The management of diabetic foot disease has recently come to attention following the publication in Diabetologia of evidence of variation in amputation rates across PCTs in England. Compared to the general population, patients with diabetes are 20x more likely to require lower limb amputation, costing the NHS £120m annually. 80% of these are thought to be avoidable. Following on from this, the recent National Diabetes in patient audit has once again highlighted the importance of foot care. Whilst only 9.5% of patients with diabetes are admitted as a result of their diabetes, 47% of this group were admitted with active foot disease. It is likely that this group of patients contribute significantly to the increased length of stay seen in diabetic patients. For other diabetic patients, only 22.4% of patients had a documented foot examination within 24 hours of admission.
In primary care, foot assessment is an integral part of diabetes care. Patient education, regular foot inspection, assessment of vascular status and identification of neuropathy (by appropriately trained staff) is essential at identifying the at risk foot.
The presence of an ulcer should usually trigger referral into a more specialist clinic. The development of a multi-disciplinary team including diabetologists, podiatrists, surgeons and specialist nurses is essential in managing high risk patients. For patients being admitted as a result of a foot problem, NICE recommend referral to the MDT within 24hrs of admission with urgent attention being paid to investigation (swabs, radiology) and treatment of infection according to guidance. Early surgical referral is usually warranted where debridement of infected tissue may limit tissue loss.
Dr. Mark Freeman