trained specialist podiatrists and orthotists, nurses with training in the dressing of diabetic foot wounds and diabetologists with expertise in lower limb complications; such a team requires unhindered access to suites for managing major wounds, inpatient facilities that are accessible urgently, multi-route antibiotic administration, community nursing, diagnostic and clinical advisory microbiology services, orthopaedic/podiatric surgery, vascular surgery, radiology and orthotics.
Organisationally, this means that such a team should be established in every health economy, and people with diabetes, primary care providers and emergency services must know of its existence and understand how to refer new problems without delay.
By bringing together relevant expertise and deploying it without delay, both temporary and permanent disability can be minimised.
The evidence as to which interventions the multidisciplinary foot care teams should best deploy is patchy.
But there is consensus or better support for wound monitoring, debridement and regularly changed dressings, intensive antibiotic therapy for invasive infection (cellulitis, osteomyelitis), offloading measures including total contact casting, revascularisation where appropriate, high-impact education and optimisation of metabolic and cardiovascular risk factors.
Some of the patients referred acutely according to the above criteria will have Charcot neuroarthropathy.
Immobilisation of the affected area plus other emerging interventions should also be a responsibility of the multidisciplinary team.
ALGORITHM OF CARE PATHWAYS
The NICE guideline contains an algorithm that describes on one page (Figure 36.2) the organ- isational arrangements outlined above.
LOCAL ORGANISATIONAL ARRANGEMENTS An average local health care economy in the United Kingdom comprises approximately 250 000 people, of whom 8000, 10 000 will presently have diagnosed diabetes. Local provider services will usually include about 120 primary care practitioners and their teams, community-based services (usually the prime working location for podiatrists and district nurses) and an acute hospital. The workload implied by the above recommendations means that
r Primary care services need to perform up to 6000 foot examinations per year; r Community podiatry services need to see and provide a foot care protection programme to 2000 people with increased risk (approximately 5000 contacts per year) and 1500 people with high risk (approximately 9000 contacts per year); r A multidisciplinary foot care team needs to see and treat 500 people with new ulceration (approximately 10 000 contacts per year, including up to 50 minor and major amputations, up to 50 revascularisations, large numbers of casts, bespoke shoes, etc.).
This is clearly a formidable management task and will deliver the evidence-based benefits safely, efficiently, effectively, equitably and in a ‘patient-centred’ manner only if each of the
JWBK089-36
On diagnosis of type 2 diabetes, and at annual review thereafter ♦ examine patient’s feet and lower legs to detect risk factors , include ♦ testing of foot sensation using 10-g monofilament or vibration ♦ palpation of foot pulses ♦ inspection for any foot deformity ♦ inspection of footwear
Is person at low current risk of foot ulcer? (normal sensation, palpable pulses) JWBK089-Boulton
No ♦ Agree management plan including foot care education Yes ♦ Arrange recall and annual review as part of ongoing care April 24, 2006 Does the individual have a foot ulcer?
As a minimum ♦ investigate and treat vascular insufficiency ♦ initiate and supervise wound management Refer urgently to ♦use dressings and debridement as indicated No Yes 20:30 multidisciplinary foot care team ♦ use systemic antibiotic therapy for cellulitis or bone infection ♦ ensure an effective means of distributing foot pressures, including specialist footwear, orthotics and casts 402 ♦ try to achieve optimal glucose levels and control of risk factors for Refer to foot protection team for classification after ulcer heals cardiovascular disease ♦ manage as ‘at high risk’ when ulcer is healed Char Count= 0 ♦ Management and frequent review (1, 3 monthly) by foot protection team ♦ At each review Is person at high risk of foot ulcer? ♦ inspect patients’ feet If new (risk factor + deformity or skin changes or previous ulcer) ♦ review need for vascular assessment ♦ ulcer (wound) ♦ evaluate provision of and provide appropriate ♦ intensified foot care education ♦ swelling ♦ specialist footwear and insoles ♦ discolouration No Yes ♦ skin and nail care ♦ Ensure special arrangements for those people with disabilities or immobility then refer to Is person at increased risk of foot ulcer? ♦ multidisciplinary foot (neuropathy or absent pulses or other risk factor) care team within 24 h ♦ Management by foot protection team ♦ Inspect patients’ feet 3, 6 monthly: ♦ review need for vascular assessment No Yes ♦ evaluate footwear ♦ enhance foot care education
Figure 36.2 NICE Foot Care Guideline: algorithm3
JWBK089-36 JWBK089-Boulton April 24, 2006 20:30 Char Count= 0
REFERENCES 403
components is integrated effectively with the others. Accordingly, there must be some form of local coordination (e.g. a multidisciplinary steering group) that keeps all members of the distributed diabetes care team up to date with local organisational arrangements, that maintains the competencies of all personnel, that creates a framework for good communication including shared record keeping and that, by means of continuous clinical audit, evaluates the service structures, processes and outcomes in order to prioritise, implement and re-evaluate incremental improvements as required.