Foot Ulcer Referral Pathway

Helen Dooley

Lead Diabetes Specialist Podiatrist

• In 2013, almost 2.9 million people in UK diagnosed with diabetes.

• 2025 estimated that in UK > 5 million people will have diabetes

• Foot complications are common in people with diabetes. (estimated 10% will have a foot ulcer at some point)

• Amputation rates are higher in patients with diabetes than patients without diabetes. 80% of amputations are preceded by foot ulcers.

• 1 in 3 people with diabetes over age of 50 are at increased risk of developing Peripheral Arterial Disease. (PAD)

Background

• Diabetic foot problems have a significant impact on patients' quality of life; for example, reduced mobility that may lead to loss of employment, depression, and damage to or loss of limbs

• In addition, Diabetic foot problems have a significant financial impact on the NHS through outpatient costs, increased bed occupancy and prolonged stays in hospital.

NICE Inpatient Guidelines 2011

How Diabetes Affects the Lower Limbs

• Diabetes is a long term condition which can cause problems as the nerves and blood vessels become damaged.

This can affect:

- The feeling in your patient’s feet (peripheral neuropathy);

- The circulation /blood flow to your patient’s feet (ischaemia)

• These changes can be gradual and may go unnoticed initially. This is why it is essential your patient has their feet screened regularly, in accordance with their stratified level of risk.

• Controlling blood sugars, cholesterol levels and blood pressure is essential to reduce the risk of limb/life threatening problems associated with diabetes.

• In addition quitting smoking, undertaking regular exercise and controlling weight will also help to reduce risks.

Screening And

Classification

• Screening is a process that categorises people into mutually exclusive groups and will give a reasonably good indication of the likelihood/risk of a person with diabetes developing a foot complications.

• Assessment is a much more intense and complex

process by which a diagnosis is reached and treatment/management is initiated

Foot screening and assessment

The aim of carrying out a foot screening is to identify the presence of risk factors for diabetic foot complications which could lead to ulceration.

Neuropathy, Peripheral Arterial

Disease, Significant structural

abnormalities, Significant callus,

previous ulceration inability to self care.

Lower Limb Assessment and Foot Screening

Assessment also includes checking for infection .

Absent pulses , Previous amputation

Classification of foot risk

• Active

• High Risk

• Moderate Risk

• Low Risk

Any of the following

• Ulceration • Spreading infection • Critical Limb ischaemia • Gangrene • Suspicion of an acute Charcot Arthropathy or an

unexplained hot, red, swollen foot with or without pain

Any of the following

• Previous Ulceration • Previous Amputation • On Renal replacement therapy

Any of the following

• Neuropathy plus non-critical limb ischaemia • Neuropathy plus callus and or deformity • Non-Critical Limb ischaemia plus callus and or

deformity

Any of the following • Deformity • Neuropathy • non-critical limb ischaemia

MODERATE

LOW

HIGH

HIGH

ACTIVE

No

No

No

Yes

Yes

Yes

Yes

No

Risk Stratification decision tree (based on the 2016 NICE guideline)

Risk Category

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Refer all patients to Diabetes Care for You

Consider referral to Diabetes Care for You

.

Low Risk remain in Primary care for annual review.

• Ulceration • Infection • Critical ischaemia or gangrene • neuropathic pain • Unexplained red, hot, swollen foot

(Suspected Charcot or #)

Action

Related to diseases that affect circulation and sensation.

Foot ulcers

Definition Active ulceration

"a full thickness wound, i.e. a wound penetrating through the dermis, below the ankle in a diabetic patient, irrespective of duration". International Working Group on the Diabetic Foot

2005 (IWGDF)

Diabetic foot ulceration is principally associated with:

PAD and peripheral neuropathy, often in combination

Other factors associated with increased risk include:

Previous amputation

Previous ulceration

The presence of significant callus

The presence of significant structural abnormality

Impact of Neuropathy

• Signs and symptoms may be minimal

• Nevertheless pathology proceeds rapidly

• The end stage of tissue death is quickly reached

• Window of opportunity is limited

Neuropathic Ulcer

Ischaemic ulcers

Ischaemia

Critical Ischaemia

Previous Amputation

Infection Control

Infection

• Laboratory Research(In vitro) evidence suggests that in the patient with diabetes the chemicals and cells which fight infection are compromised and impaired.

• In addition PAD reduces the penetration of leukocytes(Blood cells) and antibiotics to the infected sites

Infection. Why are diabetes ulcers different

Prolonged periods of hyperglycaemia lead to impairment in immune function:

• A decrease in Chemotaxis at the site of infection.

• A decrease in the ability of the phagocytes to destroy bacteria.

• Decreased intracellular killing of bacteria.

an area that has previously been ulcerated but has subsequently healed. After ulceration the affected area never repairs itself completely and only returns to 70% of tensile strength. This area is always vulnerable to future ulcerations. Previous ulceration is the highest risk factor for future ulceration. (FRAME)

Previous ulceration

Diabetes Care For You Ulcer Pathway

Refer Urgently Within 24 hours to Level 4 (secondary care) Clinic

Ulcer With spreading infection/ Swelling / discolouration/ >2cm Cellulitis

Any Arterial Ulcer (Below Ankle) Including Gangrene / necrosis

Refer Urgently within 24 hours to Diabetes Care For you via ERS

Non –Infected , Neuropathic Ulcers

(Below Ankle)

Neuropathic Ulcers with local infection (<2cm cellulitis /no deep probe/no bone

visible/ no systemic symptoms

Take Swab Start Antibiotics

Referral Form – Essential information

HW/LH Referral form. Low Risk may be treated in B&H

Where do I refer this chap?

• Type 2 Diabetes

• 49 year old gentleman

• Extremely Painful Left hallux – trauma

• Presented GP surgery

• Ingrown toe nail /Fungal nail

• Chronic Pain Left Hallux

Palpable Pulses

All sites detected (10g monofilament)

Low risk

Pain Red infection

Active Foot Problem

MRI Left foot localised bone marrow oedema in the terminal tuft of the distal phalanx of the hallux. In the absence of fracture and disproportionate pain raises the suspicion of a deep infection, confirmed on MRI scan.

GP

Antibiotic therapy

X-ray

General Podiatry MSK Foot &Ankle

MRI

DCFY Podiatrist Ulcer under hallux nail. Osteomyelitis

Left hallux

Management

Ulcer

Antibiotic Therapy

Referral Form – Essential information

HW/LH Referral form. Low Risk may be treated in B&H

Final Points • Screen and Classify

• Refer early

• Controlling blood sugars, cholesterol levels and blood pressure is essential to reduce the risk of limb/life threatening problems associated with diabetes.

• In addition quitting smoking, undertaking regular exercise and controlling weight will also help to reduce risks.

• Provide foot health education.

Skin care

Nail care

Foot wear

Check feet

Maintain the boat to weather the storm

Questions