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Wolverhampton Diabetes Foot Care pathway

Inform Diabetes retinal screening programme Eligibility Booking an appointment Screening Outcome No-urgent Referral to Hospital Eye Service  Urgent Referral to Hospital Eye Service Non-referable Retinopathy Management of Sight Threatening Diabetic Retinopathy Referral to Specialist Diabetes Service Foot Care Pathway

Diabetic Foot disease

  • Foot complications can affect anyone who has diabetes.

  • Diabetes may cause poor circulation (peripheral vascular disease) and nerve damage (diabetic neuropathy).

  • This might lead to infection, ulcers and even amputation.

  • Everyone with diabetes should have full education about their foot care at diagnosis and at their annual foot assessment.

  • People with diabetes should know exactly how to look after their feet and when and who to report if there are any foot problems.

  • At the very least, medical teams will undertake annual foot examination and assessment.

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Foot Risk Assessment

There is a district wide programme for diabetic foot screening.  The outcome of the annual foot risk assessment by clinicians (primary care, podiatry and specialist care) will be recorded in the diabetes register which will facilitate and govern risk stratified foot care. Assessment of foot risk is done based on history (previous ulcer, amputation) and simple clinical examination (deformity, peripheral sensation and circulation). The acronym of SAFE & SOuND has been created taking into account the various parameters contributing to risk.

  • Self/supported careAbility

  • Footwear

  • Established risk factors – previous foot ulcers or amputations, End stage renal failure

  • Skin health

  • Osteal foot deformity

  • Neuropathy

  • Dorsalispedis/posterior tibial pulses

A dedicated and web based foot risk assessment tool has been developed based on validated criteria that will generate the risk and drive the appropriate action for the risk as per agreed care pathway. This is available on the intranet for primary care use and on the Diabeta3 software system for the use of community podiatry and specialist teams.

Clinician responsible for annual foot risk assessment

Primary care teams

  • All newly registered diabetes patients

  • Low foot risk patients

  • Intermediate foot risk patients who are able to self-care

  • Patients who have inter-current foot problems

Community Podiatry team

  • Intermediate foot risk patients who are unable to self-care

  • High foot risk patients that are currently managed under community podiatry within an agreed high risk management plan

  • Domiciliary/dependent active foot patients (within an agreed high risk management plan)

Specialist Foot team

  • High and above foot risk patients that are currently managed under the specialist foot team

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Foot risk stratification & overview of structured foot care

The foot care pathway has been drafted to facilitate timely and appropriate care for the risk and will run on a paperless basis. Based on risk, appropriate expected care will be outlined with web based facility to refer to community podiatry/specialist MDT services. Foot administration teams in the community and diabetes centre will actively manage such referrals with audit trails to govern the process. The table below outlines the expected care for the various foot risk categories.

Foot Risk

Features

What care to expect?

Expected foot follow up

Low

No risk factors

Promote self-care

Primary care

Intermediate

Inability to self-care or presence of one or two risk factors – poor footwear, minor deformity, skin/soft tissue changes, sensory loss or absent pulses but not both

Able to self-care

  • Promotion of self- care

  • Modification of remediable risk factors

Primary care
(access to community podiatry if risk factors unresolved)

Inability to self-care

  • Prophylactic foot care at least quarterly

Community Podiatry

High

Combination of minor risk factors, marked deformity, sensory loss and loss of pulses, previous foot ulcers or amputations

Optimised medical risk factors

  • Promotion of self-care

  • Prophylactic & therapeutic foot care at least quarterly

  • Continued optimisation of medical risk factors

Community podiatry within agreed High Risk Management plan (access to specialist foot team as required)

Adverse Medical risk

  • Promotion of self-care

  • Optimisation of medical risk factors

  • High risk foot care

Specialist Foot Team

Potential Critical

New/active ulcer with or without non-critical infection, sub-acute ischaemic features, acute deformity

