Foot attack and what patients should do if it happens
Two years after Diabetes UK launched the 'Putting Feet First' campaign, preventing amputation resulting from a foot attack remains high on the agenda. Practice nurses may think this is outside their expertise - but there is much they can do.
People with diabetes are more likely to be admitted to hospital with a foot ulcer than with any other complication of diabetes and more than 6,000 leg, foot, or toe amputations are still being carried out each year on people with diabetes.1 This is more than 100 a week. If current rates continue, the number of amputations will rise from more than 6,000 in 2011-12 to more than 7,000 in 2015-16 in England,2 with a further 450 amputations a year in Scotland.3 Amputations and foot ulcers have a huge impact on quality of life in terms of pain, mobility, depression, relationships and ability to work. Up to 80% of people die within five years of having an amputation.4 This is a higher mortality rate than for colon, breast or prostate cancer.5,6
FOOT SCREENING
Traditionally, feet are examined annually by looking for any damage to the foot such as foot ulcers and other problems that need immediate attention. A properly trained healthcare professional will make an assessment of neuropathy and the pulses in the feet and legs. They will also check for corns, calluses or changes in the shape of the feet. Footware may also be checked as good fitting footware is essential to help prevent foot problems.
Unfortunately, too many - 15% - of people with diabetes are not getting their foot check and this number has not changed in recent years. (Figure 1) Anecdotally, some patients who have supposedly received their foot check have not even been asked to remove their shoes. Patients also need to be reminded about the importance of the foot check by all healthcare professionals, in order to encourage better uptake.
Best practice can make a big difference. Amputation rates currently vary widely from one area to another — in the worst performing area a person with diabetes is 10 times more likely to have a major amputation than in the best.7
About 15% of patients with diabetes experience serious foot problems and about 85% of amputations start with foot ulcers. In general, foot ulcers develop because there is impaired blood supply to the foot, which affects healing of any foot injury. Infection can also occur. Numbness from nerve damage, which is common in diabetes, compounds the danger since the patient may not be aware of injuries. It is important that patients understand this and if necessary ask someone else to check their feet for them every day.
RAISING AWARENESS
Despite the potential of developing such a devastating complication, more than half of people with diabetes surveyed in 2007 said that they did not realise that having the condition puts them at more risk of having an amputation.8 Hopefully, awareness has improved since then.
Complications of diabetes happen because of raised blood glucose, blood pressure and cholesterol over a long period of time. Good diabetes management and support for self-management is important for the prevention of all complications of diabetes, including foot problems.
Patients should know how to look after their feet, be told what risk they have of developing a complication, understand the implications of their risk status and be aware of what care they should get from the health service. A 'Touch The Toes test' guide is available on the Diabetes UK website so people can get another person to check their feet. Crucially, patients must realise the importance of urgently seeking medical attention in the event of any problems.
QUALITY TRAINING
There is a need for improved education and training for staff working in primary care; so that all healthcare professionals looking after people with diabetes know how to carry out foot checks, inform people about their risk status and know how to refer appropriately. If you need to be trained then request support to get up-skilled.
Standards of care should be monitored nationally, and the impact on amputation rates should be measured. All staff should be encouraged to participate in diabetes audits. There should be speedy access to Multi-disciplinary footcare teams (MDfTs) within 24 hours. The roles, skill set and organisation of these teams is set out in Putting Feet First, available at http://www.diabetes.org.uk/putting-feet-first
GIVING PATIENTS THE TOOLS
Diabetes UK has produced a booklet called 'How To Spot A Foot Attack' which has been sent to every GP surgery in England and Northern Ireland. It is also free to order at our on-line shop at Shop.diabetes.org.uk/go/spot-a-foot-attack. The booklet is designed for people who have been categorised as being at high risk of a foot attack. As well as advising patients that they should have been referred to the foot protection team or specialist podiatrist, it tells the patient how to spot a foot attack and what to do if one happens. The booklet also includes a card, which can be kept in a wallet, where the person can write the emergency contact numbers of their GP, MDfT and podiatry/footcare services.
WHAT YOU NEED TO DO
- Order copies of the booklet to distribute to patients at high risk of a foot attack and alert your colleagues to its importance and availability
- vKnow the contact details of your footcare team and ensure this information is easily accessible for everyone in the practice
- Find out what training on footcare is available locally. Is it possible for you to spend a few hours shadowing at a diabetes clinic or with a member of a local footcare team?
- Engage with patients and explain to them the importance of attending their footcare yearly review and that either they themselves or a carer should check their feet daily
CONCLUSION
The current rate of major amputation is too high. It is vital that healthcare professionals understand the importance of good quality annual foot checks and that they give their patients the tools they need to understand their risk of a foot attack and, if necessary, enable them to access specialist help as quickly as possible.
Spare a few minutes to order the booklet, discuss it with your patient and give it to them at their next review. It could make all the difference.
REFERENCES
1. The Information Centre for Health and Social Care. Hospital Episode Statistics 2007/08-2010/11
2. The Health and Social Care Information Centre. Hospital Episode Statistics 2007/8-2010/11. Linear regression of the values from 2007-8 to 2010-11
3. Scottish Diabetes Survey 2011. Available at: http://www.diabetesinscotland.org.uk/Publications/SDS%202011.pdf
4. Khanolkar MP, Bain SC, Stephens JW. The diabetic foot. QJM 2008;101(9):685-95
5. 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.
6. Moulik PK, Mtonga R, Gill GV. Amputation and mortality in new-onset diabetic foot ulcers stratified by etiology. Diabetes Care 2003;26(2):491-4
7. The Health and Social Care Information Centre. (2013) National Diabetes Audit 2011-2012. Report 2: Complications and Mortality
8. Ipsos MORI (2007) Survey on awareness of Diabetes and Diabetes UK Amongst the General Public, conducted on behalf of Diabetes UK
