Educational Resources & Summary

Wendy McInnes; Vascular Nurse Practitioner

The Lyell McEwin Hospital, Adelaide, South Australia

wendy.mcinnes@sa,gov.au 0447 051 036

Diabetes:- the Global Epidemic 2015 415 million adults world wide with diabetes

By 2040 estimated 642 million

Prevalence in 30 years has increased from 4.7 to now 8.5%

1 in 4 people with diabetes is at risk of ulceration

Commonwealth of Australia (2011) National Evidence based Guideline - Prevention, Identification and Management of Foot Complications in Diabetes International Diabetes Federation (2015) IDF Diabetes Atlas; 7th Edition, International Diabetes Federation Diabetic Foot Problems – NICE Pathway (2011) http://publications.nice.org.uk/diabetic-foot-problems-cg119/guidance

Australia

Even minor injuries caused by a small cut, bruise or a blister can develop into a diabetic foot ulcer

Every three hours in Australia, a person with diabetes has a lower limb removed as a direct result of diabetes-related foot disease.

50% of these will go on to live less than five years

With best practice treatment, and ongoing management, 80% of amputations are preventable.

https://www.diabeticfootaustralia.org/

Previous amputation

Past foot ulcer history

Peripheral neuropathy

Foot deformity

Peripheral vascular disease

Visual impairment

Diabetic nephropathy

Poor glycaemic control

Smoking

Diabetic Foot: Risk Factors

Clinical Practice Guidelines; Management of Type II Diabetes – 4th edition –– Malaysia - http://www.docstoc.com/docs/80288898/Malaysian-Diabetes-Association

World Wide: Guidelines/Programs International Working Group on the Diabetic Foot

UK – NICE – Clinical guidelines / pathways

SIGN – Clinical Guideline 116

Australia – Prevention, Identification and Management

of foot complications in diabetes & Diabetic Foot Australia

US – LEAP

Clinical Practice Guidelines - Malaysia

Aim – prevent minor/major amputation

Commonwealth of Australia (2011) National Evidence based Guideline - Prevention, Identification and Management of Foot Complications in Diabetes International Working group on the Diabetic Foot (2011) http://www.iwgdf.org/index.php?option=com_content&task=view&id=16&Itemid=26 Diabetic Foot Problems – NICE Pathway (2011) http://publications.nice.org.uk/diabetic-foot-problems-cg119/guidance

Clinical Guidelines

• Prevention and management

• Inpatient management

Other resources

• Patients

• Health Professionals

– Algorithms

– Patient education framework

National Institute for Clinical Evidence (NICE)

Scottish Collegiate Guidelines Network (SIGN)

National Institute for Clinical Evidence http://www.nice.org.uk/

Scottish Collegiate Guidelines Network http://www.sign.ac.uk/guidelines/fulltext/116/index.html

US : 5 Step Lower Extremity

Amputation Prevention (LEAP) Program

Annual Foot Screening

• Monofiliment to screen those at risk

• Those at risk to be seen 4 times per year to check feet and footwear

Patient Education

• Patient assumes personal responsibility – partner with health care team

Daily Self Inspection

• Early detection of injury, nail problems

Footwear Selection

• Correct fit for length, width, box depth

Management of Simple Foot Problems

• Autonomic neuropathy, cracks, dry skin

• Identify problems early and report

Free resources available on the site for patients and health care professionals

US Department of Health and Human Services - Health Resources and service Administration

http://www.hrsa.gov/hansensdisease/leap

Advise the patient to

Check their feet every day

Be aware of loss of sensation

Look for changes in the shape of their foot

Not use corn removing plasters or blades

Know how to look after their toe nails

Wear shoes that fit properly

Maintain good blood glucose control

Attend their annual foot review

Putting Feet First Campaign – Diabetes UK

Putting Feet First – Diabetes UK - http://www.diabetes.org.uk/Documents/Professionals/Education%20and%20skills/Footcare-pathway.0212.pdf

Risk status

should be

Documented

& patient

informed

Diabetes Foot Screening

Foot Risk Awareness & Management Education (FRAME)