Early assessment for new ulcers and on-going care with specialist foot team

Specialist Foot Team

Critical

Critical foot or limb ischemia, critical infection

Urgent assessment via emergency services

Foot MDT team

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Community Foot Protection Team

Community foot protection team is led by the community podiatry service with support from Orthotics, Biomechanics, Tissue Viability and Community nursing teams.
These services are not intended to provide a nail cutting service.
They should not be seeingthose patients categorised as having low risk or those with intermediate risk that are capable of self/supported care.
They should see those patients defined asintermediate risk with unresolved risk factors and those that are unable to have self/supported care.
They may follow up patients with high foot risk provided this is part of an agreed careplan with the high risk service.

Community Orthotics and Biomechanics
All people with diabetes require appropriate footwear but few require specially made footwear.Neither specialised footwear nor Biomechanics assessment is likely to be required unlessthereis significant foot deformity, gait abnormality or active or previous foot ulcer.Most patients requiring Orthotics or Biomechanical assessment will be at high risk. TheOrthotics and Biomechanical services will provide specialised assessment to patients withdiabetes in conjunction with the specialist high risk foot service.

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Diabetic Foot Specialist Multi-disciplinary Team

The Specialist Diabetic Foot MDT is located within the Wolverhampton Diabetes Centre. The members of the MDT include the following core members with access to other specialist teams.

Core Membership

  • Specialist Podiatrist

  • Specialist Medical

    • Diabetologist

    • Diabetes Specialist Nurse

    • Vascular Surgeon

Allied Specialties supporting Foot MDT

  • Orthopaedics

  • Orthotics & Biomechanics

  • Tissue Viability team

  • Radiology

  • Microbiology

Specialist foot clinics are fully supported by the wider MDT including the specialist nurses and Diabetes Consultants. In addition, dedicated joint clinics are run every Thursday to deal with those patients with active/critical foot problems with support of other MDT members as required. A similar joint clinic between Podiatrist and Orthotist is run every Tuesday. The specialist foot MDT also supports hospitalised patients with foot problems including in vascular and other ward areas.

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Assessment and management of diabetic foot ulcers

Foot ulcers/wounds precede diabetic lower limb amputations in the vast majority and early identification and MDT involvement have been shown to prevent unnecessary limb losses.
All diabetic foot ulcers need to be assessed to determine underlying cause and the removal or reduction of this cause is paramount for a treatment to be successful. Wound debridement should be performed judiciously and only attempted by specialist team practitioners or surgical teams. Regular inspection with meticulous long term surveillance is required for all patients presenting with foot ulceration.
 
Diabetic foot ulcers are commonly neuropathic or neuro-ischaemic.

  • Neuropathic ulcers are usually associated with trauma from excess pressures from footwear, deformity, callus and abnormal gait. The treatment of neuropathic ulcers requires off loading of pressures, debridement, and control of infection.

  • Neuro-Ischaemic ulcers require joint diabetes and vascular review with re-vascularisation where appropriate, specialist foot wear provision and infection control.

The general differences between neuropathic and neuro-ischaemic ulcers:

SIGNS & SYMPTOMS

NEUROPATHIC

NEURO-ISHCAEMIC

Deformity:

Clawed /retracted toes, high arch, charcot deformity

Deformity may be  present dependant on neuropathic involvement

Skin temperature

Warm

Cool

Colour

Normal

Pale, cyanotic or rubour

Pain

Painless

Painful  but may be reduced dependant on level of concurrent neuropathy

Sensation

Insensitive to 10g monofilament

May be present or absent

Pulses

Palpable

Not palpable or diminished

Callus formation

Commonly found on pressure points on the toes and plantar surface with or without sub-cutaneous hemorrhage

Not usually present or very little

Ulcer sites

Usually associated with high pressure points on the toes and plantar surfaces

Marginated, commonly found on the toes and edges of the feet

Document - The wound should be documented by clinical photography.
Refer - All patients with foot wounds or ulcers are to be seen by the Specialist high risk foot team at the Wolverhampton diabetes centre or being jointly managed with them.

