Effective Community Management of Diabetic Foot: Key Strategies and Pathogenesis Insights

1. Community Management of the Diabetic FootDr Fiona StrachanDr Gray’s Hospital, Elgin

2. St Vincent Declaration (WHO and IDF, 1990) • Set the target for reduction in incidence of amputation by 50% in 5 years • Unrealistic time frame given multifactorial nature of problem • Difficult to quantify improvement due to poor baseline register data • Little to assess QOL and functional assessment pre-and post operatively • Crude indicator in quality of ulcer care delivered

3. The Vulnerable Diabetic Foot • 30% of diabetic patients at risk of foot ulceration; most costly complication of DM management (20% of total costs) • Ischaemia • Macrovascular and microvascular • Neuropathy • Structural deformity • Visual impairment • Hyperglycaemia

4. Peripheral Vascular Disease • History of IHD; calf claudication on exercise • Cool pulseless foot • Palpation of posterior tibial and dorsalis pedis pulses • Doppler US (ABPI 0.9-1.3 normal; 0.5-0.9 suggests significant PVD; <0.5 implies severe PVD) • Heavy callus build-up suggests reasonable peripheral perfusion • Generally ischaemic ulcers on the margins of the foot rather than plantar aspect

5. Diabetic Neuropathy • 35% of diabetic patients have asymptomatic neuropathy • Patient will often fail to complain of pain, even with significant foot lesion • Motor • Prominent metatarsal heads; claw toes may be a clue • Sensory • Best detected with monofilaments (10g and 75g) • Autonomic neuropathy • Dry skin with fissuring; distended veins over dorsum of foot

8. Painful Neuropathy • Intensity variable and may be aggravated by rapid tightening of control/depression • Aim to improve control gradually (DCCT;UKPDS) • Offer • Simple analgesia • TCADS (block serotonin re-uptake to increase pain threshold) • Gabapentin • Carbamazepine (stabilise neuronal membrane Na channels) • Capsaicin (release of substance P in nerve endings) • TENS machines • Opsite dressings

9. Pathogenesis of Diabetic Ulcers • Hyperglycaemia causes • Abnormal neutrophil function increasing susceptibility to infection • Advanced glycosylation end-products accumulate, leading to abnormal collagen production (inflexible and prone to breakdown • Abnormal fibroblast activity prevents robust extracellular matrix production in proliferative phase of wound healing • Repeated trauma maintains chronic inflammatory phase, aggravated by abnormal pressure distribution

10. Moray Podiatry Annual Review 2005 • Retrospective audit of diabetic patients presenting with acute foot lesion in 2005 (ulceration, infection or Charcot arthropathy) • Includes only those receiving podiatry intervention ie known to podiatry dept • Episodes of acute foot lesion may be recurrent in same patient – audit expressing number of patients affected only • Does not include those with previous ulceration but no active lesion in 2005

11. Moray Podiatry Annual Review 2005 • 227 patients identified • 7.6% of the Moray diabetic population as expressed as percentage of population of approx 3000 • Approx 60% managed by primary care; 40% attending secondary care • Prevalence of foot ulceration in people with diabetes in UK between 5% and 7% (Scottish Collegiate Guidelines Network, 2001) • Extrapolated to Grampian, potential for over 1500 patients with active foot ulcers requiring integrated care.

12. Key Components in Effective Management of the Vulnerable Diabetic Foot • Prompt referral for revascularisation when appropriate • Wound Management • Offloading Strategies • Optimising the metabolic environment and controlling CVS risks • Managing the patient at risk of ulcer recurrence

13. Key Components in Effective Management of the Vulnerable Diabetic Foot • Prompt referral for revascularisation when appropriate When? • Wound Management • Review by appropriate team member • Debridement – mechanical/chemical/larvalWho? • Infection control either at primary or secondary care level

14. Antibiotics and the Diabetic Foot • Little evidence base to guide practice • Consider “colonisation” vs infection – but even skin commensals can be relevant in immunocompromised patient • Prompt management of neuroischaemic ulcers due to increased risk of sepsis • Infection may be present without signs of local erythema (failure of vasodilatation) – beware of pain in “neuropathic foot” • Microbiology can be complex – G-positive aerobic and G-negative aerobic and anaerobic bacteria, singly or in combination • Initial broad spectrum antibiotics tailored once reliable swab specimens available

15. Key Components in Effective Management of the Vulnerable Diabetic Foot • Prompt referral for revascularisation when appropriate When? • Wound Management • Review by appropriate team member • Debridement – mechanical/chemical/larval Who? • Infection control either at primary or secondary care level • Offloading Strategies • Orthotics How? • Dietetics • Optimising the metabolic environment and controlling CVS risks Where? • Managing the patient at risk of ulcer recurrence Who?

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18. The Stages of the Diabetic Foot • The normal foot • The high-risk foot • The ulcerated foot • The infected foot • The necrotic foot • The unsalvageable foot

19. Diabetic Foot – Integrated Care Pathway and Clinical Accord (Draft Proposals) • Screening Standard • Foot Screening at diagnosis and annually thereafter • Standardised Grampian Diabetic Foot Risk Assessment Form • Challenge of easy access to information • Barriers to provision of uniform screening/education • time, training and quality assurance • Screening Outcomes – low risk moderate risk high risk

20. Diabetic Foot – Integrated Care Pathway and Clinical Accord (Draft Proposals) • Low Risk Foot • Low risk with no podiatry need – Education and Self Care Leaflet • Low Risk with podiatry need – Above plus referral to Community Podiatry Services • Both require ongoing annual review

21. Diabetic Foot – Integrated Care Pathway and Clinical Accord (Draft Proposals) • Moderate Risk Foot • Any one of the following: • Vascular impairment • Significant neuropathy • Previous vascular surgery • Significant visual impairment • Physical disability • Referral to the Community Podiatry Service to be seen within twelve weeks • Challenges within current resources • Clarify on-going responsibilty for screening

22. Diabetic Foot – Integrated Care Pathway and Clinical Accord (Draft Proposals) • High Risk Foot • Acute or chronic active disease • Referral to Diabetes Specialist Podiatry Services by practice team/secondary care team/CPS using GDFRAF • Planned Care – foot intact 4-6 weekly review to maintain integrity • Unplanned Care – active foot lesion DSPS will act as “hub” for multi-disciplinary approach Ideally “one-stop” service for patients Need for rapid response/resource constraints may dictate whether service based in hospital or community initially

23. Diabetic Foot – Integrated Care Pathway and Clinical Accord (Draft Proposals) DSPS

24. Diabetic Foot – Integrated Care Pathway and Clinical Accord (Draft Proposals) DSPS CPS PN/DN

25. Diabetic Foot – Integrated Care Pathway and Clinical Accord (Draft Proposals) Clinician DSPS CPS PN/DN

26. Diabetic Foot – Integrated Care Pathway and Clinical Accord (Draft Proposals) Dietetics Clinician Microbiology DSN DSPS CPS PN/DN

27. Diabetic Foot – Integrated Care Pathway and Clinical Accord (Draft Proposals) Dietetics Clinician Microbiology DSN Vascular DSPS CPS Orthotics PN/DN Tissue Viability Physiotherapy Prosthetics

28. Developing an integrated pathway for diabetic foot screening and management provides a challenge for Grampian in 2006……

29. Developing an integrated pathway for diabetic foot screening and management provides a challenge for Grampian in 2006……