Community Management of the Community Management of the Diabetic FootDiabetic Foot

Dr Fiona StrachanDr Fiona StrachanDr Gray’s Hospital, ElginDr Gray’s Hospital, Elgin

St Vincent Declaration (WHO and IDF, 1990)St Vincent Declaration (WHO and IDF, 1990)

• Set the target for reduction in incidence of amputation by 50% Set the target for reduction in incidence of amputation by 50% in 5 yearsin 5 years

Unrealistic time frame given multifactorial nature of problemUnrealistic time frame given multifactorial nature of problem Difficult to quantify improvement due to poor baseline register dataDifficult to quantify improvement due to poor baseline register data Little to assess QOL and functional assessment Little to assess QOL and functional assessment pre-and post operativelypre-and post operatively Crude indicator in quality of ulcer care deliveredCrude indicator in quality of ulcer care delivered

The Vulnerable Diabetic FootThe Vulnerable Diabetic Foot

• 30% of diabetic patients at risk of foot ulceration; most costly 30% of diabetic patients at risk of foot ulceration; most costly complication of DM management (20% of total costs)complication of DM management (20% of total costs) IschaemiaIschaemia

• Macrovascular and microvascularMacrovascular and microvascular NeuropathyNeuropathy Structural deformityStructural deformity Visual impairmentVisual impairment HyperglycaemiaHyperglycaemia

Peripheral Vascular DiseasePeripheral Vascular Disease

• History of IHD; calf claudication on exerciseHistory of IHD; calf claudication on exercise• Cool pulseless foot Cool pulseless foot

• Palpation of posterior tibial and dorsalis pedis pulsesPalpation of posterior tibial and dorsalis pedis pulses• Doppler US (ABPI 0.9-1.3 normal; 0.5-0.9 suggests significant PVD; Doppler US (ABPI 0.9-1.3 normal; 0.5-0.9 suggests significant PVD;

<0.5 implies severe PVD)<0.5 implies severe PVD)• Heavy callus build-up suggests reasonable peripheral Heavy callus build-up suggests reasonable peripheral

perfusionperfusion• Generally ischaemic ulcers on the margins of the foot rather Generally ischaemic ulcers on the margins of the foot rather

than plantar aspectthan plantar aspect

Diabetic NeuropathyDiabetic Neuropathy

• 35% of diabetic patients have asymptomatic neuropathy35% of diabetic patients have asymptomatic neuropathy • Patient will often fail to complain of pain, even with Patient will often fail to complain of pain, even with

significant foot lesionsignificant foot lesion Motor Motor

• Prominent metatarsal heads; claw toes may be a clueProminent metatarsal heads; claw toes may be a clue SensorySensory

• Best detected with monofilaments (10g and 75g)Best detected with monofilaments (10g and 75g) Autonomic neuropathyAutonomic neuropathy

• Dry skin with fissuring; distended veins over dorsum of footDry skin with fissuring; distended veins over dorsum of foot

Painful NeuropathyPainful Neuropathy

• Intensity variable and may be aggravated by rapid tightening Intensity variable and may be aggravated by rapid tightening of control/depressionof control/depression

• Aim to improve control gradually (DCCT;UKPDS)Aim to improve control gradually (DCCT;UKPDS)• OfferOffer

• Simple analgesiaSimple analgesia• TCADS (block serotonin re-uptake to increase pain TCADS (block serotonin re-uptake to increase pain

threshold)threshold)• GabapentinGabapentin• Carbamazepine (stabilise neuronal membrane Na channels)Carbamazepine (stabilise neuronal membrane Na channels)• Capsaicin (release of substance P in nerve endings)Capsaicin (release of substance P in nerve endings)• TENS machinesTENS machines• Opsite dressingsOpsite dressings

Pathogenesis of Diabetic UlcersPathogenesis of Diabetic Ulcers

• Hyperglycaemia causesHyperglycaemia causes• Abnormal neutrophil function increasing susceptibility to Abnormal neutrophil function increasing susceptibility to

infectioninfection• Advanced glycosylation end-products accumulate, leading Advanced glycosylation end-products accumulate, leading

to abnormal collagen production (inflexible and prone to to abnormal collagen production (inflexible and prone to breakdownbreakdown

