should have a fortnightly blood test to monitor liver and kidney function Patients requiring antibiotics should be encouraged to take a daily live yoghurt supplement in addition to their antibiotics For further details please refer to the full guideline on the management of diabetic foot infection Ref: (Date last accessed ) 12.0 Treatment of Osteomyelitis 12.1 Osteomyelitis is a frequent complication of diabetic foot ulceration and is usually diagnosed by a combination of routine clinical tests, clinical presentation and the palpation of bone at the base of the wound Treatment is usually either surgical management involving minor amputation or resection of bone, medical management with long term antibiotics or a combination of both Patients with osteomyelitis should be followed up regularly in the multidisciplinary diabetic foot clinic Assessment of Peripheral Arterial Disease 13.1 People with diabetes are at an increased risk of developing Peripheral Arterial Disease (PAD) Fatty plaques build up on the artery walls causing narrowings and blockages, reducing the blood supply to the feet In people with diabetes, PAD tends to involve the blood vessels below the knee, resulting in poor oxygen delivery to the tissues of the foot (ischaemia). This will contribute to skin ulceration, poor wound healing and the development of gangrene Foot ulceration and gangrene can also be described as wet and dry tissue loss, where wet tissue loss indicates the presence of infection Diabetes and smoking are the strongest risk factors for PAD. Other factors are hypertension, hyperlipidemia and advanced age Diagnosis is usually confirmed by the patient history, assessment of the limbs, the use of Doppler ultrasound to listen to the blood supply and measurement of the ankle/brachial pressure index. Diabetic Foot Complications: Clinical Practice Guidelines for the Page 13 of 19

14 13.6 History - depending on disease severity, individuals with PAD present with a spectrum of symptoms ranging from no pain, intermittent claudication (leg muscle pain or fatigue on walking), rest pain/ nocturnal pain in the leg or foot, to non healing foot ulcers and gangrene Physical examination decreased or absent arterial pulses in the distal leg and foot, and signs of chronic vascular insufficiency (cool, dry skin; absence of hair growth; dystrophic nails; dependent rubor/pallor on elevation of the foot) Diagnostic Testing. A hand held Doppler Ultrasound should be used to listen to the quality of the blood supply. The signal should be described as either, no signal, monophasic, biphasic or tri-phasic. The signal may also be described as strong or weak The presence of PAD can be confirmed by measuring the ankle/brachial pressure index A lower blood pressure in the ankle, resulting in an ABPI of <0.9 is indicative of PAD. Severe arterial obstruction usually has an ABPI < However, the ABPI is less reliable in confirming the diagnosis of PAD in some individuals with diabetes and in the elderly, who tend to have calcified, poorly compressible blood vessels, resulting in ABPI values being inaccurate and often elevated at > In an individual with confirmed PAD and diabetes foot ulceration, further tests to assess the location and severity of arterial occlusion may be performed. The patient will need to be referred to the vascular team or alternatively the band 6 and band 7 diabetes specialist podiatrist can request duplex scanning as long as a follow up is arranged in the vascular mulitidisciplinary diabetic foot clinic Management of PAD 14.1 The presence of PAD in a person with diabetes indicates high risk for other cardiovascular disease (CVD), including coronary artery disease and stroke. Therefore, medical management of PAD includes all the measures routinely recommended for CVD risk reduction, as follows: Smoking cessation Optimal glycaemic control Treatment of hypertension Use of an anti-platelet agent (e.g. Aspirin) Use of lipid-lowering drugs (e.g. Statins) Exercise. Weight management and healthy eating 14.2 All individuals with diabetes and PAD should receive regular foot care to minimize the risk of developing foot ulceration and amputation. The podiatrist should liaise with the G.P. regarding the optimisation of medicines to manage cardiovascular disease Individuals with severe PAD or symptoms suggestive of critical limb ischemia (nocturnal or rest pain in foot, progressive or non-healing ulceration, or gangrene) require urgent referral to a Vascular department. Diabetic Foot Complications: Clinical Practice Guidelines for the Page 14 of 19

