Appendix 1 Guide to foot screening 15 2 Crtical limb ischeamia 18 3 Community emergency clinic contact details 20

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1 Foot Complications in People with Diabetes Prevention and Management of Classification: Clinical Guideline Lead Author: Dr Paul J Chadwick Additional author(s): Dr Adam Robinson Authors Division: CSS&TM Unique ID: TWCG29(14) Issue number: 2.1 Expiry Date: October 2018 Contents Section Page Intro Who should read this document 2 Key practice points 2 Background 3 Guideline 5 Low risk of foot ulceration 5 Foot Protection service 5 Foot Ulceration 5 Peripheral Arterial Disease 8 Charcot Foot 10 Painful Neuropathy 12 Standards 12 References and Supporting Documents 13 Roles and Responsibilities 14 Appendix 1 Guide to foot screening 15 2 Crtical limb ischeamia 18 3 Community emergency clinic contact details 20 Document control information (Published as separate document) Document Control 21 Policy Implementation Plan 21 Monitoring and Review 21 Endorsement 22 Equality analysis 23 Page 1 of 20

2 Who should read this document? This document is aimed at all staff managing patients. Key Practice Points A. All people in Salford who are not at increased risk of active foot disease e.g neuropathy or peripheral arterial disease, foot deformity or previous foot disease should have an annual foot screen in primary care (see appendix 1) B. Any person who is identified as having an increased risk of developing diabetic foot disease should be offered acces to the foot protection service. C. If a person has a limb-threatening or life-threatening diabetic foot problem, refer them immediately to acute services and inform the multidisciplinary foot care service, so they can be assessed and an individualised treatment plan put in place. Patients who attend Salford Royal NHS Foundation Trust Emergency department will be booked into the podiatry department the next working day. If the patient has critical limb ischaemia they should be referred to the Vascular team at Central Manchester Foundation Trust as per PAD pathway. Examples of limb-threatening and life-threatening diabetic foot problems include the following: o Ulceration with fever or any signs of sepsis. o Ulceration with limb ischaemia o Clinical concern that there is a deep-seated soft tissue or bone infection (with or without ulceration) o Gangrene (with or without ulceration). o unexplained hot, red, swollen foot with or without pain o Ischaemic rest pain D -All other active diabetic foot problems, refer the person within 1 working day to the multidisciplinary foot care service or foot protection service for triage within 1 further working day on (NICE 2015) For domicillary patients contact or fax E- All diabetic patients who attend the Emergency Department with a foot problem even if this does not meet the criteria for a life or limb threatening condition must be referred to the podiatry clinic within 1 working day Page 2 of 20

3 Emergency access to foot services Salford Royal NHS Foundation Trust runs an emergency foot clinic (Appendix 3) each working day (Monday to Friday) in the community see Appendix 3 for contact details. If in doubt about a proposed course of action ring (9-5 Monday to Friday) for advice about what action to take. Out of office and public holidays if the problem is felt to be limb or life threatening attend the Emergency Department at Salford Royal NHS Foundation Trust unless the crisis is felt to be ischaemic in origin i.e critical limb ischaemia then they should attends Emergency Department at Central Manchester Foundation Trust. Background Around 6,000 people undergo leg, foot or toe amputation each year in England. Many of these amputations are avoidable. The risk of lower extremity amputation for people is more than 20 times that of people without diabetes. Around 61,000 people are thought to have foot ulcers at any given time, approximately 2.5% of the diabetes population. Ulceration and amputation substantially reduce quality of life, and are associated with high mortality. Studies suggest that only 50% of patients who have had an amputation survive for a further two years. Even without amputation, the prognosis is poor. Only just over half of people who have had ulcers survive for five years, a much worse prognosis than for many cancers. In , the NHS in England spent an estimated 639 million 662 million, % of its budget, on diabetic foot ulceration and amputation Kerr (2012) There has recently been a raft of new National guidance to address disparity in care across England and this has culminated in the Putting Feet First Document (Diabetes UK 2012). The guidelines that follow, reflect Putting Feet First (2012) in the context of the foot care services of Salford.For clarity within Salford the whole Podiatry team is part of Multidisciplinary Footcare Team (MDFT). This is an integrated team across primary and secondary care. Further, the foot protection service (FPS) is a service which is provided in the community care setting. (see Diagram 1) Pressure combines with peripheral neuropathy and/or peripheral vascular disease to cause ulcers. Redistribution of this pressure, away from the ulcer site, or relief of the pressure over the ulcer site are an important part of care. Pressure should be assessed at initial presentation of the ulcer, and appropriate care given or initiated. Pressure should also be re-assessed throughout the period of ulceration, especially if the ulcer deteriorates or fails to progress. Page 3 of 20

