Foot Ulcer Workshop: Prevention and Management of Diabetic Foot Ulcers Aparna Pal, Consultant Endocrinologist, RBH Keith Hilston, Podiatrist, BHFT
High mortality and morbidity Complex condition, longterm impact on morbidity and mortality Patients with diabetic foot ulcer (DFU) greater risk premature death, MI and fatal stroke Often potentially preventable initiating event (minor trauma) can often be identified Foot amputation, many of which are preventable with early recognition and therapy, may be required
High mortality and morbidity 1 in 10 patients with a DFU will require surgery UK annually 5000 diabetes-related amputations (15X more than for people without diabetes) 72% diabetes-associated amputations are preceded by ulcer Around the world it is estimated that a lower limb is amputated every 20secs due to complications of diabetes National Diabetes Support team 2006 Pecoraro 1999
High mortality
WHY - Quality of Life
Diabetic foot problems are common (but preventable) In UK 5-7% diabetes patients currently have or have had a DFU, but over lifetime 25% risk of development DFU Has been suggested that upto 85% amputations can be avoided if an effective careplan is adopted Pecoraro Diabetes Care 1990
High impact upon individual and to NHS In England, foot complications account for 20% of the total NHS spend on diabetes care Equates to approx 650 million per year Having a pressure ulcer increased LOS 4.31days
WHY - Cost
Clinical condition Pathophysiology Primary prevention Treatment Service design and referrals Community Diabetic Foot Clinic Inpatient foot pathway
Pathophysiology
Diabetic foot ulcers pathophysiology Neuropathic DFU Ischaemic DFU Neuroischaemic DFU
Major RFs Peripheral neuropathy Peripheral vascular disease Deformity History of ulceration and amputation
Major RFs Peripheral neuropathy Peripheral vascular disease Deformity History of ulceration and amputation Additional RFs Longstanding diabetes Male Poor glycaemic control Cardiovascular disease Nephropathy Retinopathy Social factors
Local admission and amputation rates
Episodes of care
Outcomes
Outcomes
HOW Foot Screening That HCP should have the skills necessary to: a. identify the presence of sensory neuropathy (loss of ability to feel monofilament, vibration or sharp touch) and/or the abnormal build up of callus b. identify when the arterial supply to the foot is reduced (absent foot pulses, signs of tissue ischaemia, symptoms of intermittent claudication) c. identify deformities or problems of the foot (including bony deformities, dry skin, fungal infection) that may put it at risk d. identify other factors that may put the foot at risk (which may include reduced capacity for self-care, impaired renal function, poor glycaemic control, cardiovascular and cerebrovascular disease). Putting Feet First: national minimum skills framework: March 2011
Foot Screening - NDA Care Process - Foot examination Year of audit England % Berkshire West % 2006-07 73.6 76.0 2007-08 77.1 76.1 2008-09 82.9 80.7 2009-10 82.3 78.9 2010-11 84.4 84.7 2011-12 85.3 85.2 2012-13 85.1 85.4
Foot Screening - QOF 2012-13 Percentage of patients receiving DM29 by practice QOF 2012-13
National Diabetes Audit 2011/12 Report 1 NDA Care Processes Berks West 95.5 92.6 90.8 90.9 85.4 84.8 76.6 92.4 We are missing feet and an opportunity
A neuropathy C deformity B vascular D other Basic patient education Inform patient risk rating
Foot Screening -Education leaflets http://www.berkshirewestdiabetes.org.uk/professionals/carepathways/foot-care-pathway/patient-leaflets
Care of people at low current risk of foot ulcers normal sensation, palpable pulses *Risk of ulceration 0.1%, 70% of diabetic population Management Basic foot health education Annual foot screening *The Tayside foot-risk Stratification Scheme (Leese et al 2006, 2007)
Care of people at moderate risk of foot ulcers neuropathy or absent pulses or other risk factor *6x risk ulceration than low risk, 20% diabetic population Management Refer to community foot protection team Arrange regular review, 3 6 monthly, by foot protection team *The Tayside foot-risk Stratification Scheme (Leese et al 2006, 2007)
Care of people at high risk of foot ulcers neuropathy or absent pulses + deformity or skin changes or previous ulcer *83x risk of ulceration than low risk, 4-8% diabetic population Management Refer to community foot protection team Arrange regular review, 1 3 monthly, by foot protection team *The Tayside foot-risk Stratification Scheme (Leese et al 2006, 2007)
Care of people with foot care emergencies and foot ulcers Foot care emergency (new ulceration, swelling, discolouration) *1-4% diabetic population Management refer to multidisciplinary foot care team within 24 hours. *The Tayside foot-risk Stratification Scheme (Leese et al 2006, 2007)
Integrated Foot Care Pathway Secondary Care Primary Care
Management Annual foot review Primary prevention Risk rating and appropriate follow-up Infection Neuropathic pain Vascular disease
Foot review Deformity and integrity of skin Assess for neuropathy Screen for peripheral arterial disease Advice for prophylactic foot care Refer high risk patients http://www.nwyhelearning.nhs.uk/elearning/yor ksandhumber/shared/diabeticfoot/html_fe B14/index.html
Foot review Deformity and integrity of skin Assess for neuropathy Screen for peripheral arterial disease Advice for prophylactic foot care Refer high risk patients
Deformity Callus indicates areas of tissue damage Assess bony deformity Abnormal plantar pressure Atypical gait Altered biomechanical loading Bakker 2011 Diab Met Research Rev; Wounds Int Best Pract Guidelines Edmonds 2013
Deformity