The general principles of diabetes foot ulcer management include:

  • Wound assessment to grade, document, debride, protect, and dress

  • Immediate cause of the wound must be determined, documented and corrected

  • Infection needs to be eradicated

  • Circulation needs to be restored if inadequate.

  • Footwear needs to be reviewed.

  • The multi professional team needs to be involved.

  • The care plan must be clear and documented

  • The patient needs to be informed and educated.

  • Follow up must be meticulous

Glycaemic control
Wound healing is impaired by hyperglycaemia. Optimal control should be the aim Patients with foot ulcers pose high medical risk and as such require specialist input to address metabolic risk factors.
Referral should be made to Diabetes specialist team (Diabetologist, Diabetes Specialist Nursing team or GP) to address this problem.

Education
Ongoing foot education is crucial in both prevention and management of foot ulcers. All patients with foot ulcers should be re-educated on signs of deterioration, what to do if deterioration occurs and where to report especially during ‘out of hours’.

Secondary Ulcer Prevention
Patients with a history of foot ulceration are highly at risk for future ulceration. Once an ulcer has healed the risk of further ulceration must be minimized. This is can be achieved by meticulous structured long term surveillance.

  • Regular monitoring by the Podiatry Team, 1-3 monthly,

  • Appropriate footwear provision. This may require the provision of specialist foot wear from the orthotics department.

  • Ongoing foot education: Education on what “danger signs” to look for and who and how to contact the Podiatry service if a problem develops.

  • Ongoing Multidisciplinary team management

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Infection Management and Antibiotic Use in Diabetic Foot Wounds and Ulcers

Non-bacterial foot infection such as “Athletes Foot” should be treated promptly and effectively to avoidprogression to more complex problems.
Suspected bacterial foot infection complicating foot ulcers and woundsshould be under diabetes specialist review. Such cases should not bemanaged by other general medical teams or solely by surgical teams. Patients admitted to hospital with a foot related problem should similarly have the specialist diabetes foot MDT involvement as soon as possible and preferably within 24h of admission
Remember that clinical signs of inflammation may be less obvious in an ischaemic foot.

General approach to diabetic foot ulcer management

Specimens for culture

  • Clinically uninfected ulcers rarely need to be cultured

  • An acutely infected wound of mild or moderate severity in a person who has not recently been treated with antibiotic does not need to be routinely cultured

  • Other wounds should almost always be cultured

  • Superficial wound swabs for culture are rarely of help – enterococci, pseudomonas and anaerobes are frequently isolated from diabetic foot wounds, often representing colonisation rather than infection.

  • Deep tissue culture by aspiration of purulent secretions or of abscess cavities, curettage of post-debridement wound base, punch biopsy and extruded or biopsied bones are the best specimens for culture.

  • Blood cultures should be undertaken in systemically toxic patients.

Diagnosing and classifying infection

It is recommended that the presence and severity of infection be classified using the Infectious Disease Society of America classification system.

Grade 1

No Infection

No purulence or signs of infection

Grade 2

Mild Infection

No systemic illness and evidence of either

  1. pus or

  2. two or more signs or symptoms of inflammation (erythema, warmth, pain, tenderness, induration) - any cellulitis <2cm around the wound and confined to skin or subcutaneous tissue

Grade 3

Moderate Infection

No systemic infection and evidence of either

  1. Lymphatic streaking, deep tissue infection (involving subcutaneous tissue, fascia, tendon, bone) or abscess or

  2. Cellulitis >2cm

Grade 4

Severe Infection

Any infection with systemic toxicity
Presence of critical ischemia of the involved limb may make the infection severe

Diagnosing bone infection (Osteomyelitis)
If there is clinical suspicion of acute osteomyelitis, plain X-ray is the usual first investigation although serial X-rays may be required. Where the clinical suspicion remains high and plain X-ray is not diagnostic, carry out MRI or white cell scanning if MRI contraindicated. Probe to bone test is no longer acceptable to exclude or diagnose osteomyelitis.