4 Multidisciplinary Foot Clinic (C+D above) - Multidisciplinary Team (D Above) - Hospital Clinic - Community Clinic - Ward Visit -Domicilliary Visits Foot Protection Service (B above) Foot Screening ( A Above) Diagram 1 Page 4 of 20

5 Guideline The management and prevention of foot complications in diabetes can be divided into five areas: 1) Management of people currently low risk for foot ulceration: All people in this category should have an annual foot screen carried out in primary care as per Salford Diabetes Foot Screening guidelines (appendix 1) All people identified at their screen as increased risk should be offered a referral to the Foot Protection Service(FPS), contact for details of local clinics. All people should be given a leaflet advising them of their risk status and how to access foot services urgently if they develop a problem. 2) Prevention of active disease of the Foot in those at increase risk Patients with increased risk should be advised of their risk and offered a referral to the Foot Protection Service (FPS). There Patients should have: - Regular podiatric review in-line with their clinical need. - Assessment of their footwear, foot function and appropriate referral for footwear and/or biomechanical intervention. - Education relevant and tailored to the individual and advice on how to access foot service urgently if they develop a problem. - Review of their cardiovascular and peripheral arterial disease risk and signposting to the appropriate service for example: community lower limb vascular assessment service ( ) smoking cessation; and best medical therapy. 3) Active Foot Disease: a) Ulceration, b) Perpiheral Arterial Disease, c) Charcot neuro arthropathypathy, d) Painful diabetic neuropathy (see below). 4) Treatment of a person s foot disease that is in remission. The person who has an episode of foot disease has a 40% chance of a second episode within 12 months. They should: a) Remain under close observation in the Foot Protection Service. b) Have intensive cardiovascular risk modification c) Have tailored education and reinforcement of key messages and key actions for the individual should there be a newly occurring problem. 5. All Patients admitted to Salford Royal NHS Foundation Trust hospital for any reason. All patients on admission to hospital should have their feet examined as part of their Waterlow assessment- see Feet First Policy. Page 5 of 20

6 a) Ulceration 1. Commence Salford Diabetic Foot Ulcer forms and a Patient Held Record (instructions on back of form) and complete National Diabetic Foot Ulcer form (NDFA). 2. Identify and remove any physical cause (e.g. tight footwear; hot water bottle; inappropriate self treatment). 3. Assess for infection refer to Management of diabetic foot infection gudeline Assess circulation. Any patient who has symptoms of critical limb ischemia should be referred to Vascular Team on call as per PAD pathway (below) 5. Refer to Multidisciplinary Foot Care Team (MDFT) within one working dayas per NICE (2015) guidelines If felt to be life or limb threatening e.g ulceration with fever or any signs of sepsis or ulceration with limb ischaemia refer urgently to acute services. 6. Consider referral to Community nurse as per combined care protocol. 7. Select dressing regime appropriate to state of ulcer (see wound care formularly). 8. Provide appropriate pressure relief and footwear (see below). 9. Inform patient / carer regarding care of ulcer: issue guide to foot ulcer leaflet (pod10). 10. Ascertain when patient last had diabetes annual review and most recent HbA1c, blood pressure, lipids (see Salford Integrated Care Record on EPR.) Consider liaising with others to optimise metabolic control (e.g. GP or Diabetes Specialist Nurse). 11. When ulcer healed, close-down ulcer form on EPR. Assess future podiatric needs and implement a plan to prevent further ulceration (e.g. increase frequency of review, consider biomechanical / footwear referral, education). 12. Review within one month of healing as a minimum, 13. If a person undergoes an amputation, they should be referred back to podiatry immediately post-operatively. PRESSURE REDISTRIBUTION GUIDELINES FOR DIABETIC FOOT ULCERATION The choice of pressure redistribution method will be dependent upon various factors including: o Vascular and neurological status of the patient. o Presence of infection. o Presence of oedema and the viability of the skin o Dressing choice. o Pain. o Foot function including biomechanical assessment. o Mobility of the patient. o Normal activities that the patient will be performing. o Quality of life. Page 6 of 20

