MODERATE Risk

1. MODERATE Risk 1 RISK FACTOR PRESENT Deformity OR Neuropathy OR Peripheral arterial disease No other risk factors x6 more likely to ulcerate Annual assessment by health care professional Agree individual management/treatment plan Written and Verbal Education with emergency contact details Refer people who are at moderate or high risk of developing a diabetic foot problem to the foot protection service (community podiatry)

2. High Risk Previous ulceration/amputation/renal replacement therapy or >1 risk factor Loss of sensation Peripheral arterial disease Deformity Significant callus x83 more likely to ulcerate Annual assessment by health care professional Agree individual management/treatment plan Written and Verbal Education with emergency contact details Refer people who are at moderate or high risk of developing a diabetic foot problem to the foot protection service (community podiatry)

3. Foot Protection Service = Community Podiatry

4. Referrals accepted for Diabetes Patients with: Low risk with: Ingrowing Toenails Symptomatic Nail Conditions Corns Callus Foot Deformity Heel Pain/Plantar Fasciitis Moderate/High foot risk: Peripheral Neuropathy Peripheral Arterial Disease Renal Replacement Therapy History of Foot Ulceration • Timescales for Referral: • Moderate/High Risk with Urgent problem – Seen within 5 working days • Moderate/High Risk with Non-Urgent problem – Seen within 30 working days

5. Refer to Community Podiatry • Nail surgery: May be necessary, especially if recurrent/chronic • Carried out in local health centres by community podiatry • Patient may require: Improved glucose control advice • Antibiotics • Podiatrists will contact GP for support if these needed Ingrowing Toenails

6. What can podiatry do for the diabetic foot??? Callus & Corn Reduction Problematic Toenails Nail Surgery Functional Problems Looking after Feet Footwear Risk Status What can go wrong Holiday Feet

7. How Do I Refer to Community Podiatry?

8. ‘Podiatry Service Referral Form’

9. Send to: Email:not-tr.PodiatrySPA@nhs.net (From NHS.net account) Post to: Community Podiatry Single Point of Access Mansfield Community Hospital Stockwell Gate Mansfield NG18 5QJ For telephone queries please phone: 01623 785208 / 01623 785186 / 01623 785029

10. Ulcerated Foot (active foot disease) Presence of active ulceration, spreading infection, critical ischaemia, gangrene, charcot, unexplained hot, red, swollen foot (with or without pain) All Active Diabetic Foot Problems should be referred to Multi-Disciplinary Diabetes Foot Clinic within 1 working day NICE 2015 If a person has limb-threatening or life-threatening diabetic foot problem refer them IMMEDIATELY to acute service IF FOOT GANGRENOUS OR CRITICAL LIMB ISCHAEMA SUSPECTED → STRAIGHT TO VASCULAR ONE-STOP Now at: SURGICAL TRIAGE UNIT @ QMC 07812 269454 Consultant/Registrar 24:7

11. Diabetic foot ulceration is defined as: “a wound penetrating through the dermis, below the ankle in a diabetic patient” International Working Group on the Diabetic Foot

12. How Do I Refer to Diabetes Foot Clinic?

13. Complete ‘Diabetes Foot Clinic’ Referral Form or Referral Letter On Referral letter we need: Medical history & Medication What is the foot problem??? – duration, location, infection Patient contact details – telephone number please! Communication Issues Transport Issues

14. Please Note: Patient MUST have Diabetes We do not accept referrals for painful neuropathy We do not accept referrals for leg ulcers Check: Is the patient aware of referral? Are they willing to attend? Can they attend – do they need transport? We cannot visit patients at home We cannot accept patients in stretchers

15. Send to: Email:NUHNT.diabetesfootreferrals@nhs.net (From NHS.net account) Fax to: Diabetes Foot Clinic0115 9627959 Urgent Queries: Phone Dundee House 0115 9627622 or City Hospital 0115 9691169 ext 56622 And ask for Diabetes Foot Team If Urgent Vascular: Please contact Surgical Triage Unit at QMC

16. Who is the Diabetes Foot Clinic Multi-Disciplinary Team of Medical and Health Professionals working together to treat Active Diabetic Foot Problems

17. NUH – City Campus – Dundee House Multi-Disciplinary Team consists of: Consultant Diabetologists Vascular Surgeons Podiatrists Orthopaedic Surgeons Orthotists Podiatric Surgeons Plaster Room Microbiologists Staff Nurses OPAT Team Diabetes Specialist Nurses Radiographers 4 Days Consultant led MDT clinic 1 Day Pod/Plaster and MDT Ward Round 120+ Patients/Week and rising

18. Soft tissue infection – IWGDF 2015 Recommends: Do not offer antibiotics to prevent diabetic foot infections Do not treat clinically uninfected wounds with antimicrobial therapy Diabetic Foot Infection must be diagnosed clinically All skin wounds harbour microorganisms, therefore their presence cannot be taken as evidence of infection Clinical findings of infection and systemic inflammatory signs can be diminished by peripheral neuropathy and ischaemia Start antibiotic treatment for suspected diabetic foot infection as soon as possible

19. Remember… Keep an eye on those feet ! Thank You!

20. Further Information • NICE 2015 Diabetic Foot Problems: prevention and management, www.nice.org.uk/guidance/ng19 • NICE 2012 Lower limb peripheral arterial disease: diagnosis and management, www.nice.org.uk/guidance/CG147 • Scottish Intercollegiate Guidelines Network 116 Management of diabetes: A national clinical guideline www.sign.ac.uk/pdf/sign116.pdf • IWGDF 2015: Prevention and Management of Foot Problems in Diabetes Guidance Documents and Recommendations www.iwgdf.org/guidelines • Foot Risk Awareness and Management Education ww.diabetesframe.org • Charcot patient information http://www.futu.co.uk/patient.htm