Management Of The Diabetic foot Aims, Pathways, Treatments Nikki Coates 12/1/18
Diabetic foot pathology Neuropathy Foot deformity Vascular disease Sensory neuropathy Limited Joint Mobility Smoking Autonomic Neuropathy Footwear Difficulties Dyslipidaemia Motor Neuropathy Hypertension Lack of pain sensation Difficult foot shape Ischaemic foot FOOT ULCERATION Injury
Scale Of the problem Between April 2007 - March 2010, the incidence rate of lower limb amputations in people with diabetes was 2.51 per 1,000 person-years; those without diabetes incidence rate was 0.11 per 1,000 person-years In 2009/10 over 6,000 lower limb amputations occurred in people with diabetes.(yhpho- March 2012) Two-year survival rate following amputation in people with diabetes is only 50 per cent 80% of amputations could potentially be preventable through access to good quality structured care and improved awareness among people with diabetes about their risk status and the actions they should take. NHS expenditure on diabetic foot ulceration and amputation was estimated to be between 639m and 662m (0.6% - 0.7% of NHS budget).
Aims Newcastle - Diabetic foot risk profile ULCERATED HIGH RISK INCREASED RISK LOW RISK Foot risk category profile MDT management of foot ulceration to Prevent amputation Optimal management foot problems to prevent foot Ulceration. Foot protection team Manage foot risk factors to prevent Diabetic foot complications. Foot protection team Education of patients re. prevention of Diabetic foot disease. Effective foot screening programme
Preventing Amputation The Putting Feet First campaign aimed to reduce the rate of lower limb amputations in people with diabetes by 50% Via four key objectives: 1. Raise awareness with people with diabetes, healthcare professionals and the public of the seriousness of amputations and the impact of diabetes on feet 2. Improve standards of care by ensuring people with diabetes have annual foot checks and know how to look after their feet 3. Improve access to multidisciplinary foot care teams (MDFT) by ensuring these teams are available in all areas 4. Increase foot examinations for people with diabetes admitted to hospitals. https://www.diabetes.org.uk/documents/nhs-diabetes/footcare/footcare-for-people-with-diabetes.pdf https://www.diabetes.org.uk/upload/shared%20practice/improving%20footcare%20economic%20study%20 (January%202017).pdf
Diabetic Foot Disease Pathway Framework Improve standards of care Equitable access to care -Both feet assessed and documented within 24 hours of admission to hospital -Every ulcer has size, depth & position recorded -Referred to podiatry in a timely manner -Integrated care across all layers of foot care pathway
Newcastle Diabetes Foot Care Pathway Patient with Diabetes Stage 1 Annual foot assess For all HCP involved in annual review (Training delivered by podiatry) LOW RISK PTS. Stage 2 Foot Protection team podiatry Annual assess, risk categorisation and treatment as clinically required Stage 3 Diabetes Centre Podiatry assess & treatment of Complex foot & active foot disease Stage 4 Medical foot clinic Diabetes Centre Multi- Disciplinary management of complex & Acute Diabetic foot Patient admitted to hospital with Diabetic foot disease Optimal in- patient foot care, minimal length of stay and re- admission avoidance
OUTPATIENT DIABETES ACTIVE FOOT DISEASE REFERRAL PATHWAY ACTIVE FOOT DISEASE IDENTIFIED Diabetes UK 2009 > Active Ulceration The term active foot disease refers to anyone with diabetes who has: > Spreading Infection An ulcer, blister or break in the skin on any part of the foot, or any sign of infection > Critical Ischaemia Unexplained pain in the foot > Gangrene Fracture or dislocation in the foot with no preceding history of significant trauma > Unexplained hot, red, swollen foot Gangrene of all or part of the foot > Acute Charcot Monday- Friday 8:30-4:00 RAPID REFERRAL WITHIN 24 HOURS TO THE MULTIDISCIPLINARY FOOT TEAM Fax : 0191 2821018 (Newcastle Diabetes centre) Telephone : 0191 2823129 (specialist podiatrist) ASSESS CLINICALLY and discuss with a specialist podiatrist who will triage the request to the most appropriate clinic/ time. 1.Superficial Ulceration. Diabetic foot ulcer without clinical signs of infection. Apply dressing to the area and advise patient to minimise weightbearing until appointment 2 If Charcot Foot suspected. A Red, hot swollen foot on a patient with Diabetes and Neuropathy with or without a history of trauma. Advise not to weightbear until appointment 3. If ulcer is deep or infected / cellulitus / gangrene. Apply dressing to the area and not to weightbear. 4. If you suspect admission is needed speak to the Diabetes registrar on call who may suggest admission via the Medical assessment suite Out of hours, weekends and holidays WALK IN CENTRES OPEN 8AM- 8PM, 7 DAYS PER WEEK INCLUDING BANK HOLIDAYS Molineux street- Byker- Tel: 2755862 CAV site, Westgate road- Tel:2823000 Emergency department- RVI, Tel:2336161 x 26100 or 26200
Principles of managing Diabetic foot ulceration 1. Refer to your Diabetic foot MDT as per your local pathway without delay. 2. Relief of pressure and protection of the ulcer 3. Treatment Of Infection 4. Restoration of skin perfusion 5. Metabolic control and treatment of co- morbidities 6. Local wound care 7. Determining the cause and prevention of re-occurance Optimum wound care cannot compensate for continuing trauma to the wound bed, or for ischemia or infection. (IWGDF 2007 )
Treatments Foot pressure relief - If its red keep it off the bed! Pillows to float heel and knee break in bed Leeder boot/ PRAFO Temporary sandal Heel lift boot X
Treatments Diabetic foot infection -send deep tissue or bone sample as per local microbiology guidance -all departments should have antibiotic guidelines covering the care pathway taking into account local patterns of resistance -consider x- ray to determine extent of infection - If you suspect osteomyelitis which is not confirmed by x- ray then MRI - Prolonged antibiotics ( 6 weeks ) to patients with osteomyelitis Diabetic foot ulceration -offloading- for plantar neuropathic, non- infected ulcers offer nonremovable casting -debridement- should be carried out by a member of the Diabetic foot MDT or in community on the advice of a member of the MDT
Treatments Following Surgical debridement - consider NPWT in conjunction with the Diabetic foot MDT Charcot Arthropathy - For suspected or confirmed charcot arthropathy offer nonremovable cast
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