7 Remember that rest is one of the most effective methods of relieving pressure. This includes removing footwear when at rest. It is important to negotiate, with the patient, what levels of activity will be pursued whilst there is an active ulceration. It is important to note: that transferring from chair to bed will create pressure on the foot, especially on the plantar aspect. when redistributing pressure, that excess pressure is not positioned over a vulnerable site. that removable padding is only a temporary first aid measure and should NEVER be placed directly onto the skin. It can be placed over a dressing or a bandage. that BK casts, both removable and non-removable, and slipper casts are not recommended for use in the presence of PAD. that bulky dressings might be necessary at some points of the ulcer episode, but they will not provide pressure relief as they flatten with pressure and do not have effective cushioning properties. Dressings can make it difficult to achieve an intimate relationship between the foot and the appropriate pressure redistribution device. that specialist therapeutic footwear can be considered during active ulceration in a small number of complex cases. The following is a guide to the range of measures that can be taken to redistribute or relieve pressure. The guidance is based on available evidence-based guidance and expert opinion. SITE Dorsal toes and subungual (beneath the nail) Dorsal foot Apical toes Interdigital (i.e. between the toes) FIRST AID AT INITIAL PRESENTATION cut a hole in slipper or footwear use sandal removable padding use sandal slippers use sandal removable padding foam dressing WALKING AIDS darby sandal or darco boot with padding (ideally including 7mm poron insole) crutches, walking frame, wheelchair SPECIALIST INTERVENTION otoform crescent remove nail otoform prop TCI/functional orthosis otoform wedge functional orthosis AT REST/ IN BED remove footwear bed cage Lateral or medial metatarsal heads cut a hole in slipper or footwear use sandal removable padding Softcast or slipper cast (FRC) pillow to raise foot off bed permalux bootee specialist Page 7 of 20

8 Lateral border of foot Medial border of foot and inner longitudinal arch mattress use sandal rocker-soled sandal (ideally with 7 mm poron insole) TCI/functional orthoses removable slipper cast with 3mm poron liner removable or nonremovable BK cast with TCI BK/short walker & TCI Plantar heel removable padding remove footwear Plantar forefoot forefoot offloader with 7mm poron liner or TCI Plantar hallux stiff-soled shoe with TCI REVIEW BY PODIATRY ORTHOTICS TEAM i. If pressure re-distribution initiated and no response in wound size over 4 weeks. Please ensure orthotics review (Hospital Band 7/8 Bio team). ii. If pressure re-distribution initiated and no response in red, hot swollen joint, foot or ankle in 2 weeks. Please ensure urgent review by Paul Chadwich, Jill Halstead-Rastrick or hospital Band 7 Bio team. REVIEW BY PODIATRY HIGH RISK TEAM i. Failure to improve within any two weeks of treatment (e.g. size, depth, infection, pain). ii. Diagnostic uncertainty. iii. iv. Non-urgent, ischaemic ulceration. Deteriorating claudication and/or rest pain (see Critical Limb Ischaemia pathway Appendix 2). v. New swelling or discolouration or pain or discharge. vi. Antibiotics required beyond initial two-week period. b) Peripheral Arterial Disease People with suspected peripheral arterial disease should be referred to the Vascular Triage team (enquiries on ) and see flow sheet below. People with suspected critical limb ischemia should be referred urgently to the MDT/Vascular Unit (see Critical Limb Ischaemia pathway Appendix 2). Page 8 of 20

