Diabetic foot Ulcer Dressings Guidance and Referral Advice

Transcription

1 Diabetic foot Ulcer Dressings Guidance and Referral Advice Approved By: Professional Advisory Forum Date: October 2002 Review Date: October 2003 Originator: Diabetic Foot Ulcer Working Group

2 Diabetic foot Ulcer Dressings Guidance and Referral Advice 1 Aim 1.1 The aim of this advice is to produce a coordinated approach across Leicestershire to the Management of diabetic foot ulcers. 2. Introduction 2.1 Over a million people in the united kingdom have diabetes of which the majority have Type 2 (non insulin dependent) diabetes % of people with diabetes develop foot ulcers associated with nerve damage (neuropathy), lack of blood supply (ischaemia) or both Serious infection originating in a diabetic ulcer is the most common reason for amputation apart from trauma. 2.4 It has been demonstrated that the most effective method of treating foot ulcer problems is within the multi disciplinary setting. Interventions, such as education to increase patients knowledge about foot care, podiatry and therapeutic shoes, can improve the condition of the feet and help to reduce ulcer and amputation rates. 3. Wound Dressings 3.1 A variety of dressings intended to promote healing have been compared in small randomised controlled trials. None yielded evidence of superiority for any particular type of dressing In view of the above and complications reported in Leicestershire with use of a number of dressing products, the following guidelines have been drawn up by a multi professional group (see membership) in order to promote a cost-effective and coordinated approach to the dressing of diabetic foot ulcers. Ref: 1. The University of York Effective Health Care Complications of Diabetes August , Boulton A, Connor H, Cavanagh P. The Foot in Diabetes Chichester Wiley 1995

3 4. Diabetic Foot Ulcer Information 4.1 The following information is intended to assist practitioners in caring for and managing diabetic foot ulcer patients. 4.2 This includes information on examination of the feet, referral and contact information of the acute hospital facilities for diabetic care. 4.3 List of membership of the Diabetic Foot Ulcer Working Group.

4 DRESSINGS FOR DIABETIC FOOT ULCERS WOUND TREATMENT ATTRIBUTES RATIONALE Necrotic/Sloughy Mechanical debridement of ulcer by podiatrist. Use simple non adherent dressing Decrease risk of infection. Gangrenous Dry: low/non adherent dressing e.g Release, Melolin To prevent formation of wet gangrene. Infected Wound Depth - Flat Low exudate High exudate Wound Depth-Cavity Without Sinus With Sinus Low/non adherent dressing with daily dressing changes Inadine, Iodoflex or Iodosorb dressings. Daily flamazine dressings. Low/non adherent Dressing e.g. Release, Melolin Foam Dressing e.g. Biatain, Lyofoam Low/non adherent dressing e.g. IntraSite conformable or Sorbsan ribbon (do not use alginate on the plantar surface of the foot) covered with a low/non adherent dressing e.g. Release, Melolin IntraSite conformable wound packing covered with a low/non adherent dressing as above. Regular dressing changes to monitor for deterioration of the ulcer. To reduce bacterial colonisation. For the treatment of Pseudomonas infection To absorb exudate and prevent maceration. To absorb exudate and promote healing. To ensure effective removal of the dressing. To ensure effective removal of the dressing Malodorous/Infected Charcoal Dressing e.g. Actisorb Silver 220 To reduce odour and bacterial contamination

5 1. Dressings should be changed frequently to check for any deterioration in the wound Bulky dressings should be avoided so as pressure is not exerted to the foot inside a shoe or plaster boot. 3. Routine irrigation with 0.9% normal saline is not advocated 4. Wounds should only be irrigated to remove debris or dressing products. Surrounding skin should be dried thoroughly prior to redressing. References 3 Miller M, Glover N (1999) Wound Management Theory and Practice. NT books, London 4 Dealey C (1994) The care of wounds. Blackwell Scientific, London.

6 DIABETIC FOOT ULCER INFORMATION. 1. Regular Examination of Feet to Identify High Risk Feet And Active Problems Patients should be encouraged to examine their own feet on a regular basis and not walk barefoot at any time. Health care professions should perform a foot history and examination as part of each diabetic patient s annual review. Feet should be deemed high risk if there is evidence of diabetic peripheral neuropathy and/or peripheral vascular disease. 2. Referral to a State Registered Podiatrist in the Community - The presence of corns, calluses and nail dystrophy can lead to more severe foot problems, and such problems can be managed by a State Registered Podiatrist in the community. Close liaison should be maintained between podiatrists in the community and those based at the Diabetic Foot Clinics. Patients with active foot ulcers should be urgently referred to the hospital-based Diabetic Foot Clinics. 3. Referral to the Diabetes Out-patient Clinic If symptomatic or asymptomatic diabetic neuropathy is detected, referral should be made to the hospital Diabetes Out-patient Clinics and/or podiatrist via the General Practitioner. If neuroischaemic feet are identified, referral should be made to the hospital Diabetes Out-patient Clinics. Patients with intermittent claudication or rest pain should be referred to both the Vascular Surgery and Diabetic Out-patient Clinics. 4. Referral to the Diabetic Foot Clinic Diabetic foot ulcers can deteriorate rapidly, and should be referred immediately to the Diabetic Foot Clinics via the General Practitioner. Referrals can be made either directly to the Diabetic Foot Clinics or via the Diabetic Specialist Registrars. Referrals, dependent on the urgency, should be seen within 24 hours, with the referral letter being faxed or accompanying the patient. The Diabetic Foot Clinics are happy to accept direct referrals if the General Practitioner is in agreement. 5. Referral for Diabetic In-Patient Management Severely infected or ischaemic foot problems warrant in-patient management with either intravenous antibiotics and/or vascular investigation and intervention. Referral (usually via the General Practitioner) should be made directly to the Diabetic Specialist Registrar, and admission will be arranged within 24 hours. District admission to the Diabetic Ward will usually be arranged, although MRSA positive patients always require a side ward.

7 CONTACT NUMBERS FOR DIABETIC FOOT REFERRAL a) The Leicester Royal Infirmary (0116) The Diabetic Foot Clinic is held every Thursday morning (8.30am pm). being located in the Knighton Street Out-patient Clinic. However, Diabetes Out-patient Clinics occur every weekday, and patients with urgent foot problems will be seen at these clinics. Diabetic Foot Clinic, Thursday morning: LRI ext 5967 Diabetic Specialist Registrars: Bleep via LRI switchboard Carolyn Lowe (DSN): LRI ext 5158 Secretary to Dr Paul McNally: (0116) Secretary to DR Melanie Davies: (0116) Secretary to DR Ian Lawrence: (0116) Ward 32 (in-patient): (0116) b) Leicester General Hospital (0116) The Diabetic Foot Clinic is held every Thursday afternoon (1.30pm pm), being located in the Day Care Unit. However, urgent referrals will be seen in the Plaster Room on weekday mornings. Plaster Room Weekday mornings: LGH ext 4406 Diabetic Specialist Registrars: Bleep via LGH switchboard Secretary to Dr Robert Gregory: (0116) Ward 3 (in-patient): (0116) VASCULAR SURGERY REFERRAL The Leicester Royal Infirmary: LRI ext 6136 Leicester General Hospital: LGH ext 8164 (Mr Martin Dennis) LGH ext 4378 (Mr Rob Sayers)