Diabetic Foot Screening Policy

Transcription

1 Diabetic Foot Screening Policy This policy describes the process of assessing a patient with diabetes for foot complications, assigning appropriate risk classification and implementing Key Words: Diabetic Foot Assessment Screening Ulcer Foot Emergency Version: 2 Adopted by: Date Adopted: Name of Author: Quality Assurance Committee 25 July 2016 Amin Pabani / Helen Parberry Name of Clinical Effectiveness Group responsible Committee: Date issued for July 2016 publication: Review date: 01/04/18 Expiry date: 01/07/18 Target audience: Type of Policy All LPT staff involved in screening for Diabetic Foot Complications and involved in the care of the Diabetic Foot Clinical Non Clinical X 1

2 Contents Contents Page 2: VERSION CONTROL 4 Equality Statement 4 Due Regard 4 Definitions that apply to this policy 5 THE POLICY 1.0 Purpose of the Policy Summary of the Policy Introduction Policy Requirements Nice Classification Diabetic Foot Screening Training and Competency Screening Equipment The Diabetic Foot Assessment / Screening Tool Mental Capacity & Best Interest Decisions Flowchart / Process Chart Emergency Referral Duties within the Organisation Training Monitoring Compliance and Effectiveness Links to Standards / Performance References & Bibliography 15 2

3 Appendices Appendix 1 Due Regard Assessment 17 Appendix 2 NHS Constitution Checklist 19 Appendix 3 Stakeholder and Consultation 20 Appendix 4 Diabetic Foot Assessment Tool 21 Appendix 5 Diabetic Foot Assessment Guidance Notes..24 Appendix 6 Podiatry Service Application Form 28 Appendix 7 General Diabetes Foot Care Leaflet 30 Appendix 8 Leaflet for Patients with Neuropathy 32 Appendix 9 Leaflet for Patients with Vascular Impairment 34 Appendix 10 Ulcer Care Leaflet, Community Foot Clinics (formerly Fast Access Clinics) 36 Appendix 11 Flowchart for Referral Procedure 39 Appendix 12 Care Plan for Diabetic Foot Ulcer 40 Appendix 13 Care Plan for Diabetic Feet 42 Appendix 14 AMH / LD / FYPC Inpatient & Community Flowcharts 44 3

4 Version Control and Summary of Changes Version Date number 1 17/02/2014 Comments (description change and amendments) 2 26/05/2016 Decrease in number of assessments required to be carried out per year to maintain competence. Statement added re Mental capacity and best interest decisions For further information contact: Podiatry Services Manager Diabetes Specialist Podiatrist Equality Statement Leicestershire Partnership NHS Trust (LPT) aims to design and implement policy documents that meet the diverse needs of our service, population and workforce, ensuring that none are placed at a disadvantage over others. It takes into account the provisions of the Equality Act 2010 and promotes equal opportunities for all. This document has been assessed to ensure that no one receives less favourable treatment on the protected characteristics of their age, disability, sex (gender), gender reassignment, sexual orientation, marriage and civil partnership, race, religion or belief, pregnancy and maternity. In carrying out its functions, LPT must have due regard to the different needs of different protected equality groups in their area. This applies to all the activities for which LPT is responsible, including policy development and review. Due Regard The Trusts commitment to equality means that this policy has been screened in relation to paying due regard to the Public Sector Equality Duty as set out in the Equality Act 2010 to eliminate unlawful discrimination, harassment, victimisation; advance equality of opportunity and foster good relations. A due regard review found the activity outlined in the document to be equality neutral because implementation of this policy should not have a negative impact on any protected characteristics. It simply promotes and reinforces good clinical practice. 4

5 Definitions that apply to this Policy Foot ulceration Charcot foot Neuropathy Peripheral arterial disease Peripheral vascular disease A patient with diabetes who has an open wound on their foot A foot that presents as hot, swollen and red either with or without an open wound. Commonly the arch is flattened with a rocker shape to the foot due to pathological fractures / bony changes associated with neuropathy Interruption of nerve function Synonymous with peripheral vascular disease Any abnormal condition that affects the blood vessels outside the heart and lymphatic vessels 5

6 1.0. Purpose of the Policy The aim of this policy is to ensure that standards of care and referral strategies for patients with diabetes are known and standardised across the trust in accordance with best practice. To effect implementation of NICE guidance NG19 Diabetic Foot Problems: Prevention and Management (20015; updated 2016) and to ensure all patients with Diabetes in the care of LPT are screened for complications in a timely manner, by a suitably competent practitioner, their risk status identified and appropriate intervention / action taken or referrals made. This Policy is an interim measure. A Healthcare Community wide piece of work, commissioned jointly by East, West and City CCGs, via the Diabetes Transformation Board comprising all relevant stakeholders will finalise collaborative commissioned pathways effecting joint and seamless Community and Acute sector care for implementation. As the result of this work is imminent, the review / expiry of this policy have been kept to a minimum Summary and Key Points Diabetic foot complications are the largest single reason for hospital admissions among the diabetic population in the UK. It has the potential for devastating complications which are potentially avoidable. It is therefore essential that standards of care and referral procedures for patients with diabetes are standardised across the trust in accordance with best practice. The training which underpins the policy will ensure all patients with diabetes under the care of LPT will be screened for foot complications in a timely manner by a trained practitioner and their risk status identified with appropriate interventions or referrals actioned. Classification of risk status of diabetes patients will be in accordance with NICE guidance NG19 Diabetic Foot Problems: Prevention and Management (20015; updated 2016) 3.0. Introduction Foot disease is a devastating, but potentially avoidable, complication of diabetes. Estimations are that every 30 seconds a lower limb is lost due to diabetes-related amputation somewhere in the world (Boulton et al 2005). In the UK, diabetic foot complications are the largest single reason for hospital admissions among people with diabetes (Boulton et al, 2005) and Diabetes UK (2011) estimates that foot complications account for 20% of the total NHS spend on diabetes care. Healthcare providers in the NHS have been challenged by the Diabetes NSF (2001) to establish systems of care that will reduce the risk of disability for those with long term diabetic complications. This is to be achieved by; 6