15 14.4 Referring to the Vascular Team Referrals to the Vascular Department can be ed to the generic address (which is manned Monday Friday): Please include the following information: Name Address Date of birth NHS number Any previous medical history including vascular assessment Medication Main vascular complaint. Non urgent vascular referrals should be made via the multidisciplinary diabetic foot team at Torbay Hospital Management of the Healed Foot 15.1 The patient should be classified as being at High Risk and be informed of their high risk status and issued with the appropriate leaflet The patient needs to be aware of the vulnerability of their foot and the need to: Attend the podiatry clinic every 1 to 3 months Inspect their feet every day to search for the warning signs of impending foot ulceration Wear sensible, fitted footwear Who to contact in an emergency Diabetic Foot Complications: Clinical Practice Guidelines for the Page 15 of 19

16 MANAGEMENT OF DIABETIC FOOT COMPLICATIONS OTHER THAN ULCERATION 16.0 Painful Neuropathy 16.1 Aetiology Diabetic Polyneuropathy, (DPN) is a chronic sensory and motor neuropathy involving the distal extremities, usually commonly the lower limbs. It is the most common type of nerve damage seen in people with diabetes. DPN is associated with the following risk factors: duration of diabetes, poor glycaemic control, high blood pressure, and hyperlipidemia Patients with DPN may experience symptoms such as neuropathic pain (burning, stabbing or aching pain, paraesthesias, hyperasthesias) or numb feet. Neuropathic pain tends to be worse at night Diagnosis It is very important to rule out other causes of pain such as ischaemia or sciatica Management Includes: Reassurance It is important to reassure the patient that the pain is not a sinister sign and does not necessarily indicate a chronic foot problem. It is not associated with an increased risk of amputation. Stable and optimal blood glucose control observational studies suggest that neuropathic symptoms improve with less fluctuation in blood glucose levels. Pharmacologic therapy for neuropathic pain Various medicines can be used to treat neuropathic pain. Please see NICE guidance for treatment recommendation Patients with severe neuropathic pain that does not respond to the usual measures may be referred by the G.P. or diabetes consultant to a specialised pain clinic Deformities in the Diabetic Foot 17.1 Aetiology Distal muscle atrophy is commonly associated with loss of motor nerve function. The outcome of weakening intrinsic foot muscles is overall muscle imbalance, which produces changes in foot structure and gait. The resulting deformity and limited range of motion contribute to increased mechanical stress (compression and shear forces) on corresponding areas of the foot. The common foot deformities described below may also arise because of a non-diabetic related cause, however, they will still put the foot at the same increased risk of ulceration Common Foot Deformities Claw toes A flexible deformity with extension contracture at the metatarsophalangeal joint and flexion contracture at the proximal interphalangeal joint. Diabetic Foot Complications: Clinical Practice Guidelines for the Page 16 of 19

