Management of the Diabetic Foot Positively Podiatry Protecting Limbs Prolonging Lives Management of the Diabetic Foot NHSGGC Department of Podiatry

My feet are killing me……….. 2012 diabetes equalled HIV/Aids with 1.5 million deaths each year (1) Mortality Following first foot ulceration (2) 48% patients at 5 years 70% patients at 10 years Following first amputation (3) 11% patients at 1 year (1) http://www.who.int/topics/mortality/en/ (2) Journal of the American Podiatric Medical Association 2008; 98(6):489-93. Jeffrey Robbins (3) Jeffcoate et al, Diabetes Care 29:1784-7 2006 2 2

IMPORTANCE OF SCREENING FOR BOTH The diabetic foot Main risk factors are neuropathy and ischemia. But also external factors such as pressure and trauma It is essential that feet are screened for all these factors. IMPORTANCE OF SCREENING FOR BOTH 3

Ischaemic Foot How do we recognise an ishaemic foot? Remember in diabetes can have a bounding pulse but small vessel disease Intermittent Claudication Rest pain Ulcer –slow healing, painful Gangrene Medial artery calcification Small Vessel Disease Cold Cyanotic/pale Absent pulses Dry, shiny skin Lack of hair Atrophied nails 4

Neuropathic Foot Different types of Neuropathy Sensory neuropathy results in a patients inability to sense if there are problems. This can be a partial or complete loss of sensation which may have no symptoms for the patient to recognise. Have you all seen the 10g monofilament that is used for Diabetic Foot Screening? 10g is the pressure required to cause a foot ulcer in a diabetic patient with sensory neuropathy Remember loss of sensation of burning, test water first , no hot water bottles Numbness Loss of protective sensation Tingling , pins and needles Burning Sensation Shooting Pains AUTONOMIC NEUROPATHY impacts on tissue quality again interrupting the function of the skin increasing the risk of ulceration. Dry skin warm, fissures Arterial Venous shunting, veins prominent, oedema Palpable/bounding pulses Motor neuropathy can result in a change in foot structure and function due to a change in muscle balance. As a result the foot can become overloaded increasing pressure on the foot which will increase the risk of ulceration. You can see then why a combination of both neurological and vascular risk factors can result in a high risk of developing a foot ulcer. High arch foot Claw toes Deformity -high pressures areas Callus/ulceration Infection,osteomyelitis

Neuropathic Foot High arch foot, claw toes, typical changes in a neuropathic foot Indent in skin from a nail Typical neuropathic pressure ulcers , callous build up leading to ulceration GRI inpatients with Cellulitis and systemic infection. One with an earing in his slipper, another with a piece of crockery embedded in his foot. Both required IV antibiotics and prolonged hospital admission. On right notice bone probe , plantar and dorsal ulcers communicating, cellulites in foot and patient does not feel any pain

Tools for assessing Pressure Ulcer risk and recording Pressure Ulcers? PUDRA - Pressure Ulcer Daily Risk Assessment SSKINS – Skin Inspection, Surface, Keep Moving, Incontinence/ Increases Moisture, Nutrition, Self Care Pressure Damage Red Day Review Tool Pressure Ulcer Safety Cross Updated NHSGGC Pressure Ulcer Prevention and Management Policy Datix Some of tools used by nursing staff, you will all be more familiar with them than I am Updated NHSGGC Pressure Ulcer Prevention and Management Policy launched in 2019 refers to feet/ankles Referring all patients with or without type 1 or 2 diabetes with grade 2 and above pressure ulcer on the foot, to the Podiatry Service Ward staff should NOT datix all hospital acquired ulcers including those on feet, but refer all grade 2 and above pressure damage to Podiatry Service, who will assess the patient and complete the RDR in collaboration with the nursing staff .

