REFERRAL FOR PEOPLE NEWLY PRESENTING WITH A FOOT ULCER AND/OR CELLULITIS OF THE FOOT In this case, the NICE guidelines9 recommend referral to a specialised foot care team within 24 h.
The guidelines suggest that as a minimum the team should perform the following actions: (1) investigate and treat vascular insufficiency; (2) initiate and supervise wound management; (3) use dressings and debridement as indicated; (4) use systemic antibiotic for cellulitis or bone infection as indicated; (5) ensure an effective means of distributing foot pressures, including specialist footwear, orthotics and casts; (6) try to achieve optimal glucose levels and control of risk factors for cardiovascular disease.
These recommendations are mostly given at evidence level D.
Although most areas of the United Kingdom have such a multidisciplinary foot care team based in a local hospital, gaining access to the team within the 24-h timeframe, especially during the evenings and weekends, can be problematic.
There are also sometimes difficulties in getting the necessary foot experts in the team to work together.
These teams need clear leadership, each member needs clearly defined roles and responsibilities and the GP needs to know whom to speak with about the referral.
These details need to be clear for referrals both within ‘office’ hours, and for out-of-hour emergencies.
The development of consultant podiatrists who can lead the foot care team would be one way of resolving some of these potential difficulties.
The message about prompt urgent referral for newly presenting foot ulceration in someone with diabetes represents somewhat of a paradigm shift for many GPs.
There may be a temptation to follow a traditional management plan whereby the GP referred the patient to the practice nurse for a dressing with a prescription to the patient for a broad-spectrum antibiotic to be taken orally if infection was suspected.
The practice nurse then arranged to see the patient every few days to change the dressings.
Such a ‘wait-and-see’ policy often continued for several weeks before referral was contemplated.
Such a policy can prove disastrous.
In a study of 669 ulcers presenting to a specialist foot team,17 the median time between ulcer onset and first professional review was 4 days (range 0, 247).
The median time from first professional review and first referral to the specialist team was 15 days (range 0, 608).
Only 30% of patients were referred to the team within 1 week of onset, 48% within 2 weeks of onset and 78% within 6 weeks of onset.
It was considered that the condition of 25 ulcers may have deteriorated as a result of delayed referral to the specialist team.
This study confirms that in the United Kingdom in the 1990s, the message about prompt urgent referral had still to impact many in general practice.
It is to be hoped that the message from the NICE guideline is getting through and that prompt urgent referral is now usual.
FOOT CARE IN TYPE 1 DIABETES National clinical guidelines for the diagnosis and management of type 1 diabetes in adults18 and in children and young people19 were published by NICE in 2004.
The development group for the guidelines for adults noted that foot care had been examined by other quality guideline groups internationally in type 2 diabetes, and that consistency with prior statements would be desirable.
An annual foot review was thought to be desirable for reasons of both foot surveillance and education.
The simple and effective utility of the monofilament was noted.18 The development group for the guidelines for children and young
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130 THE DIABETIC FOOT IN PRIMARY CARE
people noted that clinical neuropathy is rare in children and young people with good glycaemic control, but recommended that all children and young people with type 1 diabetes should be offered an annual foot care review.19
EDUCATION OF STAFF IN PRIMARY CARE Few primary care physicians or nurses are likely to have had much in-depth teaching on diabetes foot care as part of their initial training.
There are now a number of excellent diabetes education and training programmes available in the United Kingdom that enable a health care professional to gain skills in diabetes care (including foot care) at certificate, diploma and masters level.
These include the Warwick Diabetes Care, Certificate in Diabetes Care (CIDC) at the University of Warwick, where there is also a Diabetes Masters programme with a foot care module that can be taken as a stand-alone post-graduate award.20 Health care professionals working to deliver good-quality diabetes care in the community need to keep themselves up-to-date and need to support each other.
To this end, a primary care diabetes society (PCDS) is being set up, dedicated to support primary care professionals to deliver high-quality clinically effective care in order to improve the lives of people living with diabetes.
It has a Web site, pages in the journal Diabetes and Primary Care and is running a national conference.21 Diabetes UK, the patient and professional group, also provides information and support for health care professionals.22 Podiatrists with a special interest in diabetes have set up a support group, Podiatry Diabetes United Kingdom (PDUK), that runs a very successful Web chat forum in which members can e-mail questions, concerns and requests for information, which are answered by other members.23
SUMMARY There is currently a rapid increase in the United Kingdom, as in many countries, in the number of people developing diabetes.
A shift in diabetes care delivery from the secondary (hospital) sector to the primary (general practice) sector is happening.
This has been facilitated by government policy (Diabetes NSFs) and through the quality and outcomes framework of the new general practice contract.
Clinical recommendations on diabetes foot care in the United Kingdom that are up-to-date and evidence based have been published by NICE to underpin management.
There is still much to be done to ensure that good-quality primary foot care screening is performed on everyone on an annual basis, and that those with at-risk feet get referred and properly managed in foot protection clinics.
Patients newly presenting with a foot ulcer and/or cellulitis also need to receive appropriate care within 24 h from a multidisciplinary foot care team.
The principles are in place, which should translate into reduced numbers of people with diabetes experiencing ulcers and amputations, and future research is likely to demonstrate that such improved clinical outcomes will be cost-effective.