17 Hammer toes - A fixed deformity that involves extension contracture of the metatarsophalangeal joint and flexion contracture of the interphalangeal joint. Hallux rigidus - Complete loss of dorsiflexion at the first metatarsophalangeal joint. Hallux Limitus - Partial loss of dorsiflexion at the first metatarsophalangeal joint. Hallux Abducto Valgus Commonly known as a bunion joint Any foot deformity has the potential to increase localised tissue pressures and can be the underlying cause of tissue breakdown. The presence of deformity in the foot will alter normal weight bearing and cause the development of high pressure points which in the presence of a loss of feeling or a poor blood supply will increase the patient s risk of developing a foot ulcer Management All patients with diabetes at risk of developing foot ulceration should be attending the podiatry department on a regular basis. As part of routine care the patient should be screened for any biomechanical condition that could predispose to the development of forefoot deformities. Treatments for such conditions usually involve the manufacture of an orthotic to be worn in sensible footwear. A sensible shoe is one that has a secure fastening around the mid foot, a firm heel counter, a deep, wide, rounded toe box and cushioned sole Once deformities have developed treatment usually is with accommodative orthotics and footwear. More aggressive management would involve orthopaedic surgery, which should comprise of joint fixation, arthroplasty or digital amputation. The goal of any treatment plan is to reduce the mechanical stress at the problematic area, thus reducing risk of skin ulceration The podiatrist can refer directly to the orthopaedic team or alternatively the patient can be seen in a multidisciplinary diabetic foot clinic by the orthopaedic consultant Charcot Foot (Neuropathic Osteoarthropathy, Diabetic Neuroarthropathy) 18.1 Definition Charcot Foot is a progressive condition characterised by joint dislocation, pathological fractures and severe destruction of pedal architecture. This may result in debilitating deformity or amputation. The condition is associated with peripheral neuropathy and the most common aetiology is diabetes mellitus. Eichenholz s classification divides the Charcot foot into developmental, coalescent and reconstructive stages Aetiology The aetiology of Charcot foot most likely is a combination of both the neuro-vascular and neuro-traumatic theories. It is generally accepted that trauma, superimposed on a neuropathic extremity, can precipitate the development of an acute Charcot foot. With the development of autonomic neuropathy, there is an increased blood flow to the foot, resulting in osteopenia and a relative weakness of the bone. The presence of sensory neuropathy renders the patient unaware of the precipitating trauma and often profound bone destruction that occurs during ambulation. A vicious cycle ensues, whereby the patient continues to walk on the injured foot, thereby allowing further bone and joint damage to occur. Diabetic Foot Complications: Clinical Practice Guidelines for the Page 17 of 19

18 18.3 Diagnosis of Acute Charcot Arthropathy a) Clinical Examination The following characteristics, in the presence of intact skin, are often diagnostic of acute Charcot Arthropathy: Profound unilateral swelling Increased skin temperature. Usually more than 2 warmer than the other foot. Erythema Joint effusion Fragmentation and new bone formation seen on x-ray Pain in a usually numb foot 18.4 Differential Diagnosis Charcot Arthropathy can often be mistaken for the following: Gout Infection DVT Inflammatory arthritis Soft tissue injury 18.5 b) Investigation X-Rays - Plain radiographs are invaluable in ascertaining the presence of Charcot arthropathy. In most cases, no further imaging studies will be required to make a correct diagnosis. However, with a concomitant wound, it may be difficult to differentiate between acute Charcot arthropathy and osteomyelitis based solely on plain radiographs. Laboratory and other imaging studies may be required, including: white blood cell count (WBC); a bone biopsy; nuclear medicine scans; Magnetic Resonance Imaging (MRI) Management of Acute Charcot Arthropathy Immobilisation and reduction of stress are the mainstays of treatment for acute Charcot Arthropathy. Usually the affected limb will be offloaded with a combination of non-removable and removable casts. The length of time for off-loading will vary depending on the severity of the deformity and may take from 6 months to 2 years to resolve. However, the off-loading is weight bearing, so the patient will be able to mobilise in a limited way Once the skin temperatures have returned to normal and any deformity in the foot is stable, the patient may slowly introduce footwear. Often prescription footwear and custom moulded insoles will be required. Diabetic Foot Complications: Clinical Practice Guidelines for the Page 18 of 19

19 18.8 Reconstructive surgery may be considered if a deformity or instability exists that cannot effectively be controlled or accommodated by prescription footwear or bracing. If the arthropathy is identified in its early stages and non-weight bearing is instituted, surgery is usually unnecessary 19.0 Major Amputation Unfortunately, despite best efforts, and in some cases to save a life it becomes necessary to amputate the leg, usually below the knee but occasionally above the knee and in some very rare cases through the hind quarter A root cause analysis (RCA) is carried out when a diabetic patient undergoes a major amputation. This is used to identify what the key causes of the amputation were and to identify if anything could have been done differently that would have prevented the amputation. Any learning is shared with all parties involved and an action plan agreed to improve practice. Appendices Appendix 1: The Multidisciplinary Foot Care Team. 20 Appendix 2: Torbay and South Devon NHS Foundation Trust: Guidance for Undertaking a Diabetic Foot Screen 21 Appendix 3: Podiatry referral Pathway Algorithm Appendix 4: Torbay Diabetic Foot Protection Programme, Standard Operating Procedure Including The Ipswich Touch Toe Test 24 Appendix 5: Touch Toe Test Screening tool 28 Appendix 6: Foot Ulcer care Pathway 28 Appendix 7: Patient Information leaflet Charcot 31 Appendix 8: References.33 Document Control Information 34 Mental Capacity Act and Infection Control Statement 35 Quality Impact Assessment (QIA) 36 Rapid Equality Impact Assessment 37 Diabetic Foot Complications: Clinical Practice Guidelines for the Page 19 of 19