Differentiating Osteomyelitis from Acute Charcot foot
Differentiating Acute Charcot and Osteomyelitis can be difficult and both conditions frequently occur simultaneously. Diagnosis is based on good history and examination and is assisted by obtaining supplementary investigations including X-ray, MRI, isotope bone and white cell scans. These patients should generally be under the remit of the specialist foot MDT.

General principles of antibiotic use

Prophylactic antibiotic use
There is no evidence for prophylactic antibiotics in clinically uninfected foot ulcers and antibiotics should therefore be used only in those with clinical signs of infection.

Therapeutic antibiotic use
Initial therapy is frequently empirical, based on the presumed pathogen and local epidemiological and susceptibility information.

Any previous microbiology results MUST be reviewed prior to prescribing empirical antibiotics.

This guidance is of value until microbiological investigations and clinical response shed further light on the nature of infection, where available.

Direct contact with local microbiologist may be necessary for advice on specialised use of these or other antibiotics.

Intravenous or oral
The choice of antibiotic and the route of delivery should reflect the severity of infection. Intravenous antibiotics are only required in patients with foot infection with:

  • Systemic ill-health

  • Deep or tracking infection

  • Complicating necrosis or gangrene

  • Those that have not improved or deteriorate on oral antibiotics.

When intravenous antibiotics are used, theyshould continue until the patient is not toxic, is able to take oral drugs and the foot lesion isdefinitely improving.
Duration of treatment

  • Duration of treatment should similarly be adjusted according to the severity of infection and be guided by clinical improvement.

  • In general, the duration of antibiotic should be kept to a minimum.

Allergies include skin rashes and anaphylaxis but do not include minor side-effects such as nausea.  The nature of any antibiotic allergy needs to be fully elucidated and clearly documented.

Before prescribing any empirical antibiotic therapy the following questions must be addressed:

  1. Has the patient received any recent antibiotic treatment (in the last 3 months), either from the GP or from the hospital? If so, which antibiotic(s) and duration?

  2. Does the patient have any previous positive microbiology, either from samples sent by the GP or the hospital? If so, what are the results and the antibiotic sensitivity patterns?

  3. Does the patient have any allergy to antibiotics, if so what is the nature of these? This MUST be clearly documented in the patient notes.

  4. Has the patient had any recent hospital admissions for management of the diabetic foot? If so what treatment was given?

  5. What is the patient’s MRSA status?

The answers to the above questions will greatly influence initial choice of antibiotics therefore care must be taken to ensure that these questions are answered fully and clearly.

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Antibiotic guidance

Treatment may need to be altered based on the results of microbiological investigations and clinical response

Infection grade

MILD

 

MODERATE

Out-patient treatment

SEVERE
(or hospitalised moderate)
In-patient treatment

Definition

 

No systemic infection & evidence of either
a. pus or
b. two or more inflammation signs or symptoms:any cellulitis <2cm around the wound and confined to skin or subcutaneous tissue

No systemic infection & evidence of either
a. Lymphatic streaking, deep tissue infection (subcutaneous tissue, fascia, tendon, bone) or abscess or
b. Cellulitis >2cm

Any infection with systemic toxicity

Presence of critical ischemia of the involved limb may make the infection severe

Likely pathogen

Staph aureus or β haemolytic Strep.

