Training the trainers - management of the diabetic foot


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An example of how on locality in UK disseminates good practice for managing the diabetic foot.

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  • I’m sure I don’t need to tell you the impact of foot related complications to the NHS. Diabetes is the most common cause of lower limb amputations
  • I thought it would be most useful in this session to review annual review risk classification , how that relates to referring to podiatry, what podiatry will offer those patients we see, a few case studies. I realise that it’s not always the diabetes specialist that might see a patient with an emergency so I’m also going to discuss the Red, Hot Swollen foot.
  • All patients with type 2 and all those with type 1 aged over 17 should have an annual review within primary care. This should include an annual foot assessment . This should include: Foot Inspection: looking at Dorsal , plantar and posterior surfaces of the foot and between the toes, looking for Foot deformity,Callus,Skin and nail conditions or any trauma Vascular status Palpation of pulses and look for evidence of ischaemic change History of intermittent claudication or rest pain
  • Neurological – NICE guidance states use 10g monofilament. We in podiatry also test vibration sensation as an indicator of neuropathy using a 128 HZ tuning fork and neurothesiometer in hospital sites To ensure reproductability of test monofilaments should be replaced when worn, or after 100 uses.
  • The risk classification within the Local Enhanced Service Agreement and by NICE is : At low current risk At increased risk At High Risk Ulcerated foot
  • If there is normal sensation, adequate circulation , no podiatry need and no previous ulceration these patients should continue to be screened annually in primary care.
  • Neuropathy – Neuropathies may affect up to 50% of patients with diabetes (Boulton AJM (2005) management of diabetic peripheral neuropathy. Clinical Diabetes 23:9-15.) This figure is based on four different studies in which estimates of neuropathy range from 66% in people with type 1 diabetes over 60 years of age to 41.6% in people who have been diagnosed for over 7 years Chronic painful neuropathy is estimated to affect about 1 in 6 ( 16.2%) of people with diabetes compared with 1 in 20 ( 4.9%) in the age and sex matched control group (Daousi C et al ( 2004) Chronic painful peripheral neuropathy in an urban community a controlled comparison with and without diabetes. Diabetic medicine 21(9) 976-982) if symptomatic: Shooting pains, cold feet,burning,tingling,stabbing. Important to ask about symptoms and if affecting lifestyle and consider guidelines on painful neuropathy. Ischaemia :If absent pulses, listen with doppler , if biphasic no further action needed , if monophasic, do ABPI If absent pulses and non-healing foot wound refer to Vascular If ABPI less than 0.5 consider urgent referral to Vascular team If significant symptoms, eg intermittant claudication, regardless of ABPI consider referral to Vascular Deformity – foot deformity Nail deformity or callus Or any other factor which puts the foot at increased risk of infection
  • Sensory neuropathy is a major cause of injury to the foot. It is damage to the nerves that perceive vibration, temperature, heat and pain. If the patient cannot feel pain they are unaware of any injuries to the foot this can be a sudden injury such as standing on a bit of glass/ burning the skin or gradual injuries for example the build up of callus. This can lead to ulceration and infection. When patients develop ulcers it may only be a smell, a blood stain on the sock or somebody else's observation that makes them aware of the problem. I found this in a journal that less than two thirds of ulcers are detected by the patient or relative This 59 year-old patient with type 2 diabetes of over 15 years duration- Although pulses palpable, monophasic with history of IC and was under vascular at Stoke Mandeville and was to have angioplasty, absent vibration and abnormal 10g monofilament. Patient fell asleep with his foot against a hot radiator.
  • Diabetics with infection need more aggressive antibiotic therapy than general population. Initially with a broad spectrum antibiotic  specific antibiotic + a longer course Decrease phagocytosis – due to defective delivery of neurophils and moncytes Poor tissue oxygenation – bacteria compete with tissues for oxygen and nutrients causing a downward cycle of delayed healing and potential limbloss This is to show clinically what Osteomyelitis looks like You get the typical sausage shape toe swollen and red. You can actually see the bone here too. If bone is exposed then we presume there is Osteomyelitis this can be catastrophic. This would need to be treated good bony penetrating antibiotics for at least 6 weeks
  • Whatever the risk classification people should be given appropriate advice. People newly diagnosed with diabetes may be referred onto a DESMOND course which includes raising awareness of foot health. I have asked that within your pack you have 2 diabetes foot leaflets – one by Diabetes UK and 1 by Society of Chiropodists and Podiatrists ( both are available online) which you may wish to review and choose one to re-enforce any verbal advise. Our service has produced a 2 page leaflet which is available online on the Hertfordshire Community NHS Trust
  • So to begin with what is the acute foot? Well it is Any Infected ulceration with neuropathy and / or ischaemia A Rapidly spreading or deep infection such as osteomyelitis Any Red Hot Swollen Foot, which could be infection, a fracture or foreign body or a Charcot?) Or if the patient has a foot problem and is systemically unwell.