20 Appendix 1 The Multidisciplinary Diabetic Foot Care Team Diabetic foot ulceration cannot be managed by any one single health professional. It has to be a multidisciplinary approach. The core team consists of: Consultant Endocrinologist/Diabetologist tel: Lead Diabetes Podiatrist tel: Consultant Vascular Surgeon tel: Consultant Vascular Surgeon tel: Consultant Orthopaedic Surgeon tel: Orthotist tel: In addition to the above team several other health professionals will be called on if required to help with individual cases: Diabetes Specialist Nurse Diabetes Specialist Dietician Consultant Microbiologist Tissue Viability Psychology Plastic Surgery Fracture clinic/plaster room The Multi-Disciplinary Diabetic Foot Care Team Page 1 of 1

21 Risk factors Clinical Guidance for undertaking Diabetic Foot Checks Assessing Risk of Developing Foot Complications Preventing foot complications begins with identifying those at risk. The risk of foot ulceration and amputation is increased in patients with the following four risk factors: Previous Foot Ulceration or Previous Amputation Peripheral Neuropathy Appendix 2 Peripheral neuropathy can be easily identified using ordinary bedside clinical tools. The best evidence for identifying the risk of neuropathic ulceration supports use of the 10g monofilament. Peripheral Arterial Disease The best clinical guide to ascertain the presence of peripheral arterial disease is palpation of foot pulses, which has been shown to predict foot ulceration and amputation. Although claudication can be a useful symptom, peripheral arterial disease is commonly asymptomatic in people with diabetes. The ankle-brachial pressure index (ABPI or ABI), using Doppler ultrasound is a useful adjunct to assess foot perfusion. The results of this investigation can be falsely elevated in the presence of arterial calcification in people with diabetes. Foot Deformity This includes, but is not limited, to such conditions as: hallux deformity, hammer/claw toe, callus, previous amputation, excessively flat or high arched feet, abnormally wide feet and Charcot s neuroarthropathy. There is also evidence to suggest that the following factors increase risk of foot complications: Visual impairment Kidney disease Poor glycaemic control Ill-fitting footwear Socio-economic disadvantage Whilst the presence of peripheral neuropathy is the leading risk factor for foot ulceration, a pivotal event, such as trauma from footwear, is also needed for most ulcers to occur. How to Identify Those at Risk of Foot Complications Step 1 Remove any dressings or bandages from the feet. Thoroughly inspect each foot, remembering to look in-between the toes and at the back of the heel. Search for: Any active ulcers or open wounds Sinister blisters containing blood or pus Callus Callus with bleeding Deformity Clinical Guidance for undertaking Diabetic Foot Checks Page 1 of 3

22 Step 2 Search for neuropathy: Using a 10g monofilament, test the five sites on both feet. If the patient is unable to feel one or more of the ten sites tested, they should be classed as having neuropathy. Neuropathy Yeso No o Step 3 Check the blood supply can you feel the foot pulses? Right foot Left foot Dorsalis pedis (hand) Palpable/non-palpable Palpable/non-palpable Dorsalis pedis (doppler) Triphasic/biphasic/monophasic Triphasic/biphasic/monophasic Posterior tibial (hand) Palpable/non-palpable Palpable/non-palpable Posterior tibial (doppler) Triphasic/biphasic/monophasic Triphasic/biphasic/monophasic If pulses not palpable or are monophasic classify as having peripheral arterial disease Step 4 Classify the foot At low risk of ulceration (normal sensation, palpable pulses) At increased risk of ulceration (neuropathy or absent pulses or other risk factor) At high risk of ulceration (neuropathy or absent pulses + deformity or skin changes or previous ulcer) Ulcerated o o o o Self-monitoring and inspection of feet by people with diabetes should be encouraged. Clinical Guidance for undertaking Diabetic Foot Checks Page 2 of 3