 

Staph aureus or β haemolytic Strep.Anaerobes, Enterobacteriaceae&pseudomonas may need to be treated.Obligate anaerobes often associated with limb ischemia, gangrene, necrosis or wound odour

Primary

PO Amoxicillin 500mgtds + Flucloxacillin 1gqds

PO co-amoxiclav 625mg tds

IV Piperacillin/tazobactam 4.5g tds

Alternative or
Penicillin allergic

PO Doxycycline 100mg bd
OR
PO Clindamycin 600mg qds

PO clindamycin 600mg qds for 7days initially;
if fails to respond or gram negatives likely, add PO Ciprofloxacin 500mg bd

IV Meropenem 1g tds
(If severe allergy discuss with microbiologist on call)
OR
IV Clindamycin 600mg -1.2g qds plus IV Gentamycin 5mg/kg
OR
IV Vancomycin 1g bd plus
PO ciprofloxacin 500mg bd plus IV Metronidazole 500 mg tds

MRSA

PO Trimethoprim 200mg bd
or Doxycycline 100mg bd
plus
PO Rifampicin 300-600mg bdorSodium fusidate 500mg tds

PO Trimethoprim 200mg bdorDoxycycline 100mg bd
plus
PO Rifampicin 300-600mgbdorSodium fusidate 500 mg tds

OR
Oral linezolid 600 mg bd
(Maximum 14 days)

IV Piperacillin / tazobactam 4.5g tdsplusIVVancomycin  1g bdplusPO Rifampicin  600 bdorPO Sodium fusidate 500 tds
OR
IV Piperacillin/tazobactam 4.5g tdsplusIV Daptomycin 4mg/kg od (monitor creatinine kinase)
OR
IV Piperacillin/tazobactam 4.5g tdsplus oral or IV Linezolid 600 bd(14 days maximum)

Treatment duration

10 – 14 days and review

14 days and review. If osteomyelitis suspected discuss with microbiology & treat for at least 4-6weeks. Longer may be required

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Wound Management

  • Debridement is thought to be essential for optimal healing rate, (Foster and Edmunds, 2000). Where significant arterial disease is absent, callous together with any necrotic, non-viable tissue, should be removed with a sterile scalpel using an aseptic technique.

  • Sharp debridement of diabetic foot ulcers should only be undertaken by the specialist foot service, specialist practitioners and surgical teams

  • Debridement may also be undertaken using larvae or appropriate dressings that promote debridement.

  • In the ischemic foot it may not be appropriate to use a debriding dressing which hydrates necrotic tissue converting it into wet gangrene. The patient’s vascular status must always be assessed prior to any debridement.

  • Sharp debridement where there is an ischemic component should only be considered following discussion with specialist diabetes foot team, vascular team or Tissue Viability Service.

The rational for debridement:

  • Allows the true dimensions of an ulcer to assessed

  • Allows the drainage of exudates and removal of dead tissue rendering infection less likely.

  • Enables a deep swab to be taken

  • Encourages healing by restoring a chronic would to an acute wound.

Wound Swabbing

Should be undertaken following debridement (Refer to antibiotic guidance)

Wound Cleansing

See Section 2 in main wound care policy

Dressing Selection

All dressings should provide the optimum wound healing environment and each stage of wound healing requires a specific type of dressing. Regular dressing change is crucial in the management of diabetic foot wounds due to the risk of rapid deterioration.

WOUND TYPE

AIM OF MANAGEMENT

DRESSING

OTHER
CONSIDERATIONS

Eschar

Rehydrate eschar

Hydrogels

Dry gangrene must not be rehydrated.
Consider high risk of wet wound to infection & deterioration where vascular supply is compromised.

Sloughy

Removal of debris from the wound bed

Hydrogels
Hydrofibers

High risk of infection with wet wound.
Moisturebalance  versus moist wound healing

Infected

Treat infection, manage exudates and odour

Honey
Cadexameriodine
Silver/
CharcoalPovidoneiodine

 

Granulating

Create a moist environment, manage exudate

Alginates
Foams

 

Epithelialising

Create a moist environment

Foams

 

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Pressure Relief

Foot ulcers are often caused by pressure. This may be due to deformity, gait or inappropriate footwear. When dressing a wound, deflective padding, insoles, footwear and casts must be considered to redistribute pressure away from ulceration and so allow healing.

