Diabetic footcare: Part 1 Avoiding amputations

With around 120 foot amputations in people with diabetes in England alone every week, practice nurses should be competent to carry out the annual foot check and be confident that they know when and where to refer

People with diabetes are up to 30 times more likely to have an amputation compared with the general population, and people with diabetes are more likely to be admitted to hospital with a foot ulcer than any other complication of diabetes. It's a huge problem that needs addressing by healthcare professionals in primary and secondary care to deliver the best outcome.

Each week in England there are around 120 amputations in people with diabetes. The majority of diabetes-related amputations are caused by a 'foot-attack' — a foot ulcer or infection failing to heal. The good news is that when people with a foot attack (active foot disease) get rapid access for treatment by a specialist multi-disciplinary team, it has been shown to promote faster healing and fewer amputations, saving money and lives.

Costs

Amputation is not only devastating in its impact on the person with diabetes and their family, leading to a loss of independence and livelihood, it is also expensive for the NHS. Over £119 million is spent each year in England on diabetes-related amputations.

Scale of the problem

The number of amputations is rising, from 5,700 in 2009—2010 to more than 6,000 in 2010—11. It is projected that there will be more than 7,000 amputations in people with diabetes in England by 2014—15 if urgent action is not taken to reduce complications of diabetes.¹ It is also estimated that around 61,000 people with diabetes in England have foot ulcers at any given time.²

Life limiting

People with diabetes who have an amputation or foot ulcer have a relative increased likelihood of death within five years of up to 80 per cent, which is greater than that for colon cancer (49%), prostate cancer (20%) or breast cancer (17%).³ The number of people with diabetes with one or more major amputations is also on the rise.

MULTIDISCIPLINARY FOOTCARE TEAMS

Amputations have been reduced by over 50% where hospitals have introduced multidisciplinary footcare teams (MDfT) and promoted rapid access to them. In addition, through the reduction of costly amputations, such teams can save over four times their cost.²

Diabetes UK's aim, outlined in its new report, Fast Track For A Foot Attack: Reducing Amputations, is to achieve rapid access to specialist assessment and treatment for all those with a foot problem. Diabetes UK believes this would make all the difference in achieving its goal of reducing amputations by 50% over the next 5 years. Secretary of State for Health, Jeremy Hunt has also committed to this target, outlined in Diabetes UK's Putting Feet First campaign.

Footcare profiles

There is currently considerable variation in amputation rates across England with some areas experiencing five times the rate of amputations as others (see resources). All CCGs should be looking at how they can improve footcare for people with diabetes, and those CCGs with a higher than average amputation rate compared with the England average should take urgent action to reduce it.

Rooting out the cause

A tool for conducting a root cause analysis of amputations has been developed by the NHS Diabetes Footcare Network.

A root cause analysis of every amputation across 13 London hospitals was conducted in April and May 2012, and examined 27 patient datasets. The results suggested a lack of integration of the pathway across primary and secondary care — only 54% of those having amputations were known to footcare services. A number of recommendations were made and work is now being taken forward to target specific local issues including:

• Establishing a central phone line
• Having a named Diabetic Foot Protection Team including podiatrists with expertise in diabetes
• Having a named Multidisciplinary Footcare Team

Establishing MDfTs

The National Institute for Health And Care Excellence (NICE) recommends that a Multidisciplinary Footcare Team should manage the care pathway of patients with diabetic foot problems who require inpatient care. The team must include, or have ready access to, members of the following specialist groups and have an identified clinical lead:⁴

• Medical: diabetologists
• Surgical: vascular, orthopaedic and plastic surgeons
• Other medical staff including microbiologists
• Diagnostic and interventional radiologists
• Podiatrists and podiatric surgeons
• Diabetes specialist nurses
• Plaster theatre nurses
• Other nursing staff
• Orthotists

In 2011 the National Diabetes Inpatient Audit found that 75 hospital sites (40.5 per cent) in the audit did not have a multi-disciplinary team comprising:

• A diabetologist with expertise in lower limb complications
• A surgeon with expertise in managing diabetic foot problems
• A diabetes specialist nurse
• A specialist podiatrist
• A tissue viability nurse

There was no improvement from the previous year.

