People with diabetes are often given a fright when they're diagnosed, after all it's a life changing moment. Everything about life from that point onward will be different, and for sure that includes how much care and attention ones feet should receive. It's well known that serious foot problems can be associated with diabetes, which is good because this is a serious topic. In my opinion the more people that know about the risks and complications associated with diabetes the better, because it's increasingly common and the potential foot problems are no joke.
The National Institute for Health and Care Excellence (NICE) released their Guideline N19 on diabetic foot problems in 2015, it was then brought up to date in October 2019. This guideline is often cited as the go-to reference for best practice when it comes to preventing and managing foot problems in people with diabetes. In this blog post, we'll take a closer look at some of the things included in this comprehensive paper so you'll have a better idea of what to expect from your podiatrist and the team around them.
Guideline N19 is relevant to children, young people and adults with diabetes. It covers a range of topics from preventing foot problems in the first place, to managing existing foot problems and reducing variation in practice (including antibiotic prescribing for diabetic foot infections). First of all a quick summary just in case you're pushed for time and don't get to the bottom of this post. There are some key points that everyone should take away from this guideline (from a Podiatry perspective anyway):
Podiatrists should be actively involved in the multidisciplinary team caring for people with diabetes
Podiatry input is essential at all stages of diabetes care, from diagnosis onwards
Annual foot examinations are recommended for all people with diabetes
Essentially this document recognises the important role that podiatrists play in diabetic foot care, placing us right at the heart of the multidisciplinary team required to deliver care right through from prevention to (in the worst cases) amputation and wound care.
So, who is the document for?
Healthcare professionals caring for people with diabetes
Commissioners and providers of diabetes foot care services
People with diabetes, and their families and carers
Guideline N19 exists to educate everyone about what a person with diabetes needs and should expect to keep their feet safe and well.
What are the key recommendations?
Care within 24 hours of a person with diabetic foot problems being admitted to hospital, or the detection of diabetic foot problems (if the person is already in hospital)
This means:
1. Each hospital should have a care pathway for people with diabetic foot problems who need inpatient care.
2. A named consultant should be accountable for the overall care of the person, and for ensuring that healthcare professionals provide timely care.
3. Refer the person to the multidisciplinary foot care service within 24 hours of the initial examination of the person's feet. Transfer the responsibility of care to a consultant member of the multidisciplinary foot care service if a diabetic foot problem is the dominant clinical factor for inpatient care.
4. The named consultant and the healthcare professionals from the existing team should remain accountable for the care of the person unless their care is transferred to the multidisciplinary foot care service.
Care across all settings
This means that the following should be in place in every NHS locality:
1. A foot protection service for preventing diabetic foot problems, and for treating and managing diabetic foot problems in the community.
2. A multidisciplinary foot care service for managing diabetic foot problems in hospital and in the community that cannot be managed by the foot protection service. This may also be known as an interdisciplinary foot care service.
3. Robust protocols and clear local pathways for the continued and integrated care of people across all settings including emergency care and general practice. The protocols should set out the relationship between the foot protection service and the multidisciplinary foot care service.
4. Regular reviews of treatment and patient outcomes, in line with the National Diabetes Foot Care Audit.
5. A 'foot protection service' led by a podiatrist with specialist training in diabetic foot problems, who has access to healthcare professionals with skills in the following areas: Diabetology, biomechanics and orthoses, wound care.
6. There should also be a 'multidisciplinary foot care service' led by a named healthcare professional consisting of specialists with skills in the following areas:
Diabetology
Podiatry
Diabetes specialist nursing
Vascular surgery, Microbiology
Orthopaedic surgery
Biomechanics and orthoses
Interventional radiology
Casting
Wound care
Rehabilitation services
Plastic surgery
Psychological services
Nutritional services
Assessing the risk of developing a diabetic foot problem
Frequency of assessments
1. For children with diabetes who are under 12 years, give them, and their family members or carers (as appropriate), basic foot care advice.
2. For young people with diabetes who are 12 to 17 years, the paediatric care team or the transitional care team should assess the young person's feet as part of their annual assessment, and provide information about foot care. If a diabetic foot problem is found or suspected, the paediatric care team or the transitional care team should refer the young person to an appropriate specialist.
3. For adults with diabetes, assess their risk of developing a diabetic foot problem at the following times:
When diabetes is diagnosed, and at least annually thereafter
If any foot problems arise.
On any admission to hospital, and if there is any change in their status while they are in hospital.
Assessing the risk of developing a diabetic foot problem
1. When examining the feet of a person with diabetes, remove their shoes, socks, bandages and dressings, and examine both feet for evidence of the following risk factors:
Neuropathy (use a 10g monofilament as part of a foot sensory examination).
Limb ischaemia (see the NICE guideline on peripheral arterial disease).
Ulceration
Callus
Infection and/or inflammation
Deformity
Gangrene
Charcot arthropathy
2. Use ankle brachial pressure index in line with the NICE guideline on peripheral arterial disease. Interpret results carefully in people with diabetes because calcified arteries may falsely elevate results.
3. Assess the person's current risk of developing a diabetic foot problem or needing an amputation using the following risk stratification:
Low risk:
No risk factors present except callus alone.
Moderate risk:
Deformity or
Neuropathy or
Non-critical limb ischaemia.
High risk: Previous ulceration or Previous amputation or On renal replacement therapy or Neuropathy and non-critical limb ischaemia together or Neuropathy in combination with callus and/or deformity or Non-critical limb ischaemia in combination with callus and/or deformity.
Active diabetic foot problem: Ulceration or
Spreading infection or
Critical limb ischaemia or
Gangrene or
Suspicion of an acute Charcot arthropathy, or an unexplained hot, red, swollen foot with or without pain.
What else do you need to know?
Guideline N19 then goes even further covering the management of risk, patient education and the treatment of specific foot problems associated with diabetes. If you would like to read more then click here and scroll down to page 9 of the document. As for my blog post I've covered the aspects I feel are most important to the diabetic patient. Specifically the final section on assessing a persons risk and how it is classified within the guideline. A persons risk can change at any time so if you have diabetes please remain vigilant and check your feet regularly.
In fact, there is a useful publication by Diabetes UK that provides an excellent summary of ten foot related tips that everyone with diabetes should be aware of. The flyer aims to reduce the risk of diabetic foot problems and help people understand when they should seek help through education, click here to read the document. If this post has raised any concerns or you or you have a question, please don't hesitate to get in touch or arrange a free phone call here. Find Your Stride podiatrists are HCPC registered and work with a detailed understanding of the information you have just read.
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