7 Risk factor surveillance. Timely and appropriate intervention Access to specialist multi-disciplinary foot services 4.0. Policy Requirements NICE Classification Prevention and Management of Foot Problems Diabetic patients are classified to help predict diabetic foot complications and provide appropriate, tailored education. NICE CLASSIFICATION Low Risk Increased Risk High Risk Foot Emergency/Ulcer Palpable pulses Normal sensation No foot Pathology / deformity Neuropathy or Absent pulses or Other risk factor e.g. foot pathology / deformity Neuropathy or Absent pulses plus Deformity or Skin changes or Previous ulcer / amputation New ulceration / Skin Breach Swelling Discolouration Acute Charcot foot Cellulitis No Peripheral Vascular / Arterial Disease 4.1. Diabetic Foot Screening Successful assessment and classification will inform the management strategy and is aimed at reducing the incidence of foot ulcers; 12 25% of diabetics (Cavanagh et al, 2005) and amputations; more than 1 in 10 foot ulcers (Williams and Pickup, 2004) People with a serious mental illness are at increased risk of developing type 2 diabetes mellitus due to antipsychotic medication prescription and its associated side effects (Nash 2009, Mackin et al 2007, Llorente et al 2006). 4.2 Training and competency Screening for foot complications must only be carried out by an appropriately trained and deemed competent practitioner. As this is a technical based task, the training is suitable for Health Care Assistants through to Diabetes Specialist 7

8 Initial training for staff in AMH/LD/FYPC required to screen for diabetic foot disease will be provided. Appendix 1 Nurses and GPs. The LPT Podiatry Service provides regular courses on assessment and management of the diabetic foot, entitled Care of the Diabetic Foot. This course is cross referenced with Skills 4 Health, includes a practical session and provides competency assessment and certification. It is recommended that staff involved in DFAs attend an annual refresher and full training course every 3 years (provided by LPT Podiatry Services). To maintain competency a practitioner is recommended to carry out at least 12 screens per year. It is also recommended competency status be monitored and recorded within staff members PDR to evidence compliance. Diabetic Foot screening should be carried out on all patients with diabetes annually or more frequently dependent on risks; this must be recorded in patients record to evidence compliance. Refer to flowchart appendix Screening Equipment Where possible, all LPT wards should screen diabetic patients for foot complications within 72 hours of admission. Those with known ulceration will be screened and action taken immediately. If they are unable to perform an assessment within the expected time frame a note detailing the reason why must be entered in the patient s documentation. It is recommended that a simple assessment must comprise at least: Tests for Neuropathy, as a minimum o 10g Monofilament (large fibre) o Neurotip (small fibre) Tests for impaired circulation, as a minimum o Testing for pulses (palpation or doppler use) o Observing for colour changes, vulnerability of skin / tissue, hair loss and changes to nails o Checking for temperature gradient Observing for foot deformity and / or pathology A completed copy of the tool (described below) with results with any recommendations should be forwarded to the patients GP. The above regime will be sufficient in most cases, allowing appropriate classification and follow on action and / or indicating need for further in depth and targeted testing, e.g. if tests failed or are inconclusive. For patients exhibiting an inability to appropriately respond to neurological tests e.g. due to ill health or disability, it is to be considered that the foot is neuropathic. Classification and follow on action should proceed accordingly. 8

9 Screening results for inpatients should be included on GP discharge summary 4.4. The Diabetic Foot Assessment / Screening Tool The recommended Diabetic Foot Assessment Tool (Appendix 5) provides a standard approach to the assessment process and must be used by all LPT staff involved in diabetic foot screening. This tool is available electronically on SystemOne, EMIS and TIARA, and RIO. The Tool is structured to be user friendly and enables the practitioner to assess the patients risk status in relation to their feet. 5.0 Mental Capacity and Best Interest Decisions Where there is doubt if a patient lacks mental capacity to agree to assessment and treatment, an assessment of their capacity under the Mental Capacity Act (2005) should be completed. This is a decision-specific test and no one can be regarded as lacking capacity to make decisions in general. If the person is deemed to lack capacity then a decision in the person s best interest must be made. The Act provides a checklist of factors that decision-makers must work through in deciding what is in a person s best interests. Also, carers and family members have a right to be consulted Process Chart The above form should accompany any referral made as a result of the assessment e.g. accompanied by an appropriate application form. Provision of care and thus appropriate referral should be as follows, according to NICE: NICE Classification Referral to Surveillance Interval Education Leaflets Low Risk GP Practice Annually (min) General Diabetic Foot care (Appendix 8) Increased Risk No foot Pathology Increased Risk with Foot Pathology GP Practice Podiatry Mark as Routine (Appendix 11) 3-6 Monthly Neuropathy (Appendix 8) or Vascular (Appendix 9) as appropriate 9