Foot review Deformity and integrity of skin Assess for neuropathy Screen for peripheral arterial disease Advice for prophylactic foot care Refer high risk patients
Assessing for peripheral neuropathy
Monofilament estimation of pressure sensation Place filament at right angle Pressure increased Patient asked if pressure felt Patients insensitive are at increased risk of foot ulcers
Assessing for peripheral neuropathy Ipswich touch test Simple bedside test Reproducible Comparable to monofilament
Foot review Deformity and integrity of skin Assess for neuropathy Screen for peripheral arterial disease Advice for prophylactic foot care Refer high risk patients
Assessing peripheral vascular disease General signs - decrease in skin temperature, thin skin, lack of skin hair, and bluish skin color. Not sensitive nor specific More useful - lower limb pulses and measurement of venous filling time The absence of pedal pulses, the presence of femoral bruits, or prolongation of venous filling should prompt referral for more detailed evaluation Patients with clinical evidence of peripheral vascular disease should have ankle-brachial pressure index (ABPI) testing
Foot review Deformity and integrity of skin Assess for neuropathy Screen for peripheral arterial disease Advice for prophylactic foot care Refer high risk patients
Primary prevention Avoid smoking, walking barefoot, the use of heating pads or hot water bottles, and stepping into a bath without checking the temperature Trim toenails to the shape of the toe and file to remove sharp edges Inspect daily, looking between and underneath the toes and at pressure areas for skin breaks, blisters, swelling, or redness Well fitting shoes, cotton socks, customised shoes for misshapen feet, good insoles to reduce pressure Wash daily in lukewarm water with mild soap and pat dry Moisturiser
Foot review Deformity and integrity of skin Assess for neuropathy Screen for peripheral arterial disease Advice for prophylactic foot care Refer high risk patients - >1 of neuropathy/deformity/pvd or previous ulcer/amputation
DFU assessment Examine the ulcer Sensation PVD Deformity Identify infection Edmonds 2013 Int Best Pract Guideline
Infected DFU Can be difficult to identify infection Common 56% DFU will become infected 20% infected DFUs will undergo lower limb amputation RFs probe to bone, >30days, recurrent DFUs, trauma, PAD, barefoot walking, renal insufficiency, sensory neuropathy, previous amputation Take cultures/deeps swabs from infected DFUs
Infected DFU Edmonds Wound Int Best pract Guidelines 2013
Wound classification
DFU suspecting osteomyelitis Wounds that are chronic, deep, overly bony prominence at high risk Sausage toe Exposed bone Depth of probe to bone, gritty on probing Xray, MRI Bone biopsy, debridement
DFU wound management Treat underlying disease processes Ensure adequate blood supply Local wound care, including infection control Pressure offloading
Treat underlying disease processes Treat severe ischaemia Tighten glycaemic control Treat other RFs BP, lipids, smoking Address nutritional deficiencies
Ensure adequate blood supply Angioplasty Stent Bypass Enarterectomy
Peripheral Arterial Disease Macro/Micro Acute/Chronic Calcification Painful Increased risk of heart attack and stroke
Infection Mild Moderate Severe
What you take off the wound! Debridement Sharp NPWT Larvae Off-loading TCC rtcc wound shoe felt
Neuropathic pain All neuropathic pain (except trigeminal neuralgia) 1.1.8 Offer a choice of amitriptyline, duloxetine, gabapentin or pregabalin as initial treatment for neuropathic pain (except trigeminal neuralgia)[3]. 1.1.9 If the initial treatment is not effective or is not tolerated, offer one of the remaining 3 drugs, and consider switching again if the second and third drugs tried are also not effective or not tolerated. 1.1.10 Consider tramadol only if acute rescue therapy is needed (see recommendation 1.1.12 about long-term use). 1.1.11 Consider capsaicin cream[4] for people with localised neuropathic pain who wish to avoid, or who cannot tolerate, oral treatments. NICE Clinical Guideline 173 2013
Cases for urgent referral Infection and systemic sepsis Acute ischaemia Acute Charcot
Cases for urgent referral Infection and systemic sepsis Acute ischaemia Acute Charcot
Charcot s neuroarthropathy
Clinical condition Pathophysiology Primary prevention Treatment Service design and referrals Community Diabetic Foot Clinic Inpatient foot pathway
Diabetic Foot MDT clinic/nice Excellent team podiatrists daily clinics Diabetologist joins the team for Wednesday clinic Vascular surgeon joins alternate Weds clinic Monthly Xray meeting Monthly meeting with renal Access to plaster room, orthotics, TVN, orthopaedics, microbiology
The wishlist. Adequate site for clinics Weekly vascular surgeon in clinic to also do joint ward round of inpatients following clinic 2 weekly Xray MDT Orthotist and DSN also in clinic Virtual microbiologist Rapid access to orthopaedic and plastic surgeon On site duplex ultrasound Rapid imaging and angioplasty as required Links with Oxford BIU
Radiology
Foot surgery
Secondary Care Diabetologist Vascular Orthopaedics Microbiology Radiology Orthotist Tissue Viability Podiatrist Patient Primary Care GP District Nurse Practice Nurse OT Physio Dietician IC Nurses Podiatrist
Questions Thank you for listening
Cases
National Diabetes Foot Audit What will the NDFA measure? Structures: are the nationally recommended care structures in place for the management of diabetic foot disease? Processes: does the treatment of active diabetic foot disease comply with nationally recommended guidance? Outcomes: are the outcomes of diabetic foot disease optimised?
Outcome measures