• Abnormal fibroblast activity prevents robust extracellular Abnormal fibroblast activity prevents robust extracellular matrix production in proliferative phase of wound healingmatrix production in proliferative phase of wound healing

• Repeated trauma maintains chronic inflammatory Repeated trauma maintains chronic inflammatory phase, aggravated by abnormal pressure distributionphase, aggravated by abnormal pressure distribution

Moray Podiatry Annual Review 2005Moray Podiatry Annual Review 2005

• Retrospective audit of diabetic patients presenting with acute Retrospective audit of diabetic patients presenting with acute foot lesion in 2005 (ulceration, infection or Charcot foot lesion in 2005 (ulceration, infection or Charcot arthropathy)arthropathy)

• Includes only those receiving podiatry intervention ie known Includes only those receiving podiatry intervention ie known to podiatry deptto podiatry dept

• Episodes of acute foot lesion may be recurrent in same patient Episodes of acute foot lesion may be recurrent in same patient – audit expressing number of patients affected only– audit expressing number of patients affected only

• Does not include those with previous ulceration but no active Does not include those with previous ulceration but no active lesion in 2005lesion in 2005

Moray Podiatry Annual Review 2005Moray Podiatry Annual Review 2005

• 227 patients identified227 patients identified• 7.6% of the Moray diabetic population as expressed as 7.6% of the Moray diabetic population as expressed as

percentage of population of approx 3000percentage of population of approx 3000• Approx 60% managed by primary care; 40% attending secondary careApprox 60% managed by primary care; 40% attending secondary care

• Prevalence of foot ulceration in people with diabetes in UK Prevalence of foot ulceration in people with diabetes in UK between 5% and 7% (Scottish Collegiate Guidelines Network, between 5% and 7% (Scottish Collegiate Guidelines Network, 2001)2001)

• Extrapolated to Grampian, potential for over 1500 patients Extrapolated to Grampian, potential for over 1500 patients with active foot ulcers requiring integrated care.with active foot ulcers requiring integrated care.

Key Components in Effective Management of Key Components in Effective Management of the Vulnerable Diabetic Footthe Vulnerable Diabetic Foot

• Prompt referral for revascularisation when Prompt referral for revascularisation when appropriateappropriate

• Wound ManagementWound Management• Offloading StrategiesOffloading Strategies• Optimising the metabolic environment and Optimising the metabolic environment and

controlling CVS riskscontrolling CVS risks• Managing the patient at risk of ulcer recurrenceManaging the patient at risk of ulcer recurrence

Key Components in Effective Management of Key Components in Effective Management of the Vulnerable Diabetic Footthe Vulnerable Diabetic Foot

• Prompt referral for revascularisation when appropriate Prompt referral for revascularisation when appropriate When?When?• Wound ManagementWound Management

• Review by appropriate team member Review by appropriate team member • Debridement – mechanical/chemical/larvalDebridement – mechanical/chemical/larval

Who?Who?• Infection control either at primary or secondary care level Infection control either at primary or secondary care level

Antibiotics and the Diabetic FootAntibiotics and the Diabetic Foot

• Little evidence base to guide practiceLittle evidence base to guide practice• Consider “colonisation” vs infection – but even skin commensals can be Consider “colonisation” vs infection – but even skin commensals can be

relevant in immunocompromised patientrelevant in immunocompromised patient• Prompt management of neuroischaemic ulcers due to increased risk of Prompt management of neuroischaemic ulcers due to increased risk of

sepsissepsis• Infection may be present without signs of local erythema (failure of Infection may be present without signs of local erythema (failure of

vasodilatation) – beware of pain in “neuropathic foot”vasodilatation) – beware of pain in “neuropathic foot”• Microbiology can be complex – G-positive aerobic and G-negative aerobic Microbiology can be complex – G-positive aerobic and G-negative aerobic

and anaerobic bacteria, singly or in combinationand anaerobic bacteria, singly or in combination• Initial broad spectrum antibiotics tailored once reliable swab specimens Initial broad spectrum antibiotics tailored once reliable swab specimens

availableavailable

Key Components in Effective Management of Key Components in Effective Management of the Vulnerable Diabetic Footthe Vulnerable Diabetic Foot