10 High Risk Podiatry Mark as Urgent 1-3 Monthly Neuropathy and / or Vascular as appropriate Foot Emergency / Ulceration Community Foot Clinic / Emergency Referral within 1 working day (Drop-in formerly Fast Access) Intensive as required Ulcer care (Appendix 10) 6.1 Community Foot Clinic (Formerly Fast Access) / Emergency Referral The LPT Podiatry Service hosts emergency Community Foot Clinics across City and County Localities (Appendix 10); these are Drop-in clinics covering the entire span of the working week, operating on different days. The purpose is to enable a patient with a Foot emergency e.g. newly discovered ulcer, suspected infection or charcot joint access to a diabetes lead / specialist podiatrist (as part of the Multi-Disciplinary Foot Team (MDFT) within 1 working day. The clinics also welcome pre-ulcerative referrals as a means of preventing deterioration but will not accommodate routine podiatric care. ALL PATIENTS WITH AN ULCER OR SUSPECTED ULCER MUST BE REFERRED TO THE PODIATRY SERVICE IMMEDIATELY AND SHOULD BE SEEN WITHIN 1 WORKING DAY* CALL: Diabetic Foot Emergency HOTLINE The Hotline, operating Mon Fri 8am 6pm, will be given priority over other calls within the Podiatry Appointments Booking Centre and staff will direct the caller to the next available Community Foot Clinic with details of clinic times and address. Should the patient be housebound (unable to embark a suitable vehicle) or an inpatient, the referrer MUST make this clear and the booking clerks will attempt to provide a home visit within 1 working day should this not be possible, the case will be referred to the appropriate Podiatry Team Lead to arrange a visit. The Community Foot Clinics, manned by a Diabetes Lead or Specialist Podiatrist (as a member of the MDfT), will provide an assessment / triage, first line emergency care e.g. provision of antibiotics, immediate treatment and off-loading in order to stabilise the patient. The patient will then be either referred by the podiatrist to the main Foot Clinic for full MDT assessment and advice, and / or passed to the patient s local 10

11 Community Foot Clinic / Podiatry clinic for onward care. Ulcers or suspected ulcers discovered on the weekend should be referred to appropriate emergency care e.g. A and E It is recognised that the patient may not always be fit to travel to an alternative location - this and any other delays in access / referral will require reporting via an incident form. This will instigate a full investigation and will allow for future developments and service improvements. Patient unable to travel on Health grounds will be seen as home visits *this Key Performance Indicator for the Podiatry Service is monitored via the Trusts waiting times reporting to commissioners and the validation process therein. The diabetic foot audit will be used to monitor compliance with the referral process. Duties within the Organisation 7.0 The Trust Board has a legal responsibility for Trust policies and for ensuring that they are carried out effectively. 7.1 Trust Board Sub-committees have the responsibility for ratifying policies and protocols. 7.2 Divisional Directors and Heads of Service are responsible for: Ensuring Team managers / leads are given clear instruction about arrangements for implementation and monitoring of this policy. Ensuring that all staff are aware of their responsibility to adhere to the policy. Ensuring appropriate resources and mechanisms are in place to facilitate adherence 7.3 Managers and Team Leaders are responsible for: Ensuring that the policy is understood and followed as appropriate by each relevant member of staff. Policy information is shared with all relevant new staff on induction. Ensuring staff know how and where to access most current version of this policy. Ensuring staff adhere to the policy and carry out relevant audits to measure compliance. Ensuring any recommended training is undertaken as specified in the policy 7.4 Responsibility of Staff All staff (including seconded staff, agency and bank staff) should be aware of their individual responsibility to: Adhere to the policy and take appropriate action as required. Feedback to their managers the need for any specific training or update 11

12 training as they deem relevant / required. All staff should be aware of how this policy impacts on their practice and be able to follow the specified requirements set out. 8.0 Training needs There is a need for training identified within this policy. In accordance with the classification of training outlined in the Trust Learning and Development Strategy this training has been identified as role development training. Dates for training will be provided on a demand basis. Service managers should contact the Podiatry Service to request training dates. All training packages will be designed by the Podiatry service to ensure a consistent and coordinated approach Once staff have completed the training they must undertake to undertake an annual update then complete the training in full every 3 years. The governance group responsible for monitoring the training is the Clinical Effectiveness Group Training Required YES X NO Training topic: Type of training: (see study leave policy) Division(s) to which the training is applicable: Staff groups who require the training: Regularity of Update requirement: Who is responsible for delivery of this training? Diabetes Foot Screening Mandatory (must be on mandatory training register) X Role specific Personal development X Adult Mental Health & Learning Disability Services Community Health Services X Enabling Services X Families Young People Children Hosted Services Inpatient areas only; Bradgate unit, Hershel Prinz and Agnes Unit Minimum of 2 staff (HCSW and Link Nurse) Every 3 years Podiatry Service 12

13 Have resources been identified? Has a training plan been agreed? Where will completion of this training be recorded? Yes; staff from areas above, Podiatrist and Tissue Viability Nurse to deliver initial training. Podiatry support following training Yes: 28 staff over 2 days ULearn x Other (please specify) Trust learning Management System How is this training going to be monitored? Initial training figures will be provided to inpatient matrons and clinical governance leads. Individual areas will be responsible for ensuring they have sufficient trained staff 9.0 Monitoring Compliance and Effectiveness Where monitoring identifies any shortfall in compliance with policy and requirements for assessments; the group responsible for the Policy (as identified on the policy cover) shall be responsible for developing and monitoring any action plans to ensure future compliance Ref Minimum Requirements Evidence for Selfassessment Process for Monitoring Responsible Individual / Group Frequency of monitoring 4.2 Maintain competency in assessment of diabetic foot by carrying out at least 12 assessments per year Section 4.2 To be recorded in PDR Incident reporting Podiatry referrals Team managers Podiatry service ongoing 13