  • This lady is aged 55, with Type 2 diabetes and significant neuropathy. She was referred to us by the Practice nurse. And we saw Mrs S the following day in Feb 2010. Her HBa1c was 12.2% and her CRP was 21 where she was admitted into hospital. As you can see this is a good example of a deep spreading infection. She had 4 separate ulceration sites – all probing to bone, Swab result showed moderate staph and group c strep X-ray confirmed osteomyelitis and a small avulsion fracture at the base of the distal phalanx. This lady was in hospital for 2 weeks on Iv antibiotics and then discharged under the care of the joint Podiatry diabetes clinic where she is reviewed weekly. The management for osteomyelitis is at least 6 weeks of good bony-penetrating antibiotics. She is being offloaded in an Aircast and this is her foot six weeks later with just one ulcer remaining. Once healed she was referred to the orthotist for surgical footwear.
  • This is another example of a red hot swollen foot. This is patient, Aged 66 with Type 2 diabetes and significant neuropathy. This problem was picked up in a routine community podiatry appt and was referred urgently to the podiatry multidisciplinary team at the hospital, he’d had this problem for some weeks prior to this appt and as you can see he already had established deformity. xray confirmed a left midfoot charcot. He was treated with a total contact cast, he also had an interdigital ulcer on his fourth toe with osteomyelitis. This was back in September 2008, and unfortunately he is still having ongoing problems with ulceration under the charcot deformity. URGENT referral for this condition is essential in prevention of deformity and possible amputation.
  • This patient was regularly seen within a community podiatryclinic. Seen on 26 th July “I've had terrible problems with my toe, saw GP who prescribed antibiotics.” There was a sudden colour change of toes with history of pain. I spoke to GP and requested urgent referral to vascular and referred to MDT. Pt was sleeping in chair at night as foot so painful. Admitted to vascular team . We saw him again in September and are now seeing him weekly to redress amputation site
  • I hope what these case studies demonstrate is that any Acute diabetes Foot should be dealt with urgently as part of a multi-disciplinary team. So to sum up Any foot ulceration should be referred to podiatry. Faxed through as a matter of urgency. Any spreading / deep infection / red, hot swollen foot / critical ischaemia should be admitted – Immediate action may help prevent amputation
  • Large number of people in diabetic team No one person can manage diabetic foot, need to work as a team Patients often take their foot problems to other health professionals . If someone has high blood glucose levels they may have an underlying foot problem Need to work as a team .
  • Podiatrists have a role to play in both the Acute foot and in maintaining and preventing foot problems
  • Take over nail care where nail deformity or self-care poor.
  • Podiatry obviously has a role to maintain foot health – managing nails and callus / corns
  • Footwear – is it: Long enough Deep enough Have fastening – velcro / strap / lace Heel height Suitable for shape of foot materials
  • What happens if things do go wrong. Involved in treatment and monitoring of Charcot foot- regularly monitoring temps
  • Hard skin which may look innocent , can be hiding an underlying ulcer
  • Podiatrist may use various techniques and dressings in managing ulcers including Redistributive padding, larvae therapy or casting.
  • So to sum up any foot ulceration should be referred immediately by fax to the appropriate podiatry office. At current low risk do not require referral to podiatry. At high risk should be referred to podiatry by sending an application through to the appropriate podiatry office. At increased risk consider whether a referral is necessary. Application forms can be found on the Hertfordshire Community NHS Trust website – we are listed under adult services – Podiatry Service
  • Training the trainers - management of the diabetic foot

    1. 1. Train the Trainer 2011/12The Diabetes Foot Sandra Regan
    2. 2. Costs to the NHS• Around 1 in twenty people with diabetes will develop a foot ulcer in one year *2AbbottCA, VileikyteL,Williamson S et Al(1998) Multicenter study of the incidence of predictive risk factors for diabetic neuropathic ulceration. Diabetes Care 21(7): 1071-1075• 100 people a week lose a toe, foot or lower limb due to diabetes Amputee Statistical Database for the United Kingdom(2007)• Early diagnosis and early intervention by an MDT approach can achieve good outcomes (Edmonds 2009)• Longer ulcers are left untreated the greater the risk of deterioration, limb loss, mobility, disfigurement, mood and independence (Jeffcoate 2009)