What tools are there specifically for protecting feet? TrakCare Alerts CPR for Feet Diabetic Foot Risk Stratification and Triage (SCI-Diabetes) https://learn.nes.nhs.scot/3704/rrheal/healthy-aging/cpr-for-feet All podiatry patients with high risk feet should have an alert on TrakCare Tools specific for feet GG&C CPR updated in 2018 refers to all high risk feet / link to NES CPR training . New posters coming to wards soon if not already out there Learnpro module for staff

SCI Diabetes Traffic Light system for foot risk stratification and triage. Updated 2016 By screening for sensory loss, assessing circulation, deformity, callous, history of previous ulceration, chacot arthropathy and now including renal function , GFR as an additional risk factor. SCI Diabetes will calculate the patient’s risk factor. There is a action for each risk. All diabetics should be screened annually, SCI updated and given appropriate education and management plan for their risk. We cannot prevent a patient going from low to high risk but we can identify the high risk patients Management plan always includes education.

Education, Education, Education! Patient Carer Relatives Healthcare Staff Mydiabetesmyway www.mydiabetesmyway.scot.nhs.uk Diabetes UK www.diabetes.org.uk Diabetes in Scotland www.diabetesinscotland.org.uk FRAME www.diabetesframe.org Specifically for patients is Mydiabetesmyway is the NHS Scotland interactive diabetes website which allows patients to access their own diabetes information, let them see how diabetes affects their body and lifestyle, shows patients how to take control of their diabetes ,provides leaflets, videos, educational tools and games. Diabetes UK is a British-based patient, healthcare professional and research charity that describes itself as the "leading UK charity that cares for, connects with and campaigns on behalf of all people affected by and at risk of diabetes Site provide by NHS Scotland to provide diabetes health information, news, publications, and conferences for people with diabetes Foot Risk Awareness and Management Education, online training modules Recent Israeli study looked at cognitive impairment in patients with diabetes . Patients with a diabetic foot ulcer had impaired cognitive ability compared with those without a foot ulcer. Micro vascular changes in eyes, kidneys, feet also in brain.

Managing The Diabetic Foot Early diagnosis of underlying aetiology Early management Avoid amputation (unless clinically appropriate) Maintain mobility Improve quality of life Annual screening and foot risk stratification. We cannot prevent a patient going from low to high risk but we can identify the high risk patients Going to talk about Diabetes wound management principles

Altered response to trauma & infection in diabetes Normal immune response produces inflammation which is recognised by the nervous system With neuropathy, this sensory monitoring of host attack is impaired and the nervous system cannot properly co-ordinate host defence activity Diabetic foot infections do not always present with the classical signs of systemic infection 74% tensile strength in wound following ulceration after 16 months 14 14

Diabetic Foot Ulcer or Pressure Ulcer? Confusion around naming ( diagnosing) and treating pressure related foot ulceration in people with diabetes, especially on the heel Diagnosis can and does affect subsequent assessments and management All patients with diabetes and foot ulceration, irrespective of wound aetiology , should be seen by a multidisciplinary diabetic foot team Peter Vowden, Kathryn Vowden Diabetic Foot Journal 2015 Can get confusion around classification. Any hole in the foot of a diabetic patient is a diabetic foot ulcer and needs referred to the Multidisciplinary Diabetic Foot Team This can be done through a referral to podiatry.

Nursing staff use the The Scottish Adapted European Pressure Ulcer Advisory Panel (EPUAP) Grading Tool 5 for the grading of pressure ulcers, podiatrists use The University of Texas Classification System for Diabetic Foot Wounds . Different grading /classification tools but principles of management same Problems can arise when definitions of disease 16

This is the tool used by Podiatry and Tissue Viability when completing RDR. Podiatry now complete RDR for patients within acute sites presenting with acquired grade 2 or above pressure damage. Nursing staff no longer require to initiate datix but should make a referral to the Podiatry dept via Trakcare. A member of the ward staff should be present with the Podiatrist when RDR is completed. Podiatry referrals for a red day review are presently carried out in collaboration with nursing staff in Acute sites only. Partnerships and community sites are part of the implementation plan and will be advised of progress. DN Peer review pilot site due to start on June 1st. If an inpatient is identified as being at risk and develops a red heel, despite being in a prolevo boot, with correct profiling of bed and 2 hourly repositioning (2 x 2hourly repositioning) and no improvement noted a referral should be made on the same day to the orthotics dept via trak to assess suitability for alternative pressure relieving device.