14 4.2 Every Diabetic patient should have had a diabetic foot assessment within the last 12 months or more frequently depending on risk factors Section 4.2 Annual Diabetic Foot Screening Audit Team Managers Ongoing Annual and 3 yearly 4.3 Where possible, every diabetic patient admitted should have a screen conducted within 72 hours of being admitted Section 4.3 Annual Diabetic Foot Screening Audit Team Managers Annually 6.1 Every patient with a foot ulcer must be referred to the Podiatry Service immediately Section 6.1 Annual Diabetic Foot Screening audit Team managers ongoing 6.1 Every patient with a foot ulcer must be seen by Podiatry Services within 1 working day (once referred) Section 6.1 Podiatry Services Waiting times KPI reports and validation process Podiatry Service Team managers ongoing 14

15 10.0 Standards/Performance Indicators TARGET/STANDARDS CQC Fundamental Standards Regulation 9 Person Centred Care, Regulation 10 Dignity and Respect Regulation 11 Need for consent Regulation 12 Safe Care and Treatment Regulation 13 Safeguarding service users from abuse and improper treatment Regulation 15 Premises and Equipment Regulation 16 Receiving and Acting on Complaints Regulation 17 Good Governance Regulation 18 staffing, Regulation 19 Fit and Proper persons employed KEY PERFORMANCE INDICATOR For patients classified as Routine an initial Appointment will be provided with the Podiatry service within 4 weeks. Patients classified as Urgent will be provided with an appointment within 5 working days. Diabetic Patients will have a foot screen at least annually or more frequently dependant on risk factors A diabetic foot screen will be carried out within 72 hours of admittance NICE Guidance NG19 Diabetic Foot Problems; Prevention and Management (2015, updated 2016) 11.0 References and Bibliography This policy was drafted with reference to the following: Cavanagh et al (2005) in McIntosh C (2007) Diabetic foot ulcers; what is best practice in the UK. Wound Essentials (2): Diabetes UK (2009) Putting feet first; commissioning specialist services for the management and prevention of diabetic foot disease in hospitals. Diabetes UK DoH (2001) The National Service Framework for Diabetes. DoH, London Edmonds M (2008) A natural history and framework for managing diabetic foot ulcers. British Journal of Nursing Tissue Viability supplement 17 (11): Fletcher J (2006) Full nursing assessment of patients at risk of diabetic foot ulcers. British Journal of Nursing Tissue Viability supplement 15 (15):

16 Frykberg et al (2006) in McIntosh C (2007) Diabetic foot ulcers; what is best practice in the UK. Wound Essentials (2): Llorente D, Urrutia V (2006) Diabetes, psychiatric disorders and the metabolic effects of antipsychotic medications. American Diabetes Association Clinical Diabetes 24 (1) Mackie S (2006) Developing an education package on diabetic foot disease. Wound Care (Dec 06): S6-14 Mackin P, Bishop D, Watkinson H, Gallagher P, Ferrier N (2007) Metabolic disease and cardiovascular risk in people treated with antipsychotics in the community. British Journal of Psychiatry 191: McIntosh C (2007) Skin and nail conditions and the diabetic foot. Wound Essentials (2): McIntosh C (2007) Diabetic foot ulcers; what is best practice in the UK. Wound Essentials (2): National Diabetes Support Team (2006) Diabetic Foot Guide. National Diabetes Support Team, Leicester Nash M (2009) Mental health nurses diabetes care skills a training needs analysis. British Journal of Nursing 18 (10): National Institute for Health and Clinical Excellence (2015, updated 2016) Diabetic Foot Problems; Prevention and Management Williams G, Pickup JC (2004) in British Journal of Nursing Tissue Viability 16

17 Appendix 1 Due Regard Screening Template Section 1 Name of activity/proposal Diabetic Foot Screening Date Screening commenced May 2016 Directorate / Service carrying out the Quality Performance and Planning assessment Name and role of person undertaking Amin Pabani Podiatry Service Manager this Due Regard (Equality Analysis) Give an overview of the aims, objectives and purpose of the proposal: AIMS:. The aim of this Policy is to provide the necessary knowledge and practical skills to allow staff to screen diabetic patients for foot disease and prevent potential future amputation OBJECTIVES: Diabetic patients to have their feet classified, infection and amputation risks to be minimised by timely and correct intervention PURPOSE: To provide consistent training for staff To screen diabetic patients for foot disease and prevent potential future amputation Section 2 Protected Characteristic Could the proposal have a positive impact Yes or No (give details) Age No No Disability No No Gender reassignment No No Marriage & Civil Partnership No No Pregnancy & Maternity No No Race No No Religion and Belief No No Sex No No Sexual Orientation No No Other equality groups? No No Could the proposal have a negative impact Yes or No (give details) Section 3 Does this activity propose major changes in terms of scale or significance for LPT? For example, is there a clear indication that, although the proposal is minor it is likely to have a major affect for people from an equality group/s? Please tick appropriate box below. Yes 17 No

18 High risk: Complete a full EIA starting - click here to proceed to Part B Low risk: Go to Section 4. Section 4 It this proposal is low risk please give evidence or justification for how you reached this decision: Signed by reviewer/assessor Amin Pabani Date 26/05/16 Sign off that this proposal is low risk and does not require a full Equality Analysis Head of Service Signed Date 18

19 Appendix 2 The NHS Constitution The NHS will provide a universal service for all based on clinical need, not ability to pay. The NHS will provide a comprehensive range of services Shape its services around the needs and preferences of individual patients, their families and their carers Respond to different needs of different sectors of the population Work continuously to improve quality services and to minimise errors Support and value its staff Work together with others to ensure a seamless service for patients Help keep people healthy and work to reduce health inequalities Respect the confidentiality of individual patients and provide open access to information about services, treatment and performance x x x x x x x 19