9 Patient has a lower limb assessment by: GPs, Nurses or Allied Health Professionals Baseline peripheral arterial assessment Cardiovascular risks Foot pulses Doppler Signals (where available) Leg Symptoms No PAD Foot pulses palpable No intermittent claudication Doppler signals tri / bi phasic No ischaemic rest pain No clinical signs of PAD Consider non-vascular cause Suspected PAD Any one of the below: No foot pulses palpable Symptoms with existing non palpable foot pulses Symptoms of intermittent claudication Doppler signals monophasic Clinical signs e.g. atrophy, cold, capillary refill > 3 seconds Severe/ critical limb ischaemia Foot pulses absent Doppler signals monophasic /absent PLUS 1 or more of the following: Ischaemic rest pain Deteriorating foot/ leg wound Necrosis/ gangrene Absolute ankle pressure of <50mmHg or 70mmHg if ulceration present Refer to the Vascular Triage Service if feet intact for non-invasive lower limb vascular assessment, diagnosis/ exclusion of PAD and individual treatment plan. Refer to High Risk Podiatry in presence of stable foot ulcerations for NIVA NNIVAnoninvasllowerlimb vascular asse Refer urgently within 24 hours to Hospital Vascular Team if not already with them, or if signs / symptoms have worsened. Call vascular reg on call if appears urgent and limb threatening Non-surgical management Diagnose Peripheral Arterial Disease Individual Management Plan- CVD risk management, supervised exercise, drug therapy, surgical options. Advice on onward referral Refer for surgical opinion Worsening / severe / critical PAD Severe lifestyle impacting symptoms Ankle brachial pressure index < 0.4 Ankle systolic pressure < 50mmHg or <70mmHg if ulceration present Follow up within one working day to ensure hospital vascular team has received and triaged referral. Document this clearly in clinical notes. Inform GP All patients with a confirmed diagnosis of PAD should have an individually agreed management plan, which should be reviewed periodically with their GP. The management plan will include targeting cardiovascular risk factors, limb problems and negotiating treatment options (lifestyle, medicines, surgery) by GPs, Nurses and Allied Health Professionals involved in management of the lower limb. PAD / CV risk management Target Source Antiplatelet therapy Initiate for all with established PAD NICE 2010, SIGN 2006 Lipid lowering therapy Initiate for all established PAD NICE 2012, SIGN 2006 Hypertension BP < 140/90 mmhg (<150/90 for over NICE s) Smoking Aim for quit SIGN 2006 Obesity BMI < 30 NICE 2006 Light cardiovascular exercise 30 / 45 minutes, 3 to 5 times per week DOH 2004 Glycaemic control (if has diabetes) HbA1c < 7.0 % or < 53 mmol / mol NICE 2008, IFCC 2007 Page 9 of 20

10 c) Charcot Foot People who develop unexplained warmth and swelling in their foot should be referred urgently to the MDT ( ). They should be told to nonweightbear until they have been seen (see flow sheet below) Salford Royal Foundation Trust Management of CHARCOT NEUROARTHROPATHY Charcot Foot is an acute inflammatory condition of the foot. Untreated it leads to dislocation and/or fracture and disorganisation of foot architecture. The condition is associated with osteopenia. (SIGN 2001). It is commonly misdiagnosed as a sprain or as cellulitis. The cause is not known but the majority of cases are preceded by some minor injury, preceding ulcer or other cause of inflammation. It has been suggested that inflammation is the pivotal trigger (Jeffcoate 2005). Differentiation from osteomyelitis may be impossible in people in whom the overlying skin is ulcerated. Acute Charcot foot and osteomyelitis may coexist. (Frykberg et al 2000; Jeffcoate et al 2000). Charcot Neuroarthropathy most commonly occurs in people with diabetic neuropathy, but can occur in any severe peripheral neuropathy. Any person with suspected Charcot foot should be referred for urgent assessment by a specialised foot care team: suspected and confirmed cases should be managed by weight sparing to minimise the extent of bone damage. Secondary ulceration occurs in one third, and one fifth has bilateral disease. (NICE 2004) Diagnosis should be made by clinical examination, X-ray, MR Scan & exclusion of infection when necessary. The activity of the disease may be monitored by comparing skin temperature with the non-affected side. Suspected foot fractures in diabetic patients should be managed using the following guidelines. Page 10 of 20