TIME principles All aware of principles TIME wound bed preparation which will influence management plan and dressing choice Tissue Infection Moisture balance Edges/Epithelialisation 18

Neuropathic / Ischaemic wound Treat ischaemic foot differently to well perfused foot Think before debridement and consider wound healing environment Pain in neuropathic foot – suggests infection Be aware of the difference between the ischaemic foot and the well perfused foot. Is the circulation adequate to heal the ulcer? Do you want to lift the eschar? Often see Honey and hydrogels used on black eschars and on ischaemic ulcers. ? Painful ? healing potential Does the patient need a vascular review ? 19 19

In Bed Heel Pressure Redistribution Devices As well as looking at the wound bed, managing the wound must include offloading pressure from the wound. Pressure redistribution devices should not just be used when a foot is ulcerated, should be used on the identified at risk foot to prevent any ulceration/skin damage. Pressure redistribution devices can cause pressure on other areas of the foot, in particular on the forefoot when a PRAFO type boot with a rigid sole is used Many types on market pictures of the current ones in use in NHSGGC, Wards must keep a stock of pressure redistribution devices on the ward. This is also in the updated NHSGGC Pressure Ulcer Prevention and Management Policy 2019, prevention and management of pressure damage/wounds also depends greatly on patients being correctly profiled on beds. These are not to be used for weight bearing, non ambulatory only Orthotics will fit a PRAFO- Pressure Reliving Ankle Foot Orthosis where appropriate on Grade 2 and above ulcers. Refer to orthotics on Trakcare. Do not use the old dynatek boot . Prolevo Heel safe boot, stock should be kept by ward. District nurses may have access to either maxcare of prolevo. Recommendations of the Prolevo range can be given to care homes. It is the responsibility of the care home to supply preventative pressure redistribution and not the Podiatrist. NB Prolevo foot safe boot is not available on prescription.

Ambulatory Pressure Redistribution Devices Remember the in bed heel pressure redistribution devices are not for use when walking. Have specific black sandals for forefoot, rearfoot and posterior heel offloading. They will accommodate dressings and allow the patient to be mobile. Total contact insoles used with air walker and orthopaedic footwear If patient has poor mobility use a simple kerraped or black sandal to accommodate the dressing. Refer via Trakcare to orthotics for ambulatory pressure relief devices.

Charcot Foot Non ulcerative pathology Ulcerative pathology Charcot neuroarthropathy , occurs in patients with peripheral neuropathy. Serious complication of diabetes. The bones of the foot become fragile, displaced, can have multiple fractures but no pain. Weight bearing on a charcot foot will lead to deformity Red hot swollen foot , often misdiagnosed as cellulites Think Charcot

Bony Destruction and Deformity Changes can occur in 1 / 2 weeks Heat, redness, swelling, temp gradient, may be pain Rocker bottom sole deformity X-ray shows fragmentation, fracture, new bone formation and dislocation It can be divided into 3 phases: acute onset/bony destruction/ stabilisation In the acute phase patients present with a hot swollen foot with a temperature difference of 2 degrees or more between the two feet. Early diagnosis and prompt referral to MDFT is essential as it is important to stabilise the foot to limit deformity. Leads to bony destruction and rocker bottom foot if left untreated , picture on your left A small hand held thermometer is a cheap and effective tool for aiding diagnosis