• Prompt referral for revascularisation when appropriate Prompt referral for revascularisation when appropriate When?When?• Wound ManagementWound Management

• Review by appropriate team member Review by appropriate team member • Debridement – mechanical/chemical/larval Debridement – mechanical/chemical/larval Who?Who?• Infection control either at primary or secondary care level Infection control either at primary or secondary care level

• Offloading StrategiesOffloading Strategies• OrthoticsOrthotics How?How?• DieteticsDietetics

• Optimising the metabolic environment and controlling CVS risksOptimising the metabolic environment and controlling CVS risks Where?Where?

• Managing the patient at risk of ulcer recurrenceManaging the patient at risk of ulcer recurrence Who?Who?

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The Stages of the Diabetic FootThe Stages of the Diabetic Foot

• The normal footThe normal foot

• The high-risk footThe high-risk foot

• The ulcerated footThe ulcerated foot

• The infected footThe infected foot

• The necrotic footThe necrotic foot

• The unsalvageable footThe unsalvageable foot

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

• Screening StandardScreening Standard• Foot Screening at diagnosis and annually thereafter Foot Screening at diagnosis and annually thereafter • Standardised Grampian Diabetic Foot Risk Assessment FormStandardised Grampian Diabetic Foot Risk Assessment Form

• Challenge of easy access to informationChallenge of easy access to information• Barriers to provision of uniform screening/education Barriers to provision of uniform screening/education

time, training and quality assurancetime, training and quality assurance

• Screening Outcomes – low riskScreening Outcomes – low risk moderate riskmoderate risk high riskhigh risk

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

• Low Risk Foot Low Risk Foot • Low risk with no podiatry need – Education and Self Care LeafletLow risk with no podiatry need – Education and Self Care Leaflet• Low Risk with podiatry need – Above plus referral to Community Low Risk with podiatry need – Above plus referral to Community

Podiatry ServicesPodiatry Services

• Both require ongoing annual reviewBoth require ongoing annual review

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

• Moderate Risk FootModerate Risk Foot• Any one of the following:Any one of the following:

• Vascular impairmentVascular impairment• Significant neuropathySignificant neuropathy• Previous vascular surgeryPrevious vascular surgery• Significant visual impairmentSignificant visual impairment• Physical disabilityPhysical disability

• Referral to the Community Podiatry Service to be seen within twelve Referral to the Community Podiatry Service to be seen within twelve weeksweeks

• Challenges within current resourcesChallenges within current resources• Clarify on-going responsibilty for screeningClarify on-going responsibilty for screening

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

• High Risk FootHigh Risk Foot• Acute or chronic active diseaseAcute or chronic active disease• Referral to Diabetes Specialist Podiatry Services by practice Referral to Diabetes Specialist Podiatry Services by practice

team/secondary care team/CPS using GDFRAFteam/secondary care team/CPS using GDFRAF

• Planned Care – foot intact 4-6 weekly review to maintain integrityPlanned Care – foot intact 4-6 weekly review to maintain integrity• Unplanned Care – active foot lesionUnplanned Care – active foot lesion

DSPS will act as “hub” for multi-disciplinaryDSPS will act as “hub” for multi-disciplinary approach approach

Ideally “one-stop” service for patientsIdeally “one-stop” service for patients Need for rapid response/resource constraints Need for rapid response/resource constraints

may may dictate whether service based in hospital or dictate whether service based in hospital or community initiallycommunity initially

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

DSPS

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

DSPS CPS

PN/DN

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

DSPS CPS

PN/DN

Clinician

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

DSPS CPS

PN/DN

Clinician MicrobiologyDSN

Dietetics

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

DSPS CPS

PN/DN

Clinician MicrobiologyDSN

Dietetics

Orthotics

Vascular

Physiotherapy

Prosthetics

Tissue Viability

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

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