20 Appendix 3 Stakeholders and Consultation Key individuals involved in developing the document Name Designation Amin Pabani Podiatry Services Manager LPT Helen Parberry Diabetes Specialist Podiatrist LPT Victoria Peach Nurse Consultant Tissue Viability Circulated to the following individuals for comment Name Designation Anita Kilroy - Findley Tissue Viability Nurse AMH/LD/FYPC Ann Silver 20

21 Appendix 4 A University Teaching Trust Community Health Services Division Podiatry Service Podiatry Services 21

22 22

23 23

24 Appendix 5 Diabetic Foot Assessment Guidance Notes The Diabetic Foot Assessment Tool is divided into eight main sections: 1. Personal details This section must be completed in full or using a patient identification sticker if available. 2. Diabetes It is recommended that this section also be completed in full on each assessment as: It is good practice to remind oneself of the type of diabetes the patient has and the associated risks. Also this may not be known to other practitioners involved in the patients care e.g. Podiatrists. Date of diagnosis will enable the practitioner to gauge risks associated with duration of disease and this information may also not be available to other practitioners involved in the patients care Method of control may have changed since last visit The HbA1C test result gives a good indication of patients overall diabetic control and enables the practitioner to gauge the risk of secondary pathology. Hyperglycaemia lowers immunity to infection and aids towards joint motion limitation. 3. Risk Factors It is recommended that this section be completed on each assessment as it provides completeness and enables the practitioner to confirm risk status from a medical / social grounding. It also allows for comments and communication between disciplines (though it is important to note that any serious concerns must be addressed appropriately and followed up, practitioners must not rely on action from comments on this form). The form can be referenced against previous assessments and should clearly show any increase in risk levels e.g. patient may have a recorded history of ulceration (shown on previous assessment), now lives alone due to divorce and has also started smoking. Previous ulceration maybe an indicator of existing diabetic foot disease. A person who has already had an episode of foot disease has a 40% risk of a second episode in 12 months. Previous ulceratedsites will also have reduced tensile strength increasing their susceptibility to breakdown from external factors such as ill-fitting footwear. Poor glycaemic control will increase the risk of arterial disease, neuropathy and infection. Age/sex Trials have shown that diabetic foot ulcer rates are more common in males than females and the prevalence of both PN and PVD increases with age. Smoking causes an increased risk of arterial disease; hardening and calcification of the arteries impair blood flow to the foot. Living alone and self neglect may mean that they have been unable to meet their nutritional and personal needs and are at risk of poor glycaemic control and foot care deficits 24

25 Poor eyesight also reduces the ability to self care and renders the patient unable to conduct daily visual checking of their feet. Retinopathy is associated with an increased risk of neuropathic foot ulceration. 4. Vascular assessment It is recognised that in a busy clinical/in patient environment, time is of utmost importance. For the majority of patients being assessed, it is possibly sufficient to check for palpable pulses, temperature gradient, skin colour, and capillary refill time. If the practitioner is not convinced that the patient has adequate peripheral supply, is unsure of findings or further concerns are raised through interview then further tests should be conducted e.g. Doppler ultrasound, Buergers test, ABPI etc. If the concerns remain, a second opinion or a referral to vascular surgery should be considered. 5. Neurological assessment This is designed to test small fibres controlling finer / higher sensory functions and large fibres responsible for more crude sensory detection. In a busy clinical situation together with observation, signs and symptoms this may provide sufficient information to determine neuropathic status. Other tests can be carried out if considered necessary e.g. reflexes, 2-point discrimination etc. Though the use of sharp / blunt discrimination as an affective test for gauging presence of neuropathy has been researched, there is no indication of the number of stimuli to test (as opposed to the work conducted on the monofilament) thus the number suggested per foot on this form i.e.10 provides some degree of standardisation / repeatability / credence to results found e.g. 8 out of 10 stimuli detected last visit but only 2 out of 10 detected this time thus a possible indication of neuropathy. 6. Foot Pathology It is recommended that this section be completed on each assessment as it provides completeness and enables the practitioner to confirm the risk status from a physical / pathological perspective. It also allows for communication between disciplines (though it is important to note that any serious concerns must be addressed appropriately and followed up, practitioners must not rely on action from comments on this form). The form can be referenced against previous assessments and should show, any increase in risk levels e.g. the patient may have had recorded the presence of a bony 25

26 condition (shown on previous assessment), and is now exhibiting corn and callous formation associated with the previous condition. This section can be further divided into: A thickened nail for example will increase pressure on the nail bed and thus there is potential for subungual ulceration. Involuted and ingrowing nails or neglected nails may penetrate the skin allowing entry to bacteria and increasing the risk of infection. Thickened nails, deformed nails or the absence of nails may indicate inadequate nutrition. a. Skin should be examined for callous, corns, dryness, fissuring, extravasation, broken skin, existing ulceration and gangrene etc. Here the site of the lesions should be noted. Calluses result from increased pressures and may increase these pressures further. Calluses could also result from changes in foot structure due to motor neuropathy. Callous, dryness, fissuring and poor elasticity may result from autonomic neuropathy and devitalisation through inadequate blood flow. Bleeding under the skin is a sign of pressure. Vital clues can be found on conducting skin examination towards the existence of underlying vascular and neuropathic problems., Skin examinations enable an assessment of the risk from high foot pressures and the potential for skin damage / breakage and hence infection risk. b. Structural and Biomechanical / Gait abnormalities. The obvious structural abnormality is the Cavoid foot type which may be an indication of the presence of PN but also results in increased pressures through a high medial longitudinal arch, exposed metatarsal heads and clawing of the digits. Limited joint motion may occur through prolonged hyperglycaemia. Pre existing biomechanical abnormalities may affect gait and result in other structural problems such as Hallux Valgus which may pose similar problems. A footwear assessment may identify gait patterns and identify potential risk factors by examining the wear on, and the shape of a worn shoe. Footwear should be assessed for suitability as the style and make-up of the shoe may be a risk factor in itself. 7. Conclusion This is the summary of the patients overall risk status and is dependent on the outcomes of the above tests and assessment

