New NICE recommendations for review of type 2 diabetes patients will improve early identification and management of foot problems, says Dr Roger Gadsby


NICE has recently published the fifth and final guideline in its series of guidelines on type 2 diabetes. Type 2 Diabetes: Prevention and Management of Foot Problems was developed using NICE methodology and updates an earlier foot care guideline published in 2000 by the RCGP following collaboration with the RCP, the RCN and the British Diabetic Association.1

Foot problems are a common complication of diabetes. Some 20-40% of diabetes patients have neuropathy and a similar percentage have peripheral vascular disease, which result from poor blood glucose control and arterial risk factors. Approximately 5% of diabetes patients develop a foot ulcer each year and around 0.5% will need to undergo amputation.

The new guideline is concerned with educating patients with type 2 diabetes and their carers about foot problems, identifying individuals at risk and preventing, detecting and treating foot problems.

Identifying the evidence

The development process involved the critical review of more than 300 papers and studies to form the evidence base for the recommendations. The main recommendations are graded level A or B (see Figure 1, below). Some of the recommendations concerning education are drawn from the NICE appraisal of patient education models for diabetes.2 As part of the education programme for people newly diagnosed with diabetes, regular inspection and general foot care measures need to be taught.

Figure 1: Recommendations and grades of evidence
Reproduced from Type 2 diabetes: Prevention and Management of Foot Problems by kind permission of the National Institute for Clinical Excellence

Screening for foot ulcers

The guideline recommends as a key priority a simple screening examination for risk factors for diabetic foot ulcers, to be performed as part of the annual review for all diabetes patients (Figure 2, below).3 General foot care education needs to be reinforced as part of the annual review.

Figure 2: Pathway of care
Reproduced from Type 2 diabetes: Prevention and Management of Foot Problems by kind permission of the National Institute for Clinical Excellence

Staff involved in assessing diabetic feet should be appropriately trained, and assessment should involve:

  • Examining for any foot deformity
  • Palpating foot pulses
  • Testing foot sensation using a 10 g nylon monofilament 4 or vibration
  • Inspecting footwear.

Any patient who has any of the above abnormalities but does not have an active foot ulcer should be referred to the local foot protection team for further assessment.

This team, which will typically include podiatrists, orthotists and foot care specialists, should assess the patient’s risk of foot ulcers as follows:

  • Low current risk (normal sensation, palpable pulses)
  • Increased risk (neuropathy or absent pulses or other risk factor)
  • High risk (neuropathy or absent pulses plus deformity or skin changes or previous ulcer).

Patients at increased risk of foot ulceration should be reviewed every 3 to 6 months by the foot protection team, who should:

  • Inspect the patient’s feet
  • Review the need for vascular assessment
  • Evaluate footwear
  • Enhance foot care education

Patients at high risk of foot ulceration should undergo frequent review (1-3 monthly).

At each review the team should:

  • Inspect the patient’s feet
  • Review the need for vascular assessment
  • Evaluate and ensure that the patient is provided with appropriate intensified foot care education, specialist footwear and insoles and skin and nail care.

In most practices about one-third of diabetes patients will be at increased risk of foot ulceration and thus warrant referral to the foot protection programme. The remaining two thirds of the practice population who have no at-risk features will need to be screened again at their annual review and can be given basic foot care advice in the practice.

It used to be said that all diabetes patients needed referral for podiatric assessment. This resulted in many people with diabetes and normal feet attending the podiatry services, which often became overwhelmed. The new guideline’s recommendations mean that those diabetes patients who need the expertise of the podiatry service should be able to have access to it.

There are already many local community-based foot protection programmes, and the guideline provides support for reorganising local podiatry services in areas which do not yet have them.

Footcare emergencies

The guideline’s other major recommendations concern the management of patients presenting with a foot care emergency, defined as new ulceration, swelling or discoloration.

Patients with these emergencies must be referred to a multidisciplinary foot care team within 24 hours. The team should be composed of highly trained specialist podiatrists and orthotists, nurses trained in dressing diabetic foot wounds, and diabetologists with expertise in lower limb complications.

As a minimum, the team should:

  • Investigate and treat vascular insufficiency
  • Initiate and supervise wound management, using dressings and debridement and systemic antibiotics for cellulitis or bone infection, as indicated
  • Ensure an effective means of distributing foot pressures, including specialist footwear, orthotics and casts
  • Try to achieve optimal blood glucose levels and control of risk factors for cardiovascular disease.

Some hospitals already have foot care teams of this sort; the guideline should provide impetus to develop them where they do not yet exist.

Will the guideline improve patient care?

In addition to providing support for service improvement in areas where foot care services are underdeveloped, the guideline’s key recommendations should improve patient care. The basic messages are:

  • A simple screening examination should be carried out in primary care
  • Patients who screen positive should be referred for further assessment and education to a foot protection programme
  • Patients who present with a foot emergency should be referred to a multidisciplinary foot care team within 24 hours.

The full guideline provides a wealth of information and analysis for those with a special interest. The quick reference guide, which has been sent to GPs, contains a clear and helpful algorithm (see Figure 2), which outlines the clinical decisions that need to be made at each stage of the pathway of care. The patient version will help individuals with diabetes to understand foot problems and the type of care they should expect.

Meeting the GMS contract

Two elements of the annual screening examination – palpating for foot pulses and neuropathy testing – will fulfil the requirements of indicators 9 and 10 for diabetes in the quality and outcomes framework of the new GMS contract.5

Conclusion

If fully implemented across the country, the guideline’s recommendations will reduce the number of amputations in patients with diabetes. Type 2 Diabetes: Prevention and Management of Foot Problems. Clinical Guideline No. 10 can be downloaded from the NICE website: www.nice.org.uk

References

  1. Hutchinson A, McIntosh A, Feder G et al. Clinical Guidelines and Evidence Review for Type 2 Diabetes: Prevention and Management of Foot Problems. London: Royal College of General Practitioners, 2000.
  2. National Institute for Clinical Excellence. Guidance on the use of patient-education models for diabetes. Technology Appraisal Guidance 60. London: NICE, 2003.
  3. Gadsby R, McInnes A.The at risk foot: the role of the primary care team in achieving St Vincent targets for reducing amputation.Diab Med 1999; 15(Suppl 3): S61-4.
  4. Pham H, Armstrong DG, Harvey C et al. Screening techniques to identify people at high risk for diabetic foot ulceration. A prospective multicenter trial. Diabetes Care 2000;23: 600-11.
  5. British Medical Association. Investing in General Practice: The New General Medical Services Contract. www.bma.org.uk

Guidelines in Practice, March 2004, Volume 7(3)
© 2004 MGP Ltd
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