11 Guidelines for assessment and treatment of Charcot Neuroarthropathy Clinical features and History Red, oedematous, warm and possibly painful foot. History of trauma to limb may be present, but not essential Differential Diagnosis - Charcot Neuroarthropathy, Infection, Gout, Soft Tissue Injury Fracture or any cause of foot inflammation such as arthritis. Refer to specialist foot care team Investigations Undertake neurological and vascular assessment. Confirm or exclude infection, if possible. Assess and if possible record heat difference between limbs affected limb usually >2 o C higher than contralateral foot, when tested with thermography. Blood tests include HBA1c, ESR, C-reactive protein, Alkaline Phosphatase, Renal function, Urate, Full Blood Count. X-Ray as a baseline and to exclude diabetic neuropathic fracture although X-ray may be normal (use weight bearing views) If Charcot foot is suspected but X-Ray is inconclusive, consider MRI Immediate Management 1. Immobilisation of the foot is urgently required. Non-removable below knee total contact cast is the metho of choice, but following holistic assessment, may not appropriate. Casting should be continued until all signs of inflammation regress which may not be for many months (SIGN 2001). 2. Non-weight bearing. 3. Education on the causes and management of Charcot foot and advice on prevention of complications. 4. There is insufficient evidence to support the routine use of bisphosphonates in the acute phase (SIGN 2001) although there are a small number of studies which suggest that bisphosphonates may be beneficial in some patients (Anderson 2004, Jude 2001). 5. Optimise glucose control. Medium Term Management 1. Regular clinical examination and imaging to monitor progress. 2. During post acute phase consider use of removable below knee cast. 3. Begin staged return to weight bearing, in cast, when foot temperature is equal and imaging indicates condition has reached non-destructive phase. 4. If foot remains stable & whilst still using cast, follow with staged introduction of appropriate orthotic device (e.g. boots and foot orthoses),. 5. Consider referral to an Orthopaedic surgeon for assessment and discussion of surgical remodelling. Long Term Management 1. Pressure relief with footwear and orthotic therapy as appropriate, via specialist podiatrist. 2. Classify patient as high current risk and review regularly in podiatry for signs of long -term complications. (NICE 2015) Page 11 of 20

12 d) Painful Peripheral Neuropathy See guidelines Standards SRFT.Feet First Policy (2012) SRFT Management of diabetic foot infection (2014). NICE (2004). Type 2 diabetes: prevention and management of foot problems. NICE (2011) National Institute for Health and Clinical Excellence. Diabetic foot problems: inpatient management of diabetic foot problems. Clinical guideline 119. London: NICE, 2011 : Diabetes UK. Putting feet first: National Minimum Skills Framework. Joint initiative from Diabetes UK, Foot in Diabetes UK, NHS Diabetes, the Association of British Clinical Diabetologists, the Primary Care,Diabetes Society, the Society of Chiropodists and Podiatrists. London: Diabetes UK, Explanation of terms & Definitions N/A References and Supporting Documents SRFT.Feet First Policy (2015) SRFT Management of diabetic foot infection (2016). Lipsky B, Berendt A, Cornia PB. Infectious Diseases Society of America clinical practice guideline for the diagnosis and treatment of diabetic foot infections. IDSA guidelines. Clin Infect Dis 2012; 54(12): p Page 12 of 20

