Community Management of the Diabetic Foot Dr Fiona Strachan Dr Gray’s Hospital, Elgin

1. Community Management of the Diabetic FootDr Fiona StrachanDr Gray’s Hospital, Elgin

2. St Vincent Declaration (WHO and IDF, 1990) • Set the target for reduction in incidence of amputation by 50% in 5 years • Unrealistic time frame given multifactorial nature of problem • Difficult to quantify improvement due to poor baseline register data • Little to assess QOL and functional assessment pre-and post operatively • Crude indicator in quality of ulcer care delivered

3. The Vulnerable Diabetic Foot • 30% of diabetic patients at risk of foot ulceration; most costly complication of DM management (20% of total costs) • Ischaemia • Macrovascular and microvascular • Neuropathy • Structural deformity • Visual impairment • Hyperglycaemia

4. Peripheral Vascular Disease • History of IHD; calf claudication on exercise • Cool pulseless foot • Palpation of posterior tibial and dorsalis pedis pulses • Doppler US (ABPI 0.9-1.3 normal; 0.5-0.9 suggests significant PVD; <0.5 implies severe PVD) • Heavy callus build-up suggests reasonable peripheral perfusion • Generally ischaemic ulcers on the margins of the foot rather than plantar aspect

5. Diabetic Neuropathy • 35% of diabetic patients have asymptomatic neuropathy • Patient will often fail to complain of pain, even with significant foot lesion • Motor • Prominent metatarsal heads; claw toes may be a clue • Sensory • Best detected with monofilaments (10g and 75g) • Autonomic neuropathy • Dry skin with fissuring; distended veins over dorsum of foot

8. Painful Neuropathy • Intensity variable and may be aggravated by rapid tightening of control/depression • Aim to improve control gradually (DCCT;UKPDS) • Offer • Simple analgesia • TCADS (block serotonin re-uptake to increase pain threshold) • Gabapentin • Carbamazepine (stabilise neuronal membrane Na channels) • Capsaicin (release of substance P in nerve endings) • TENS machines • Opsite dressings

9. Pathogenesis of Diabetic Ulcers • Hyperglycaemia causes • Abnormal neutrophil function increasing susceptibility to infection • Advanced glycosylation end-products accumulate, leading to abnormal collagen production (inflexible and prone to breakdown • Abnormal fibroblast activity prevents robust extracellular matrix production in proliferative phase of wound healing • Repeated trauma maintains chronic inflammatory phase, aggravated by abnormal pressure distribution

10. Moray Podiatry Annual Review 2005 • Retrospective audit of diabetic patients presenting with acute foot lesion in 2005 (ulceration, infection or Charcot arthropathy) • Includes only those receiving podiatry intervention ie known to podiatry dept • Episodes of acute foot lesion may be recurrent in same patient – audit expressing number of patients affected only • Does not include those with previous ulceration but no active lesion in 2005

11. Moray Podiatry Annual Review 2005 • 227 patients identified • 7.6% of the Moray diabetic population as expressed as percentage of population of approx 3000 • Approx 60% managed by primary care; 40% attending secondary care • Prevalence of foot ulceration in people with diabetes in UK between 5% and 7% (Scottish Collegiate Guidelines Network, 2001) • Extrapolated to Grampian, potential for over 1500 patients with active foot ulcers requiring integrated care.

12. Key Components in Effective Management of the Vulnerable Diabetic Foot • Prompt referral for revascularisation when appropriate • Wound Management • Offloading Strategies • Optimising the metabolic environment and controlling CVS risks • Managing the patient at risk of ulcer recurrence

13. Key Components in Effective Management of the Vulnerable Diabetic Foot • Prompt referral for revascularisation when appropriate When? • Wound Management • Review by appropriate team member • Debridement – mechanical/chemical/larvalWho? • Infection control either at primary or secondary care level

14. Antibiotics and the Diabetic Foot • Little evidence base to guide practice • Consider “colonisation” vs infection – but even skin commensals can be relevant in immunocompromised patient • Prompt management of neuroischaemic ulcers due to increased risk of sepsis • Infection may be present without signs of local erythema (failure of vasodilatation) – beware of pain in “neuropathic foot” • Microbiology can be complex – G-positive aerobic and G-negative aerobic and anaerobic bacteria, singly or in combination • Initial broad spectrum antibiotics tailored once reliable swab specimens available

15. Key Components in Effective Management of the Vulnerable Diabetic Foot • Prompt referral for revascularisation when appropriate When? • Wound Management • Review by appropriate team member • Debridement – mechanical/chemical/larval Who? • Infection control either at primary or secondary care level • Offloading Strategies • Orthotics How? • Dietetics • Optimising the metabolic environment and controlling CVS risks Where? • Managing the patient at risk of ulcer recurrence Who?

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18. The Stages of the Diabetic Foot • The normal foot • The high-risk foot • The ulcerated foot • The infected foot • The necrotic foot • The unsalvageable foot

19. Diabetic Foot – Integrated Care Pathway and Clinical Accord (Draft Proposals) • Screening Standard • Foot Screening at diagnosis and annually thereafter • Standardised Grampian Diabetic Foot Risk Assessment Form • Challenge of easy access to information • Barriers to provision of uniform screening/education • time, training and quality assurance • Screening Outcomes – low risk moderate risk high risk

20. Diabetic Foot – Integrated Care Pathway and Clinical Accord (Draft Proposals) • Low Risk Foot • Low risk with no podiatry need – Education and Self Care Leaflet • Low Risk with podiatry need – Above plus referral to Community Podiatry Services • Both require ongoing annual review

21. Diabetic Foot – Integrated Care Pathway and Clinical Accord (Draft Proposals) • Moderate Risk Foot • Any one of the following: • Vascular impairment • Significant neuropathy • Previous vascular surgery • Significant visual impairment • Physical disability • Referral to the Community Podiatry Service to be seen within twelve weeks • Challenges within current resources • Clarify on-going responsibilty for screening

22. Diabetic Foot – Integrated Care Pathway and Clinical Accord (Draft Proposals) • High Risk Foot • Acute or chronic active disease • Referral to Diabetes Specialist Podiatry Services by practice team/secondary care team/CPS using GDFRAF • Planned Care – foot intact 4-6 weekly review to maintain integrity • Unplanned Care – active foot lesion DSPS will act as “hub” for multi-disciplinary approach Ideally “one-stop” service for patients Need for rapid response/resource constraints may dictate whether service based in hospital or community initially

23. Diabetic Foot – Integrated Care Pathway and Clinical Accord (Draft Proposals) DSPS

24. Diabetic Foot – Integrated Care Pathway and Clinical Accord (Draft Proposals) DSPS CPS PN/DN

25. Diabetic Foot – Integrated Care Pathway and Clinical Accord (Draft Proposals) Clinician DSPS CPS PN/DN

26. Diabetic Foot – Integrated Care Pathway and Clinical Accord (Draft Proposals) Dietetics Clinician Microbiology DSN DSPS CPS PN/DN

27. Diabetic Foot – Integrated Care Pathway and Clinical Accord (Draft Proposals) Dietetics Clinician Microbiology DSN Vascular DSPS CPS Orthotics PN/DN Tissue Viability Physiotherapy Prosthetics

28. Developing an integrated pathway for diabetic foot screening and management provides a challenge for Grampian in 2006……

29. Developing an integrated pathway for diabetic foot screening and management provides a challenge for Grampian in 2006……