Caution must be taken with all non removable devices in the presence of sensory neuropathy and in the presence of active ulceration.

Consideration for formal offloading devices and footwear should be via the specialist diabetes service with appropriate liason with orthotics and Orthopaedic services.

  • Semi-compression felt – this adhesive-backed padding may be cut to the shape of the foot to deflect pressure away from an area so as to encourage healing to take place.

  • Insoles – to redistribute plantar pressures away from plantar ulcers and also provide suitable cushioning. They may need to be accommodated in bespoke shoes or extra-depth stock shoes.

  • Temporary Footwear – may be required to accommodate dressings, insoles or deformity to offload pressure form ulcerated sites.

  • Bespoke footwear – to accommodate deformity. Incorporated moulded insoles will remove pressure from vulnerable areas to allow ulcers to heal and reduce the risk of further ulceration occurring.

  • Air Casts – lightweight removable plastic casts lined with air cells that are inflated with a hand bulb to a total contact fit, reducing plantar pressures by spreading weight bearing to a larger area. These casts limit joint mobility, have plasterzote (polyethylene foam) insoles which cushion and rocker bottom sole to reduce pressure through the plantar surface during gait.

  • Total Contact Casting (Below-Knee Cast / Scotch Cast Boot) – fibreglass casts used to minimise peak plantar pressures to aid healing of plantar ulcers

Total Contact Cast: (click here)

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Peripheral vascular disease care pathway for patients with diabetes

Patients with diabetes are more prone to PAD than patients without diabetes.
A strong history of cardiovascular /cerebrovascular disease (eg MI or stroke) increases chance of peripheral arterial disease (PAD)

PAD is not an independent risk factor for foot ulcers but is significant in delaying wound healing facilitates secondary infection, and is a major risk factor for lower extremity amputation. 

When to suspect?

  • Patients with intermittent claudication*

    • Cramp like pain in legs when walking or exercising commonly involving calf, thighs or buttocks

    • Usually relieved by rest

    • Distance at onset of pain usually predictable and progressive

  • Absent or diminished foot pulses

    • Absent single pulse does not predict PVD

  • Rest pain or gangrene of foot/leg

  • Poorly healing/non-healing wounds on foot/leg

  • Patients with signs of chronic ischemia

    • Skin colour and shininess

    • Loss of hair in leg

  • Patients with known arterial disease elsewhere (coronary, caroids, renal artery)

*Intermittent Claudication checklist

*Intermittent Claudication checklist

Risk stratification tools

History – claudication distance, rest pains, non-healing ischemic/neuroischemic ulcers
Examination – signs of ischemia, foot pulses, vascular bruits
ABPI – vascular calcification can falsely elevate – consider at rest and after exercise if in doubt
Transcutaneous oximetry (if available) – rest and after exercise

  • Critical

    • rapid onset of ischemia/gangrene

  • Severe

    • ischemic rest pain,

    • non-critical chronic ischemic changes,

    • non-healing wound/ulcers especially if infected,

    • Intermittent claudication significantly affecting lifestyle

    • ABPI <0.6

  • Intermediate

    • Intermittent claudication with mild lifestyle impairment

    • ABPI 0.6-0.9

  • Mild

    • Asymptomatic absent foot pulses

    • Other arterial diseases

    • High prevalence of risk factors – smoking, hypertension, dyslipidemia, renal impairment

The vascular surgical teams do not need to see patients simply because they have absent foot pulses.
They should be involved in the management of all patients with significant  claudication (distance of <200 yards,) ischaemic rest pain, clinical critical foot ischaemia, ischaemic or mixed neuro – ischaemic  foot ulcers within an agreed management  with the specialist diabetes service
All critical ischaemic events require urgent direct referral to the vascular surgical team.