13 Kerr M. Foot care for people : the economic case for change.nhsdiabetes, Newcastle-upon-Tyne, Available at: Accessed 20/07/2016 NICE (2004). Type 2 diabetes: prevention and management of foot problems. Accessed 15/9/2016 NICE (2015) accessed 15/09/2016 NICE (2011) National Institute for Health and Clinical Excellence. Diabetic foot problems: inpatient management of diabetic foot problems. Clinical guideline 119. London: NICE, International Working Group of the Diabetic Foot (2015). K. Bakker J. Apelqvist N. C. Schaper et al Practical guidelines on the management and prevention of the diabetic foot. accessed 15/08/2016 Diabetes UK. Putting feet first: national minimum skills framework. Joint initiative from Diabetes UK, Foot in Diabetes UK, NHS Diabetes, the Association of British Clinical Diabetologists, the Primary Care,Diabetes Society, the Society of Chiropodists and Podiatrists. London: Diabetes UK, TRIEPodD-UK. Podiatry competency framework for integrated diabetic foot care a user s guide. London: TRIEpodD-UK, Anderson (2004). Bisphosphonates for the treatment of Charcot neuroarthropathy. J Foot and Ankle Surg, 43 (5), Fryberg RG and Mendeleeson E (2000).Management of the Diabetic Charcot foot. Diabetes Metab Res Rev, 16, S59-65 Jeffcoate W.J, Lima J., Nobrega L. (2000).The Charcot foot. Diab Med; 17: Jeffcoate WJ (2005). The role of pro-inflammatory cytokines in the cause of neuropathic osteoarthopathy (acute Charcot foot) in diabetes. The Lancet Jude E (2001). Bisphosphonates in the treatment of Charcot neuroarthropathy: a double-blind randomised controlled trial. Diabetiologia, 44 (11), National Institute of Clinical Excellence(NICE) (2004).Type 2 Diabetes: prevention and management of foot problems. Scottish Intercollegiate Guideline Network (SIGN) (2001) Guideline 55 section 7: Management of diabetes foot disease North West Podiatry Services Clinical Effectiveness Group for Diabetes. Guidelines for the Prevention and Management of Foot Problems for People with Diabetes 2014, Available from: df Page 13 of 20

14 Roles and responsibilities It is the responsibility of all staff who work with people to have read and act in line with this guideline.the guideline will be monitored by the diabetic foot steering group to ensure it is kept upto date and in line with the best available evidence Page 14 of 20

15 Appendices : Appendix 1 Practice Nurse Referral: 9 POINT DIABETIC FOOT SCREENING TOOL PATIENT NAME ADDRESS POSTCODE: D.O.B GP PRACTICE Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. NHS number:click here to enter text. Clinical Assessment Right foot Left foot 1. Has pt had a previous ulceration 2. Has pt had an amputation 3. Does pt have Absent foot pulses (A YES answer requires absence of both dorsalis pedis and posterior tibial pulses) 4. Does pt complain of intermittent claudication? Complete Edinburgh questionnaire if necessary to aid questioning (see reverse) If yes : Grade Site If yes : Grade Site 5. Does pt have a history of vascular surgery to the lower limb? This does not include DVT,heart surgery or varicose veins NEUROPATHY testing Using 10g Monofilament 6. Loss of sensation plantar 1 st toe 7. Loss of sensation plantar 1 st metatarsal 8. Loss of sensation plantar 5 th Metatarsal 9. Does pt have chronic kidney disease CKD 4 or 5 NEGATIVE SCREEN: (please tick) results when there are all NO responses. Patient LOW RISK. No referral to podiatry required. Educate patient and provide with details of Podiatry emergency access. Arrange annual foot screen in 12 months within your practice. POSITIVE SCREEN: (please tick) results when there are one or more YES responses. Use the guidance attached to classify risk. REFER TO PODIATRY FOR A SECOND FOOT SCREEN WITH A PODIATRIST if applicable. PLEASE INDICATE HERE PATIENT IS AWARE OF REFERRAL AND WILL ATTEND PODIATRY (please tick) Once foot examination taken place you will be sent details of patient s risk factor for you to enter onto your system. PLEASE PROVIDE CLEAR DETAILS OF WHO TO THE 2 nd SCREEN RESULTS TO: Name: Click here to enter text. Designation: address: Click here to enter text. Date of your assessment Click here to enter a date. ADDITIONAL COMMENTS / REASON FOR REFERRAL Click here to enter text. Please referral to : podiatry.secondscreenservice@nhs.net Page 15 of 20

