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VOLUME 11 NUMBER 4 • NOVEMBER 2014
161
SA JOURNAL OF DIABETES & VASCULAR DISEASE
CURRENT TOPICS
of people with diabetes surveyed in 2007 said that they did not
realise that diabetes increased the risk of having an amputation.
9
It is hoped that awareness has improved since then, but the key to
improved awareness is placing patients with diabetes at the centre
of their own care, as set out in the ‘Year of Care’ programme.
10
In common with other diabetes-related complications, foot
problems are associated with chronic sub-optimal control of modi-
fiable risk factors – blood pressure, cholesterol and glucose levels,
and smoking. Good diabetes management and support for self-
management, including smoking cessation, is important for the
prevention of complications.
Patients should be empowered to look after their feet, told of
their risk of developing a complication, understand the implica-
tions of their risk status and be aware of the healthcare they should
receive. It is crucial that patients realise the importance of urgently
seeking medical attention in the event of any problems. A ‘Touch
the Toes’ test guide is available on the Diabetes UK website and
there is information about foot care, the leaflet ‘10 Steps to Healthy
Feet’ is also available in several languages.
Quality training for staff
There is a need for improved education and training for staff in
primary and secondary care to facilitate provision of quality foot
checks, risk status assessment, explanation of implications for
the patient and appropriate referral pathways. Standards of care
should be monitored nationally, and the impact on amputation
rates measured. All staff should be encouraged to participate in
diabetes audits. In the community there should be trained staff
in foot-protection services with speedy (< 24 hours) access to
multidisciplinary foot-care teams (MDfTs).
The competency frameworks of these teams are documented
in Diabetes UK’s ‘Putting Feet First’ campaign located in the pro-
fessional resources section of the Diabetes UK website.
11
Giving patients the tools
The term ‘foot attack’ is used to describe a foot injury to a foot, or
feet, of someone with diabetes who has neuropathy or peripheral
vascular disease. Patients need to be aware that there may be no
pain, even with a visible wound and that even a small injury or
blister may lead to a major complication unless arrested early.
Diabetes UK has produced a booklet called ‘How to Spot a
Foot Attack’ for people who have been identified as being at risk.
This booklet, which was sent to every GP surgery in England and
Northern Ireland at the beginning of May, informs patients that they
should have been referred to a foot protection team or specialist
podiatrist, describes how to spot a ‘foot attack’ and what to do if
they are experiencing one. The booklet also includes a card, where
the person can write the emergency contact numbers of their GP,
MDfT team and podiatry/foot-care services.
The strength of a pathway and a multidisciplinary team is that
the patients are triaged rapidly to the right sub-speciality within
the right timeframe. All patients with diabetes should know how
to access these services if they develop a ‘foot attack’ and be
encouraged to be insistent if their referral or treatment is delayed
as a ‘foot attack’ can progress rapidly.
12
Equality in access
In England and Wales the National Diabetes Audit measures the
effectiveness of diabetes healthcare against the National Institute
for Health and Care Excellence (NICE) clinical guidelines and NICE
quality standards. This summer the National Foot-Care Audit will
commence an audit of specialist foot-care services in England and
Wales, aiming to highlight areas of good practice as well as areas
which have not developed all elements of a high quality foot-care
pathway. This will provide benchmarking data to assist clinical
commissioning groups (CCGs) to commission excellent diabetic
foot-care services.
The Vascular Society of Great Britain and Ireland published a
Quality Improvement Framework for Major Amputation Surgery
recommending that patients should be managed pre-, peri- and
post-operatively by a multidisciplinary vascular team with current
amputation experience.
13
The National Confidential Enquiry into
Patient Outcomes and Deaths is due to publish its lower limb
amputation study in Autumn 2014. This should inform on pre-,
peri- and post-operative care as well as organisational factors.
14
The Circulation Foundation has also raised awareness of the
‘foot attack’ with the ‘Save Lives and Limbs’ campaign as well as
lobbying the All-Party Parliamentary Vascular Group (APPVG). The
APPVG has recently published recommendations which should
improve patient outcomes (Table1).
15
Additionally, Strategic Clinical
Networks have been tasked with raising awareness of and reducing
major amputations by 2015.
Table 1.
The-All Party Parliamentary Vascular Group recommendations
to improve patient outcomes
1. Services should be commissioned on outcomes: an amputation should be
considered a failure; a functioning foot with minimal surgery, a success.
2. Telemedicine should link services so that appropriate care can be deliv-
ered locally with established pathway co-ordinators in hub centres and
integrated clear pathways for the diabetic foot. There should be a named
contact person in a hospital/community 24 hours a day who is a member
of the MDfT in case of emergencies.
3. All commissioners should have a sub-24-hour policy to refer patients with
suspected critical limb ischaemia (CLI) to a MDfT. Time is of the essence
with this condition, and every hour treatment is delayed increases the risk
of amputation.
4. All commissioners and providers should have a clear pathway for sus-
pected peripheral arterial disease and the diabetic foot. This pathway
must be made standard practice, and the route that patients with CLI are
referred to a hospital should be rapid, clear, and properly understood by
all healthcare workers, from primary to specialist care. There should be a
policy for referral to a multidisciplinary team with clear links to secondary
care.
5. The Quality Outcomes Framework needs to be improved so that all ‘high-
risk’ patients are referred for preventative podiatry and structured educa-
tion.
6. A patient pathway must be established as standard practice for all provid-
ers and commissioners.
7. Commissioning structures need to balance centralisation of care for com-
plex high-risk vascular procedures with the need to maintain equity of
patient access for peripheral arterial disease. This recognises that many
diabetic foot complications occur in well-perfused feet and do not need
vascular intervention. Diabetic foot services therefore need to be aligned
to the centralisation of vascular services but may not correlate com-
pletely.
8. Education for patients at risk should be made more widespread in the
community. Guidance and support on smoking cessation and exercise,
in particular for patients with diabetes, is one of the key areas that need
attention.