PVD Flowchart (click here)

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In-patient management of diabetic foot problems

All patients with diabetes admitted to hospital should have their shoes, socks, bandages and dressings removed to examine for:

  • Neuropathy

  • Ischemia

  • Ulceration

  • Inflammation and/or infection

  • Deformity

  • Charcot arthropathy


Any new and/or existing diabetic foot problems identified must be documented.
Urgent advice from an appropriate specialist must be obtained if there is strong suspicion of:

  • Foot related systemic sepsis

  • Deep seated foot infection

  • Acute limb ischemia

  • Acute Charcot arthropathy

During working hours, such urgent referrals should usually go through the diabetes outreach and the in-house vascular consultant teams for liaison with the hub vascular surgical team in Dudley and prioritised transfer as appropriate. During out of hours, such patients should have urgent review by the on-site surgical registrar who will liaise with the hub vascular specialist to agree and arrange transfer to Dudley as appropriate.

Patients with diabetic foot problems that don’t fit into the urgent advice category must have access to the MDT foot team (Diabetes outreach and in-house vascular consultant) within 24h of the initial examination of the patient’s feet. 

Patients whose foot problem is the dominant clinical factor for inpatient care at New Cross and those patients that are repatriated from Dudley after their surgical intervention must be transferred to the consultant member of the MDT foot team for ongoing responsibility and continuing care. This will usually be on the diabetes ward.

The MDT foot team should

  • Assess and treat the patient’s diabetes and medical risk factors

  • Regularly re-assess patient’s response to initial management

  • Determine need for specialist wound care, debridement, pressure off-loading and other surgical interventions

  • Assess for pain and determine need for treatment and specialist pain services

  • Assess vascular status and determine need for interventions

  • Review treatment of any infection

  • Assess and intervene to prevent deterioration and development of foot deformities

  • Arrange discharge planning including appropriate follow up

Refer to Vascular Hub care pathway and local care provision model for further details.
The MDT foot team have the responsibility to

  • Offer patients consistent, relevant information and clear explanations that support informed decision making

  • Provide opportunities for patients to discuss issues and ask questions

  • Provide a named contact to patients for information and to liaise between primary and specialist care

This will usually be provided verbally during their hospital stay and as copies of discharge letter at time of discharge with named Physician, Surgeon and Podiatry contacts.
Refer to the specialist protocols for:

  • Assessment and management of diabetic foot ulcers Infection

  • Management and Antibiotic use in foot wounds and ulcers

  • Wound Management & pressure relief

  • Diagnosis and management of Acute Charcot neuro-arthropathy

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Charcot foot in diabetes – evidence based care pathway

Charcot neuro-arthropathy is a potentially severely disabling complication of Diabetes that canresult in morbidity, mortality through decreased mobility, increased foot ulcer and amputationrisk.

When to suspect?

It should be suspected in any patient with diabetes who complains of a hot and / or swollen foot. If suspected, such patients should be brought to the attention of the specialist Foot MDT for early review.

How to confirm diagnosis?

The diagnosis of Acute Charcot is largely clinical. A hot swollen foot with active inflammation and not as much discomfort is typically seen. Patients are expected to have underlying neuropathy and often have adequate (or even dynamic) peripheral circulation.

The aim of assessment is to exclude other common differential diagnoses including infection, non-Charcot acute arthritis (e.g. Gout), DVT etc. and to arrive at an effective short, intermediate and long term treatment plan. The objective is to prevent deformity or the complications of deformity including ulcer.

Baseline observations – full foot examination, record foot deformity by clinical photography, measure skin temperature bilaterally to document differential(>=2 degrees is abnormal).
Baseline investigations – to exclude infection and other causes of acute arthropathy

  • Routine bloods including FBC, ESR, UE, CRP, HbA1c

  • Plain foot and ankle x-ray – to document baseline; x-rays may be normal in the earlystages of the Charcot process and may not become abnormal for weeks

  • If plain X-ray suggestive and infection not considered a significant possibility, no further imaging may be needed to confirm diagnosis although serial X-rays recommended to monitor response.