16 Guidance for completing foot screening tool: Q 1 Q 2 Q 3 Q 4 Yes, if patient has ever had a foot ulcer Yes, if previous amputation of a toe, foot or limb is observed Yes, palpate both dorsalis pedis and posterior tibialis pulse. A YES response requires the absence of both foot pulses. If only one pulse is palpable the response to this question is NO. Yes use the Edinburgh questionnaire below to assist diagnosis of possible intermittent claudication. Boxes in red indicate where a Yes response would be recorded on the screening tool Q1 Do you get pain or discomfort in your YES NO leg(s) when you walk? Continue questioning If the answer is NO, you need not continue questioning. Q2 Does the pain ever begin when you are standing still or sitting? YES NOT CLAUDICATION NO Continue questioning Q 5 Q 6 Q 7 Q 8 Q 9 Q3 Do you get this pain if you walk uphill or when you are in a hurry? YES Claudication NO Continue questioning Q4 Do you get this pain when you walk at an ordinary pace on the level? YES Claudication Grade 2 NO Claudication Grade 1 What happens to this pain if you rest? Q5 Usually continues for more YES NO than 10 minutes NOT claudication Usually disappears in 10 minutes or less YES CLAUDICATION NO Definition of positive claudication requires all the following responses: YES to Q1; NO to Q2: YES to Q3; NO to Q4 = Grade 1 YES to Q4 = Grade2; Usually disappears in 10 minutes or less to Q5. Yes, if patient has ever had previous revascularisation to their lower limb. This includes angioplasty or lower limb artery bypass. This does not include patients who have had heart bypass surgery, DVT or varicose veins, in this instance the response would be No 10g MONOFILAMENT test Test 3 sites*: Plantar surface of the hallux, 1st metatarsal area and 5th metatarsal area Apply the filament to a sensitive area of skin (e.g. the forearm) so that the patient is aware of the sensation they are supposed to feel. Ask the patient to close their eyes and say yes every time that they feel you touch the skin on the foot Place the monofilament at 90 to the skin surface. Slowly push the monofilament until it has bent approx 1cm (don t jab) Hold the monofilament in this position for 1-2 seconds, then slowly release the pressure. Repeat for all testing sites. If the patient does not respond, repeat the test at the site twice. If there is still no response, record as a Yes response on the screening tool. *If callus (hard skin) is present at any of the sites then test at the nearest non-calloused area Yes if the patient has an egfr of 29 or below. Guidance on Classifying foot risk RISK CATEGORY Description of risk LOW RISK All responses to screening tool are NO indicates patient is low risk INCREASED RISK Patient has neuropathy in either foot. Patient has CKD 4 or 5. HIGH RISK Patient has had a previous foot ulcer or an amputation of a toe, foot or limb related to diabetes or poor circulation Patient has absent foot pulses. ULCERATED Patient has a current foot ulcer or has had a foot ulcer in the past year Page 16 of 20

17 Reply to GP following 2 nd Screen DIABETIC FOOT SCREENING RESULTS: Please find below the results of the Diabetic Foot Screen conducted on: PATIENT NAME NHS number D.O.B Click here to enter text. Click here to enter text. Click here to enter text. Clinical Assessment Right foot Left foot Does the patient have a history of ulceration? If healed please enter date: Click here to enter a date. If healed please enter date: Click here to enter a date. Site of ulceration Has the patient had any history of amputation? Does the patient have any Foot Deformity? Can patients foot be accommodated in shop bought footwear? Circulation: Pulses: Dorsalis Pedis Posterior Tibial Does pt complain of intermittent claudication? Complete Edinburgh questionnaire If yes : Grade: Site: Claudication Distance:Distance If yes : Grade: Site: Claudication Distance:Distance Ischaemic Rest pain History of vascular intervention If yes please detail: Click here to enter text. If yes please detail: Click here to enter text. Neurological: Sensory loss (10g monofilament) Does the Patient Smoke Educational material given Does pt have chronic kidney disease CKD 4 or 5 Risk Category Please detail any referrals made: Additional comments for referrer: Click here to enter text. Assessed by: Click here to enter text. Designation: PODIATRIST Date of assessment: Page 17 of 20