23 Step 5 Inform the patient of their risk level and issue with a diabetic foot care leaflet. Referral to podiatry department if patient is: At increased risk of ulceration At high risk of ulceration Ulcerated Clinical Guidance for undertaking Diabetic Foot Checks Page 3 of 3

24 Appendix 3 Linked to Clinical Records Library: Department of Orthotics and Podiatry Foot Ulcer Pathway nd%20podiatry%20foot%20ulcer%20carepathway.pdf (Date last accessed ) Department of Orhotics and Podiatry Foot Ulcer Pathway Page 1 of 1

25 Standard Operating Procedure Title: Torbay Foot Protection Programme for Community Nursing teams Prepared by: Presented to: Date: May 2017 Lead Diabetes Podiatrist 1. Purpose of this document Appendix 4 To ensure that all patients with diabetes who are housebound living at home or in residential/nursing accommodation have at least an annual diabetic foot check as recommended by NICE guideline CG10. Diabetic foot screening traditionally has fallen under the remit of practice nurses in GP practices, however, with the increase in numbers of patients with diabetes who are unable to attend the GP practice, foot screening is now being undertaken by community nursing teams. 2. Scope of this SOP This procedure will apply to all registered and unregistered nursing staff 3. Instructions 3.1 The foot inspection should take place on at least an annual basis but for patients known to be at high risk it is recommended that it be done more frequently. Any wound dressings should be removed from both feet and the feet thoroughly inspected. This should include between the toes and the back of the heel. A search should be made for any active ulcers, the warning signs of ulceration, and signs of heel pressure damage, deformity and callus. 3.2 The presence of the following will automatically classify the patient as being at high risk of developing foot ulcers. If not already known to the podiatry team, the patient should be referred immediately and a plan put in place for the foot to be inspected on a regular basis and any problems reported immediately. Previous ulcer Previous amputation 3.3 Carry out The Ipswich Touch Toe Test: Ask the patient to close their eyes and keep them closed until the end of the test. Inform the patient that you are going to touch their toes and ask them to say yes, as soon as they feel the touch. 3.4 Perform the touch using your index finger: The touch must be as light as a feather, and brief (1-2 seconds).do not press, prod, poke or tap the skin. If the person did not respond do not attempt to get a reaction by pressing harder. Record as not felt. You must not touch each toe more than once. Do not repeat. There is no 2 nd chance Torbay Foot Programme for Community Nursing Teams Page 1 of 3

26 3.5 The toes should be touched in the following sequence: R L 3.6 Record the result by writing Y or N on the record sheet. (Appendix1) 3.7 If 2 or more sites are not felt, the patient should be classed as having neuropathy. 3.8 Vascular inspection: With the back of your hand, compare the temperature of both feet. Record if one foot feels warmer or colder than the other. Observe if there is the presence of hair on the toes and legs Observe the quality of the skin and nails 3.9 Feel the foot pulses: Palpate the dorsalis pedis and tibialis posterior pulses on both feet and record if felt or not. Use the hand held Doppler to listen to the signals and record if they are biphasic or monophasic 4.0 If the patient has non palpable foot pulses and monophasic Doppler signals the patient should be classed as having poor circulation. 4.1 Results: Low Risk No neuropathy, no poor circulation Increased Risk The presence of neuropathy and/or poor circulation but without any deformity or callus High Risk The presence of neuropathy and/or callus and the presence of deformity and callus. History of previous ulceration or neuropathy. Ulcerated Foot Active foot ulceration or warning sign of foot ulceration. 4.2 Onward referral: Low risk Arrange for at least an annual foot screen Increased Risk Refer to podiatry and agree a plan with the patient, relatives and carers for the feet to be inspected on a regular basis and any problems reported immediately. High Risk As increased risk. Ulcerated Foot Urgent referral to podiatry within 24 hours. Torbay Foot Programme for Community Nursing Teams Page 2 of 3