The MDfT also plays a crucial role in being available to assess outpatients with active foot disease within one working day of presentation. In order to ensure that people who have active foot disease can be referred and assessed within 24 hours, an integrated footcare pathway needs to be in place and accessible seven days a week.

A footcare pathway that supports NICE and Scottish Intercollegiate Guidelines Network (SIGN) guidance and has been agreed by organisations of diabetologists, podiatrists, people with diabetes and other experts has been published by Diabetes UK and is available at www.diabetes.org.uk/competencies-feet

RAPID REFERRAL

The integrated footcare pathway highlights the importance of rapid referral to, and management by, a member of the Multidisciplinary Footcare Team if someone has active ulceration or infection in their foot. It is also important to ensure that those at high risk of foot problems can be identified through good quality annual foot checks. In addition, people with diabetes who are at high risk of foot problems, and their carers, need to know what to look out for and where to go in the event of a problem.

Foot Protection Team

A Foot Protection Team (FPT) is made up of healthcare professionals (HCPs) with specialist expertise in the assessment and management of disease of the foot in diabetes, for example:

• Podiatrist
• Diabetes specialist nurse
• Diabetologist
• Vascular surgeon

Members of the FPT will work closely with the Multidisciplinary Footcare Team (MDfT) and may also be members of it. The FPT should be contactable by phone, fax or email, and their identity and contact details should be readily available to other HCPs working in the community.

The roles of the FPT may include:

• Specialist surveillance of people at risk
• Education of other HCPs in routine examination and definition of the at risk foot
• Close liaison with the MDfT
• Management of selected cases of foot disease in the community
• Long-term management of people with successfully treated foot disease
• Supporting the patient in managing their condition4

EDUCATION

It is essential that those who examine feet to determine risk status have the necessary training and competence. Training for this role can be provided by the FPT.

An essential part of the annual review of feet is patient education. The person with diabetes should be aware of the results of the examination, the services to which they should have access if they require specific preventive measures and action to be taken if they develop a foot problem.

All people with diabetes should be fully aware of what they can do to look after their feet. Diabetes UK has developed the leaflet '10 steps towards healthy feet', to which healthcare professionals can encourage patients with diabetes to refer (see resources).

People with diabetes should be advised to ask relatives or friends to carry out the Touch The Toes test regularly between annual checks (see resources). All healthcare professionals should be aware of the footcare pathway. (Table 1)

WHAT IS EXPECTED OF PRACTICE NURSES?

Practice nurses should be competent to carry out the annual foot check and be confident that they know when and where to refer. Training should have been given and a record kept of who delivered the training and when.

The practice nurse needs to be able to give their patient advice applicable to whatever level of risk is identified and education about how to keep their patient's feet in best condition.

The practice nurse must know who the FPT and MDfT teams in their area are made up of and have a record of the correct contact numbers and give this information to their patient if necessary. If there is no FPT or MDfT in their area they should raise this issue with commissioners so they can deliver the integrated footcare pathway.

Practice nurses should not accept the responsibility of carrying out the foot check if there is any doubt about their understanding of what they should be looking for and how to do the check.

CONCLUSION

To reduce the number of amputations, everyone with diabetes should have an annual foot check, be told and understand their risk score, and know how to look after their own feet. People in all areas should have quick access to a MDfT, which can significantly reduce levels of risk. Practice nurses should know to whom and when patients should be referred, but the most important step on the pathway is for all healthcare professionals to develop a greater understanding of the importance of diabetes footcare.

REFERENCES

1. Based on the annual increase in the number of episodes of inpatient care where amputations have occurred among people with diabetes. Source: The Information Centre for Health and Social Care. Hospital Episode Statistics 2007/08-2010/11

2. Kerr M. 2012 Foot Care for people with diabetes: the economic Case for Change. NHS Diabetes and Kidney Care

3. Derived from: Office of National Statistics 2010. Cancer Survival in England: One year and Five year Survival for 21 Common Cancers, by Sex and Age; Moulik K et at. 2003. Amputation and Mortality in New-Onset Diabetic Foot Ulcers Stratified by Etiology. Diabetes Care 26; Khanoklar MP, et al. 2008. The Diabetic Foot

4. Putting Feet First: national minimum skills framework. The national minimum skills framework for commissioning of footcare services for people with diabetes, Revised March 2011, Diabetes UK, NHS Diabetes