  • Where X-ray normal, confirm diagnosis with either MRI (preferred especially if concomitant ulcer) or isotope bone scan (if MRI contra-indicated/not tolerated or infection not considered likely). Increased uptake on bone scan indicates active pathology but does not differentiatebetween infection and arthropathy and may require further nuclear imaging (white cell labelled scan).

Infection reasonably excluded – infection is unlikely if the patient is apyrexial, the wbc is normal and there is no foot ulceration or other obvious portal ofentry of infection.

Unable to exclude infection – infection must not be missed, discuss with consultant radiologist to consider MRI scan or labelled WBC scan. If unable to confidently exclude infection discuss with consultant orthopaedic surgeon regarding the possibility of bonebiopsy for culture.

How to manage if suspicion confirmed?

Immobilising the joint and offloading the foot is the main stay of treatment during the acute phase of Charcot.

Most patients can be managed on partial weight bearing using Air Cast Walkers although compliance to its use has to be constantly reinforced. This is particularly useful for patients with concomitant ulcers.

Assessing activity /quiescence is very difficult but local foot temperature is the bestclinical guide and must be documented at every review. Repeat imaging tests are rarely required

Treatment and care plans

  • Immobilise the joint by casting

  • If confirmed Charcot neuro-arthropathy – consider iv pamidronate 60 mg in 200ml n saline over 4 hours and repeat once at 72hours if noresponse clinically

  • If osteomyelitis strongly suspected or confirmed, treat with intravenous then oral antibiotics for a minimum of 6 weeks.

  • Review mobility, social and work situation: may need liaison with family, socialservices, physiotherapy and occupational therapy.

  • It is usually necessary to have a multidisciplinary team review toensure all aspects of the care plan are coordinated

  • The MDT review conclusions must be documented and formally communicated to allmembers of the team and to primary care

  • Follow up must be effectively organised with the specialist medical team and the highrisk foot service.

Charcot Foot flowchart

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Patient Information Leaflets

Diabetes and foot complications
Low risk feet
Intermediate risk feet
High risk feet
Ulcerated foot
Charcot foot
Holiday feet

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Key Links

Putting Feet First
NICE Foot guidance
NICE In-patient guidance

Key Contacts

Community Foot Protection Team

Specialist Foot Health Services
13-14, Landport Road
Wolverhampton WV2 2QJ
Tel - 01902 444044
Email - specialistfoothealthservices@nhs.net

Multi-disciplinary Specialist Foot Team

Wolverhampton Diabetes Centre
New Cross Hospital
Wolverhampton WV10 0QP
Tel 01902 695310
Email – rwh-tr.wdcfootteam@nhs.net

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Governance Framework

Registered
All patients should be known both to practice based and the central diabetes registers.

Recorded
The outcomes of systematic foot examination, risk stratification and outcomes must berecorded.

Patient education programmes, Review of care plan

Full foot care education should be given at diagnosis and at each subsequent annual review.
Patient information leaflets, patient training videos, details of services and of “What Care toexpect” are available on the website www.wdconline.org.uk.
The patient should be informed of the care plan arising out of foot care review.

Effective recall systems

Defaulting from structured care is a recognised risk for foot events. Responsibility for recall ofpatients for annual foot review lies with primary care unless it has become the responsibility ofothers following referral according to risk stratification. The central diabetes information systemwill inform primary care of all patients not known to have had a foot examination within 18months.

Governed

Responsibility for the Diabetes Foot Care pathway will lie with a nominated clinical leadwho will chair a representative committee reporting to the District Diabetes lead and to theWolverhampton LIT.

They will be responsible for ensuring:
Effective management of the care pathway including effective integration of services,maintaining evidence based practice, review of protocols and guidelines, audit, critical eventanalysis, team building, training, effective service planning.

They will present an annual end of year report to the LIT.