27 The National Institute for Clinical Excellence (NICE) paper on Diabetic Foot Problems; Prevention and Management (NG , updated 2016)* gives succinct guidelines on the classification of these patients and the form is designed to reflect these (Type 1 Diabetics will also follow the same classification): - Low Risk: - normal sensation, palpable pulses Increased Risk neuropathy or absent pulses or other risk factors High Risk neuropathy or absent pulses plus deformity or skin changes or previous ulcer Foot Ulceration care of people with foot care emergencies (e.g. Charcot neuropathic osteoarthropathy) and foot ulcers There is a fair degree of practitioner autonomy / interpretation afforded in this decision (as the Tool does not rely on score sheets etc), thus practitioners are encouraged to comment. * Update of guideline entitled - Clinical Guidelines and Evidence Review for Type 2 Diabetes; Prevention and Management of Foot Problems 8. Health Education Foot health education in relation to the effects of Diabetes alone has been proven to reduce amputation rates by in excess of 50%. This section is designed to provide a record of the topics discussed with the patient on the day of assessment as well as an indicator of topics still to be discussed for the practitioner (when referenced against previous assessments) 27 25

28 Appendix 6 Office Only Date Received. TIARA No:.. Community Health Services Division Please Return To: Podiatry Service Call Centre South Wigston Health Centre 80 Blaby Road South Wigston Leicester LE18 4SE Tel: Fax : APPLICATION FOR PODIATRY ASSESSMENT ALL DETAILS MUST BE COMPLETED TO ENSURE EFFECTIVE PRIORITISATION (Incomplete applications may be returned) PATIENT NHS NO PATIENT SURNAME Date of Birth FULL ADDRESS POSTCODE TELEPHONE Home: Work: Mobile: Provide your mobile number and we will text reminders of your appointments Evidence shows that patients who receive text reminders are less likely to miss appointments; reducing wasted time and money and helping us to provide a more efficient Service. PATIENT TITLE (please circle) PATIENT FORENAME FAMILY GP NAME & ADDRESS MR MRS MISS Name: NEXT OF KIN/ CARER CONTACT Telephone: IMPORTANT as we will ring you to book your appointment. If you do not have a telephone please indicate N/A an appointment will be sent in the post. Consent to leave answer phone messages Yes No Consent to contact at work Yes No I do not wish to receive text reminders (consent assumed otherwise) Address: (by supplying your ; we will assume we have consent to contact you in this way) To be completed by GP / Consultant Referrer if on 18 weeks pathway : Please complete if the patient is on an 18 week pathway and you are referring them for definitive treatment 18 WEEK CLOCK START DATE: PPI: RTT PATHWAY YES NO 28

29 PODIATRY NEED Please explain the current problem you are having with your foot/feet: MEDICAL HISTORY Please indicate if you have any of the following: Diabetes Rheumatoid Arthritis Lower limb amputation Do you have any medical conditions / illnesses or disabilities? If so, what are they? (e.g. high blood pressure, heart condition, communication difficulties, severe mobility problems, dementia) Current Medication (please state) Do you have any known allergies e.g. latex? (please state) Have you had, or are you waiting for any operations or medical tests? (please state) Do you have any specific or special requirements / needs when being contacted, assessed or treated by Podiatry Services? Need an Interpreter Yes No If yes state language Need a Chaperone Yes No Suffer with deafness Yes No Use a Wheelchair Yes No Have any other needs Yes* No *Please state Referrer Patient Carer Consultant** District Nurse Practice Nurse INCH GP** AHP DSN Other* AQP ref* Loros *Please state **Referring GP / Consultant Name (Print) Address: Date of Next O/P Appointment Signature: Date: Print Name (if you are not the patient): Ethnic Origin: (please tick one of the boxes below) White British Indian Other Asian Background White Irish Pakistani Other Black Background White & Asian Bangladeshi Other Mixed Background White & Black African African Other Ethnic Background White & Black Caribbean Caribbean Other White Background Chinese Prefer not to State 29

30 Appendix 7 A University Teaching Trust Community Health Services Division Podiatry Services Diabetes Foot Care People with diabetes have special reason to care for their feet. Diabetes can result in damage to the circulation and feeling in their feet. However, the development of foot problems is not an inevitable consequence of diabetes. Most problems can be prevented. Have your feet checked by your podiatrist, and follow the advice given below. On average you take 5,000 steps per day Aim for the best control of your blood glucose levels and your blood pressure which will reduce your chances of complications. If you smoke you should make every effort to stop to prevent circulation problems. Also try to exercise daily to stimulate the blood flow through your feet and legs. Cut your toenails regularly (unless advised otherwise by your podiatrist) after a bath when they are softest. Try not to cut them too short. Alternatively, use a file weekly before bathing your podiatrist will show you how. Use a soft nail brush if you need to clean the edges of your nails. If you develop any corns, hard skin, ingrowing toenails or other foot problems, see your podiatrist. NEVER use corn plasters or paints as they contain strong acids. Any minor cuts or blisters should be covered with a sterile dressing. NEVER pick blisters. If they burst, treat as above. If not treated straight away, trivial and minor wounds can lead to more serious infected conditions. So, if minor injuries do not heal or improve, consult your podiatrist, doctor or nurse. Wear well-fitting shoes with soft uppers. Shoes with laces or Velcro fasteners are recommended because they hold your heel firmly in the back of the shoe. This prevents your feet from sliding forward and leaves plenty of room for your toes. If you must wear unlaced court shoes, do so for only short periods. Socks and stockings should be changed daily. Socks should be made of cotton or wool, and be long enough for your feet so that your toes are not cramped. Avoid seams, which may cause rubbing and avoid tight elastic, which might reduce your circulation. If your skin is dry, apply a little moisturising cream daily to your feet, but not between your toes. If your skin is moist between your toes, apply a little surgical spirit or witch hazel, using cotton wool. Remember Preventive care of the feet, combined with good diabetic control, is the best protection against foot problems. 30

