Additional Diabetes Information:
Diabetes is the most common cause of non-traumatic limb amputation within the UK, with diabetic foot ulcers preceding more than 80% of amputations for people with diabetes. Diabetic foot ulceration is extremely common and it is estimated that in their lives, 50% of people with diabetes will have a diabetic foot ulcer; and of course the number of people with diabetic foot ulcers is expected to increase as the number of people with diabetes increases.
People with diabetes are prone to having foot problems, often because of two complications of diabetes – nerve damage (neuropathy) or poor circulation (peripheral vascular disease) or a combination of the two.
Neuropathy can cause loss of feeling in the feet, taking away a person's ability to feel pain and discomfort, meaning they may not detect injury or irritation. Poor circulation in the feet reduces the ability to heal, making it hard for even a tiny cut to resist infection.
Diabetic foot problems can have a significant impact on a patient's quality of life as they can reduce mobility, lead to loss of employment, depression and damage to or loss of limbs. They often have a significant financial impact on the NHS through outpatient costs, increased bed occupancy and prolonged stays in hospital.
Despite a number of publications on strategies to prevent and manage foot problems, and the commissioning of specialist services in this regard, there is a wide variation in practice in the prevention and management of diabetic foot problems, both in an outpatient and inpatient setting. This variability can depend upon the level of awareness of healthcare professionals, geography, individual Trusts and which individual medical specialities are involved, ie orthopaedic surgeons, general surgeons, vascular surgeons or general physicians.
In 2004 the National Institute of Clinical Excellence published guidelines on the prevention and management of foot problems in Type 2 diabetics (NICE Clinical Guideline 10, 2004). This concentrated on the detection, general management and treatment of diabetic foot ulcers and the care pathway from this ends at referral to a multi-disciplinary team.
There is no doubt that it is recognised that patients with diabetes should have an annual diabetic check, and this is the standard which is aspired to in general practice. Such a diabetic check should include such factors as cardio-vascular aspects, blood pressure, lipids, diabetic control as well as retinal screening for diabetic retinopathy, and testing for diabetic neuropathy.
In past years the vast majority of diabetics were not subject to annual checks and some GP experts that we instructed then were of the opinion that it was not a failure in the duty of care for a General Practitioner not to have organised a regular annual check-up in the absence of any knowledge of any diabetic foot or other complications. Things are now changing with a greater awareness of diabetes and its associated complications. On any view, we think the duty of care is higher if there have been pre-existing diabetic or foot complications; and if there has, there should be an agreed management plan which should include foot care education and also regular review, which should include an inspection of a patient's feet, an evaluation of footwear and the potential need for vascular assessment.
It is generally accepted that, if either as part of a one-off attendance or as part of an annual or regular review, that a foot care emergency has been identified (such as new ulceration, swelling or discolouration) then there should be referral to a multi-disciplinary foot care team within 24 hours. That team would normally be within a specialist unit at a hospital and would include a number of experts within specialities such as vascular surgery, podiatry, orthotics, nurses trained in diabetic foot wounds and diabetologists with expertise in lower limb complications.
The team would assess the foot care emergency and decide whether or not referral, ultimately to either a physician specialising in diabetes or to a vascular surgeon should be made, and in any event closely monitor the wound and assist in changing dressings regularly, carefully remove dead tissue from foot ulcers and advise on the use of intensive systemic antibiotic therapy, and manage at a high risk when the ulcer is healed.
Unfortunately diabetic foot complications are often not managed appropriately in general practice. It is rare to see a regular annual review or an understanding of the seriousness of a diabetic foot complication on initial referral, and you often see General Practitioners prescribing antibiotics direct without referral and these are often completely inappropriate. The results from this can be disastrous and may result in an unnecessary amputation.
It can lead to the worsening of the situation and the need for a direct referral to a diabetes specialist or to a vascular surgeon as an emergency, rather than say a referral to an A&E Department of a hospital.
Sometimes Accident and Emergency employees often do not appreciate the significance of diabetic foot complications, and again can sometimes even make a misdiagnosis of athlete's foot or make an inappropriate prescription for contra-indicated antibiotics rather than a referral for inpatient care to the appropriate specialist.
The NICE organisation has now published guidelines for the management of inpatient diabetic foot problems which provides evidence-based clinical guidelines for use in England and Wales.
Amputation rates can vary up to 4-fold in the UK because of a number of factors, including varying professional opinions within the field and inconsistent management as different hospitals have different anti-microbial protocols for diabetic foot ulcers.
If you are a diabetic, or indeed develop some type of diabetic foot care emergency, contact your General Practitioner immediately. If you are diabetic then you should insist on, at the very least, an annual review; and if you have any soreness or redness or open wound on your foot suggest you contact your GP immediately and insist upon a referral to a multi-disciplinary team who are specialists in diabetic foot care management.
It might be an idea to go armed with the relevant NICE Guidelines: “Type 2 Diabetes: Prevention and Management of Foot Problems. NICE Clinical Guideline 10 (2004)” available from guidance.nice.org.uk/CG10.