Free e-learning modules

http://www.diabetesframe.org/

Diabetic foot screening

Assess

– Sensory neuropathy

– Motor neuropathy

– Vibration loss

– Pedal Pulses

– Nail/Skin Integrity

– Structural Foot Deformities

– Footwear & Offloading

– Range of Motion

– Foot care

Follow up based on risk category

Treatment Plan regime

International Diabetes Federation

Resources and information for clinicians and the public

– Patients

• Caring for you’re feet – prevention & checklists

• Where to get help & find a clinic

• Joining a clinical trial

– Clinicians

• Guidelines

• Clinical Trials

• Latest Research

https://www.diabeticfootaustralia

Australian Guidelines

Foot Protection Program

• Aim to prevent foot complications in people with diabetes and includes the following components

• Podiatry

• Hygiene maintenance – advice to inspect and wash feet daily

• Appropriate footwear and hosiery

• Protective shoes – avoid constrictive footwear

• Clinic contact initiated by patient if concerned

National Evidence based Guideline for the Prevention, 2011 “Identification and Management of Foot Complications in Diabetes” (Part of the Guidelines on Management of Type II Diabetes)

Melbourne Australia ; https://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/diabetes_foot_full_guideline_23062011.pdf

Commenced 1996 – improve outcomes

Objectives

– Multidisciplinary consensus documents

– Management and prevention

– Cost effective quality health care

– Adapt for local use

International Working Group

on the Diabetic Foot

Good Diabetic Control

• Patient self monitoring

• Recognising early warning signs of problem

• Seek help early

• Sick day management

• 3 monthly HbA1c <6.5mmHg

Evaluation and treatment of peripheral artery disease

Lifestyle/ Risk Factor modification

• Hypertension

• Cholesterol

• Smoking

Pharmacological interventions

Psychosocial issues

Education

• Risk awareness – complications – daily inspection

• Infection awareness – reduced signs of infection/inflammation/ pain

Summary of World Wide Prevention Strategies

Commonwealth of Australia (2011) National Evidence based Guideline - Prevention, Identification and Management of Foot Complications in Diabetes International Working group on the Diabetic Foot (2011) http://www.iwgdf.org/index.php?option=com_content&task=view&id=16&Itemid=26 Diabetic Foot Problems – NICE Pathway (2011) http://publications.nice.org.uk/diabetic-foot-problems-cg119/guidance Assessment & Management of foot ulcers for people with diabetes – Best Practice Guidelines – Ontario – Canada http://www.rnao.org/Storage/11/536_BPG_Assessment_Foot_Ulcer.pdf

Regular podiatry

• Early, regular assessment for neuropathy/ vascular status

• Early treatment for issues - debride callous/ wound

• Offloading/ redistribution of pressure

• Assess & address biomechanical issues if possible – referral

• Patient education / self management Daily foot inspection

Include areas between toes

• If eyesight poor or cannot do it – family, friend or carer

• Act on problems early – friction, shear, callous, cracks, blisters

Daily hygiene

• Dry between toes

• Ensure temperature of water not too hot – sensory neuropathy

• Moisturise at least daily

Footwear

• Ensure correct fit

• Inspect daily

• Orthotics/ offload/redistribute pressure

Injury Prevention

• Care when mobilising

• Never wear footwear that has caused pressure/friction/shear/ callous

Summary of World Wide Prevention Strategies

High risk patients require inter-disciplinary care

Refer to Multi-D High Risk Diabetic Foot Clinics if

• Deep ulcers – probe to tendon, joint or bone

• Ulcers not reducing in size after 4 weeks despite appropriate treatment

• Absent pulses/ limb threatening

• Ascending cellulitis and suspected Charcot neuropathy

• Pain in previously insensate foot

Summary of World Wide Prevention Strategies

Commonwealth of Australia (2011) National Evidence based Guideline - Prevention, Identification and Management of Foot Complications in Diabetes International Working group on the Diabetic Foot (2011) http://www.iwgdf.org/index.php?option=com_content&task=view&id=16&Itemid=26 Diabetic Foot Problems – NICE Pathway (2011) http://publications.nice.org.uk/diabetic-foot-problems-cg119/guidance Assessment & Management of foot ulcers for people with diabetes – Best Practice Guidelines – Ontario – canada http://www.rnao.org/Storage/11/536_BPG_Assessment_Foot_Ulcer.pdf