31 Daily check It is essential to examine your feet every day. Also check inside your shoes for anything that may irritate the skin, such as stones, sharp objects or creased insoles. As even mild infections can upset your blood glucose levels consult your podiatrist, doctor or nurse immediately if: You notice a colour change in any part of your leg or foot. You notice a discharge coming from a break in the skin, from a corn, or under a toenail. There is any troublesome pain, throbbing, swelling, or itching. Contact details for advice: Contact details for appointments: Podiatry Service Call Centre South Wigston Health Centre 80 Blaby Road South Wigston Leicester LE18 4SE Tel: Fax :

32 Appendix 8 Podiatry Services Diabetes Foot Care Poor Sensation (Neuropathy) 32 A University Teaching Trust Community Health Services Division Your examination has shown that diabetes has affected the nerves in your feet, causing loss of feeling. You may not easily be able to detect changes in temperature, or feel touch and pain as well. As a result, foot problems may occur without you being aware of them. Such damage may lead to infection that can spread and also slow down healing. Some of the symptoms you may experience include: Loss of pain sensation Feeling of walking on cotton wool Over-tight skin Tingling Pins and Needles Shooting pains Burning sensations Loss of feeling in your feet makes you more prone to accidental injury. If you suffer a foot injury, however minor, you must seek professional medical help immediately as this can be potentially serious. Daily check It is essential to examine your feet every day for cuts or grazes as walking on an injured foot could cause further damage. Because of the risk of injury, avoid walking barefoot. To prevent damage to your legs and feet, do not sit too close to fires or heaters. Turn off electric blankets and remove hot water bottles before getting into bed. Wash your feet everyday in warm water but do not soak them for long periods. Test the temperature of the water to check that it is not too hot for you. Rinse well after washing and dry carefully between the toes. Footwear Poor fitting shoes can rub the skin and cause a sore area so ensure your shoes fit properly. Patients who have lost feeling in their feet often wear shoes that may be too tight because they feel more secure. Before putting on your shoes, check inside for small stones or grit etc., and check that there are no rough seams or ridges in your shoes.

33 New shoes wear them in the house to start with for half an hour at a time. Then, check your feet for any areas of redness, blistering or swelling. Seek advice from your podiatrist about appropriate footwear. Ensure that socks or stockings do not have prominent seams before wearing them. It may help to wear them inside out. Diabetes can cause damage to the nerves in your feet which can alter their shape. You may develop a high arch, which will cause the ball of your foot to become prominent and the toes to claw. If you have difficulty finding shoes to fit, you may need specially made shoes. See your doctor or podiatrist, as these are only made on prescription. 33

34 Appendix 9 A University Teaching Trust Community Health Services Division Podiatry Services Diabetes Foot Care Poor Circulation (Ischaemia) Your examination has shown that the circulation in your legs and feet is reduced. You may experience cramp-like pains in the calf, feet and / or buttocks. This may be due to impaired circulation to the muscles of your legs. You have special reasons to care for your feet because, as a result of your circulation, your feet are vulnerable. If you suffer a foot injury, however minor, you must seek professional medical help immediately as this is potentially serious. Smoking Smoking increases the risk of further damage to your circulation; therefore it is in your best interests to stop. It also reduces the oxygen levels in your blood, which will make wounds take longer to heal. When resting, do not cross your legs as this can restrict your circulation. Daily check It is essential to examine your feet every day for any cuts or grazes, as walking on an injured foot could cause further damage. Footwear Poor fitting shoes can rub the skin and cause a sore area so ensure your shoes fit properly. Patients who have lost feeling in their feet often wear shoes that may be too tight because they feel more secure. Before putting on your shoes, check inside for small stones or grit etc., check that there are no rough seams or ridges in your shoes. New shoes wear them in the house to start with for half an hour at a time. Then, check your feet for any areas of redness, blistering or swelling. Seek advice from your podiatrist about appropriate footwear. 34

35 Ensure that socks or stockings do not have prominent seams before wearing them. It may help to wear them inside out. If you have difficulty finding shoes to fit, you may need specially made shoes. See your doctor or podiatrist, as these are only made on prescription. 35