18 Appendix 2 CRITICAL LIMB ISCHAEMIA. 5 MINUTE ASSESSMENT. Symptoms of rest pain Unremitting pain in the foot (often in the toes). May not be present in neuropathic patients. Often patients report the pain is worse when the foot is elevated and / or covered by socks or bedclothes and patients will often hang the foot down to try and achieve some relief. Non palpable foot pulses. Doppler signals will be monophasic and dampened or absent all together. Ankle systolic pressure < 50 mmhg or < 70 mmhg in the presence of tissue loss or ulceration. Be aware calcification may give an unreliable result, especially in diabetic and renal patients. If clinician is not confident in the use of the Doppler complete all other aspects of the 5 minute assessment and discuss with the High Risk team, or if no one is available and you consider it urgent, the vascular registrar on call. Temperature difference between the symptomatic and asymptomatic foot. Colour of foot. May be cyanosed with mottling at apex of toes or around the heel, white, reticular pattern. Areas of ulceration / necrosis may be present as new lesions or deterioration of existing wounds. Endorsed by Mr Vince Smyth. Consultant vascular surgeon. Central Manchester foundation trust 29/01/14 Endorsed by Mr David Murray. Consultant vascular surgeon. Central Manchester foundation trust 10/02/14 Endorsed by Dr Bob Young. Consultant Diabetologist. Salford Royal Foundation Trust 12/02/14 Endorsed by Dr Angela Paisley. Consultant Diabetologist. Salford Royal Foundation Trust. 03/03/14 Endorsed by Dr Paul Chadwick. Consultant Podiatrist.Salford Royal Foundation Trust. 01/04/14 Page 18 of 20

19 INFORMATION REQUIRED BY THE VASCULAR TEAM WHEN DISCUSSING PATIENTS WITH CRITICAL LIMB ISCHAEMIA. 1. General information about the patient including their medical history, previous vascular history/ intervention, their co morbidities and mobility. 2. Pattern of pain symptoms. Does it require analgesia? Is the pain tolerable/controlled? Is the pain relieved by hanging the foot down? 3. Non palpable foot pulses. 4. Doppler signals- are they monophasic, dampened, absent? 5. What is the ankle systolic pressure, is it < 50mmHg? Do you suspect calcification? 6. Is there a temperature difference between the problematic and asymptomatic foot? 7. What is the colour of the foot like, is it cyanosed, mottled, white, reticular pattern. 8. Are there any areas of ulceration/ necrosis? If so are these new and/ or deteriorating? 9. Onset of symptoms. Is it a gradual deterioration? Is it an acute episode? Is there infection present? Page 19 of 20

20 Appendix 3 Podiatry Emergency Drop-in Clinic The Podiatry department operates a drop-in clinic for NHS patients who have a painful foot problem and are unable to wait for a routine appointment. New patients will be seen if they have an infection or a wound. If you feel you need to attend the Drop-in Clinic please telephone the relevant clinic before 11am on the day you wish to attend. If you are attending Irlam Health Centre please ring from 9am, the drop-in clinic starts at 9:30 am. Please ensure you report to reception on your arrival Monday ECCLES GATEWAY, Barton Lane, Eccles, M30 0TU Tel No: pm. Monday Tuesday Wednesday Thursday Thursday Friday NEWBURY GREEN, 55 Rigby Street, M7 4NX Tel No: pm. SWINTON GATEWAY, 100 Chorley Rd, Swinton, M27 6BP Tel No: pm WALKDEN GATEWAY, Smith Street, Walkden, M28 3EZ Tel No: pm PENDLETON GATEWAY, 1 Broadwalk, Salford, M6 5FX Tel No: pm ECCLES GATEWAY, Barton Lane, Eccles, M30 0TU Tel No: pm. IRLAM HEALTH CENTRE, Macdonald Road, Irlam, M44 5LH Tel No: am This clinic will not provide routine nail cutting or full treatments. These clinics work on a first come first served basis and can be busy, you must therefore be prepared to wait. Patients who come after the times stated above will not be seen on that day, but can attend the next available Drop-in Clinic. Emergency clinics will not run on Bank Holidays. Yours Faithfully, Jane Steel PODIATRY MANAGER Page 20 of 20