    3. 3. The Diabetes Foot• Annual Review – risk classification• Red Hot Swollen Foot• Charcot• Services provided by podiatry – podiatry care – Acute foot
    4. 4. Annual Foot Assessment• Foot Inspection – Dorsal , plantar and posterior surfaces of the foot and between the toes, looking for • Foot deformity • Callus • Skin and nail conditions • Trauma• Vascular status – Palpation of pulses and look for evidence of ischaemic change
    5. 5. Annual Foot Assessment• Neurological status – Unable to appreciate 10g monofilament at any site – Ask about symptomsPresence of other risk factors – Visual Loss – Inability to self care – Previous ulceration / amputation
    6. 6. Risk classification• At low current risk• At increased risk• At High Risk• Ulcerated foot
    7. 7. At low current riskNormal sensationPalpable foot pulsesNo callus or deformityNo previous ulcerationFootwear adequate Annual screening in primary care
    8. 8. Increased Risk Presence of one risk factor• Neuropathy – may affect up to 50% of patients with diabetes• Ischaemia• Deformity• Callus• Visual loss• Previous ulceration / amputation;• Learning difficulties / unable to self careAnnual screening in Primary careConsider Referral to podiatry
    9. 9. At high risk• Presence of Neuropathy or ischaemia PLUS one other risk factorAnnual screening in Primary careReferral to podiatry
    10. 10. Ulcerated foot Sensory neuropathy is a major cause of injury to the foot. If the patient cannot feel pain they are unaware of any injuries to the foot this can lead to ulceration and infection. When patients develop ulcers it may only be a smell, a blood stain on the sock or somebody elses observation that makes them aware of the problem.Urgent Referral to podiatry – fax referral topodiatry admin officeAnnual screening in Primary care
    11. 11. Osteomyelitis Osteomyelitis should beconsidered if an ulcer probes to bone or if bone is visible
    12. 12. When to Problems seek help with Neuropathy FootwearFoot AdviceScreening Advice / Prevention DESMONDSelf Foot care Use of LeafletTreatmentof Corns Emollients andand Callus Surgical Spirit
    13. 13. The Acute Foot• Infected ulceration with Neuropathy and / or Ischaemia• Rapidly Spreading or Deep Infection (osteomyelitis)• Red Hot Swollen Foot (fracture / foreign body / Charcot)• Critical Ischaemia• Systemically Unwell
    14. 14. Rapidly Spreading Infection • Female, age 55 • Type 2 • HbA1c 12.2%, 110mml/mol • Osteomyelitis • Fracture distal phalanx
    15. 15. Red Hot Swollen Foot • Male, Age 66 • Type 2 diabetes • HbA1C 5.7%, 39mmol/mol • Acute left mid-foot Charcot
    16. 16. Critical IschaemiaCritical limb ischaemia is a condition withchronic ischaemic at-rest pain, ulcers, organgrene in one or both legs, attributable toobjectively proven arterial occlusivedisease.
    17. 17. Management of the Acute Foot Refer toUlceration without infection podiatryInfected ulceration withneuropathy and / or Refer to MDT via podiatryischaemiaRapidly spreading or deepinfection (osteomyelitis)Red Hot Swollen Foot ADMIT (fracture / foreign body/Charcot)
    18. 18. The Diabetic Team Paediatric Diabetologist Consultant The Patient Practice Diabetes Nurse Diabetic Team specialist nurse District Nurse Dieticians G.P. OrthotistTissue Viability Nurses Podiatrists Pharmacist Radiologist Microbiologist Vascular Surgeon
    19. 19. Chronic / Long- Advice /term Care Prevention Role of Podiatrist in DiabetesAcute / Active CharcotUlceration managementdebridement
    20. 20. Nail Cutting Reduction ofReduction of Corns and CallusThickened Nails Chronic / Long-term CareDeflective and Orthotic TherapyProtectivePadding
    21. 21. Long term foot careManaging nails particularly Managing callus with deformed nails debridement
    22. 22. Presence of other risk factors• Footwear
    23. 23. Debridemen Dressings witht of Ulcers Deflective Padding Acute / UlcerationTotal Contact Charcot FootCasting / Aircast
    24. 24. The role debridement in ulcer care Hard skin which may look innocent , can be hiding an underlying ulcer
    25. 25. Active Ulcer CarePodiatrist may use varioustechniques and dressings inmanaging ulcers includingRedistributive padding,larvae therapy or casting.
    26. 26. “Foot care is essential to diabetes patients’quality of life and wellbeing, yet is rarely given the attention it deserves” Jeffcoate 2009
    27. 27. Contacting NHS PodiatryEast and North Hertfordshire West Hertfordshire Bull Plain Clinic Harpenden Memorial 27 Bull Plain Hospital Carlton Road Hertford Harpenden SG14 1DX AL5 4TA Tel 01992 528114 Tel 01582 711544 Fax 01992 528241 Fax 01582 760326Application forms and further details about Podiatry can befound on the Hertfordshire Community NHS Trust web