How to Access Podiatry Services? Trakcare Inpatient podiatry Foot ulcer - outpatient podiatry SCI Store Email only where above not available podiatry.referrals@ggc.scot.nhs.uk Staffnet – Podiatry pages Trakcare used primarily by ward based staff, if patient is being discharged from ward and requires on going Podiatry input, ward staff should make an outpatient referral via trakcare, this allows for continuity of care and prevents patients being lost to the system. SCI- store for use from GP practices/ outpatient services Email – mainly DN use/ dom referrals Staffnet podiatry Pages – search “podiatry ulcer” and podiatry pages will come up with all info on it for referral, pressure relief, cpr for feet etc. DFU ulcer referrals aim to be actioned within 48 working hours 24

Positively Podiatry Protecting Limbs Prolonging Lives Case Study 26

Patient A 44 years old at time of accident Type 2 diabetic Well controlled , HbA1c 1 month before was 48, one month after 49, highest during treatment was 67 Peripheral Neuropathy No known vascular complications Self employed Stonemason Keen hill walker 27

A man walks into a clinic………. Patient had stood on a nail Walked around 6-8 hours with nail in foot Went away on holiday for 4 days Saw GP on return, was given antibiotics, foot not examined Patient attended A&E later that day with acute cellulites Admitted to hospital 28 28

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Factors affecting diabetes wound management Neurological Vascular disease Infection Glycaemic control Nutrition Pressure 30 30

Factors affecting concordance in diabetes wound management Religious Learning disability Cognitive impairment Socio-economic Mental health and addictions Patient acceptance 31

Tissue became necrotic within 3 weeks 32 32

Don’t panic, think……….. What am I going to take off this wound to help it heal What am I going to put on this wound to help it heal quicker 33 33

Debridement 34 34

Larvae 35 35

After 2 larvae applications Duration of ulcer 6 weeks 36 36

Ulcer deteriorates Duration of ulcer at 17 & 24 weeks 37 37

Documentation Describing the wound, wound photography S.O.A.P. E. R Trakcare, shared care documents, nursing notes, wound assessment chart, medical notes, SCI diabetes 38

WHAT AM I GOING TO PUT ON…….. TIME principles QUALITIES OF DRESSING COST APPROPRIATE USE OF ANTIMICROBIAL Not going into details of different dressings as all experienced clinicians. We should all be looking at what we want the dressing to do, what don’t we want it to do e.g dry up an exposed tendon and then choosing the most suitable dressing. Debate over whether cost should be included in thought process but cash strapped should consider if there is something that will do the same job but cost less. In the diabetic foot we tend to use an antimicrobial dressing 40

Weeks 24 - 33 41

Weeks 34 - 41 42 42

Duration of ulcer now 7 months What else was going on, constant reassessment of wound Infection Impact of ulcer on the patient 43

Infection X rays shows septic arthritis, destruction of 1st MPJ Oral antibiotics for 9 months, Flucloxacillin and Clindamycin X ray still showing ongoing bony destruction and osteomyelitis Patient was referred to OPAT for outpatient antibiotic therapy - IV Teicoplanin Treatment has to be disrupted due to deterioration of patient’s renal function Amputation of first ray discussed with patient 44 44

Duration 11 months wound healed 45 45

The end result………??? 46 46

Is this the end.........??? Loss of earning Loss of savings Fear of amputation Fear of deformity- not get walking boots on again Effect of inactivity, no exercise, Permanent renal damage Depression 47 47

Recurrence Further breakdown 2 months later Healed within 3 weeks Patient unable to wear “ normal shoes” due to toe deformity 48

34 Months after initial contact Right 1st MPJ fusion, and 2nd and 3rd hammer toe corrections by orthopaedics Patient referred back to podiatry with post op ulceration on hallux at the medial and lateral base Healed 8 weeks later 49

A happy ending…….??? 50

Is there a case for the positive amputation? Prevented renal impairment Resolved quicker unless post op complications Cost implications Patient choice No guarantee it would heal Foot function Psychological effects 51