36 Appendix 10 A University Teaching Trust Community Health Services Division Podiatry Services Looking After Your Diabetic Foot Ulcer You have been issued with this leaflet because you have an ulcer or ulcers on your foot / feet. What is a Diabetic Foot Ulcer? This is an open wound or sore on your foot that is taking longer to heal than expected. Diabetes can affect the feeling and / or the circulation to the feet, making you more prone to damage and affecting the healing You may also be more susceptible to infection. About 1 in 10 people with diabetes will develop a foot problem at some stage. Keeping good control of your diabetes, cholesterol and blood pressure is vital, as this can reduce the risk of complications such as foot ulcers. Having your feet assessed regularly by a Podiatrist or other trained healthcare professional will also help to reduce the likelihood of foot problems occurring. Podiatry treatment for your diabetic foot ulcer Your Podiatrist / Diabetes Specialist Podiatrist is fully trained and expert in caring for the feet of people with diabetes; they will assess and treat you to help heal your foot ulcer and to prevent such problems occurring again. Foot ulcers often present with a build-up of callus (hard / dead skin) over the top and surrounding them. This can sometimes hide or disguise an ulcer and only when the skin is removed, the ulcer is revealed. If there is callus present, this needs to be removed to help the heal ulcer. The Podiatrist is best placed and skilled in removing this callus and on doing so the ulcer may bleed; if this should happen, Please Don t Worry as this is normal and the Podiatrist will explain and take care of it / you. NEVER try to remove callus yourself as that could be very dangerous and cause infection etc. Your Podiatrist will also check your shoes to ensure they are appropriate and not causing pressure or rubbing your feet and will advise accordingly. Tight, inappropriate or ill fitting footwear can often be the cause of foot ulcers, make them worse and / or prevent them from healing. You may be supplied with or asked to use special footwear, casted boots etc; Often the Podiatrist will make very specialised and specific insoles to go inside your shoes or other devices to relieve pressure from an ulcer and help you to walk better, it is important that you use these devices and discuss any issues or fears. The Podiatrist may supply or recommend specific dressings that will aid the healing of your ulcer, advise on how to use them and how often the dressing should be changed. 36

37 Arrangements may be made for a district / practice nurse to help or you might be asked to contact them yourself. Again it is important that you follow the plan and advice should you be asked by any other professional to change from the plan, please inform your Podiatrist so that they may discuss this. How to Look After Your Diabetic Foot Ulcer Do not touch the dressings unless you have been shown how to remove and replace them. You may need a District or Practice Nurse to redress your foot. ALWAYS wash your hands before and after any dressing change. Do not get the dressing wet in between changes. Eat a well balanced diet and try to keep your diabetes well controlled. If you smoke try to reduce the number you smoke or try give up all together. If you drink alcohol regularly, then try to reduce your intake. Danger Signs It is essential to check your feet everyday as walking on an injured foot may cause more damage. Pay special attention to any of the following danger signs: Unexplained swelling Unexplained bleeding Pain, throbbing or itching Increase in or discharge from the ulcer An unpleasant smell Change in colour Increase in temperature (hot) around the ulcer site or on the foot Fairly quick changes in the shape / structure of your foot Other breaks, rubs or abrasions on your foot Discharge from any other breaks in the skin or under a toenail Feeling generally unwell and / or your blood sugar levels are raised or erratic. If you notice any of these symptoms, seek advice as soon as possible from your GP, Podiatrist, Nurse or other Health Care Professional; cover any new open wounds that you discover with a clean dry dressing. Antibiotic treatment If there are signs of infection in the wound or in the nearby tissue or bone, you are likely to be given antibiotics. These should be taken as instructed and you must finish the course. Report any problems you notice that might be a cause of antibiotic treatment (e.g. rashes, nausea or diarrhoea) to your GP or person who prescribed / issued them. Do not stop taking them unless advised to do so. Appointments You are likely to have regular appointments until the wound has healed, you must always attend. Your Podiatrist may feel it appropriate to refer you to the hospital Foot Clinic for further advice / care and will discuss this with you should it be required. Contact Details Podiatry Appointments (Lines open Mon Fri, 9am 4pm) If extremely urgent, you can access any of the following Podiatry Fast Access (Dropin) clinics between 9am 12pm; no appointment necessary. 37

38 A University Teaching Trust Community Health Services Division Podiatry Service Podiatry Community Foot (Drop-in) Clinics (Formerly Fast Access) Day Time Podiatry Clinics Monday 9.00 am p m Hinckley Health Centre Hill Street Hinckley Leics LE10 1DS Market Harborough District Hospita Coventry Road Market Harborough Leics LE16 5PR Tuesday 9.00 am p m South Wigston Health Centre 80 Blaby Road South Wigston Leicester LE18 4SE Wednesday 9.00 am p m Coalville Community Hospital Broom Leys Road Coalville Leics LE67 4DE Merlyn Vaz Health & Social Care Centre 1 Spinney Hill Road Leicester LE5 3GH Thursday 9.00 am p m Melton Mowbray Hospital Thorpe Road Melton Mowbray Leics LE13 1SJ Friday 9.00 am p m Loughborough Hospital Braunstone Health & Social Epinal Way Clinic Care Centre Entrance 2, Hospital Way Hockley Farm Road Loughborough Leicester LE3 1HN Leics LE11 5JU Patients can attend any clinic if they have an emergency regardless of locality Please contact the Podiatry Call Centre on:

39 Appendix 11 Flowchart for referral procedure Foot examination with shoes and socks/stockings removed Test foot sensations Inspect for any deformity Inspect footwear Check for signs of ulceration Palpate foot pulses Inspect for significant callus Ask about pain Ask about previous ulceration Low Risk Normal sensation, palpable pulses Increased Risk Neuropathy or absent pulses or foot changes High Risk Previous ulcer/amputation. Deformity/skin changes. Neuropathy/absent pulses Emergency/Ulceration Active foot ulceration, break in skin, spreading infection, hot red swollen foot No Foot Pathology With Foot Pathology GP Practice Annually Routine Podiatry 3-6 monthly OurServices-Podiatry.aspx Priority Podiatry 1-3 monthly urservices-podiatry.aspx Emergency Referral Within 1 working day Diabetic Foot Emergency Hotline General Diabetic Footcare 39 Neuropathy and/or Vascular Appendix IV Ulcer Care Appendix VI