1. Diabetic Foot Problems
Implementing NICE guidance
WARNING - The presentation includes graphic photographs demonstrating foot infections, ulcers and ischaemia.
ABOUT THIS PRESENTATION:
This presentation has been written to help you raise awareness of the NICE clinical guideline on inpatient management of diabetic foot problems.
This guideline has been written for diabetologists, physicians, surgeons, diabetes nurse specialists, podiatrists, tissue viability nurses and other staff who care for inpatients with diabetic foot problems.
The guideline is available in a number of formats, including a quick reference guide. You may want to hand out copies of the quick reference guide at your presentation so that your audience can refer to it. See the end of the presentation for ordering details.
NICE published a Quality Standard for Diabetes in March 2011, in which one statement and measure relate to the “at risk” foot and slides showing these appear at the end of this presentation.
You can add your own organisation’s logo alongside the NICE logo.
We have included notes for presenters, broken down into ‘key points to raise’, which you can highlight in your presentation, and ‘additional information’ that you may want to draw on, such as a rationale or an explanation of the evidence for a recommendation. Where necessary, the recommendation will be given in full.
DISCLAIMER
This slide set is an implementation tool and should be used alongside the published guidance. This information does not supersede or replace the guidance itself.
PROMOTING EQUALITY
Implementation of this guidance is the responsibility of local commissioners and/or providers. Commissioners and providers are reminded that it is their responsibility to implement the guidance, in their local context, in light of their duties to avoid unlawful discrimination and to have regard to promoting equality of opportunity. Nothing in this guidance should be interpreted in a way which would be inconsistent with compliance with those duties.
March 2011
NICE clinical guideline 119

2. What this presentation covers
Background
Epidemiology
Scope
Priorities for implementation
Costs and savings Discussion
Find out more
NICE Quality Standard
NOTES FOR PRESENTERS:
In this presentation we will start by providing some background to the guideline and why it is important.
We will then present the priorities for implementation. The NICE guideline contains 11 priorities for implementation, which you can find on pages 4 and 5 of your quick reference guide.
The priorities for implementation cover the following areas:
the multidisciplinary foot care team
patient information and support
initial examination and assessment
care within 24 hours of a patient with diabetic foot problems being admitted to hospital, or the detection of diabetic foot problems (if the patient is already in hospital)
investigation of suspected diabetic foot infection
management of diabetic foot infection
management of diabetic foot ulcers.
Next, we will summarise the costs and savings that are likely to be incurred in implementing the guideline.
Then we will open the meeting up with a list of questions to help prompt a discussion on local issues for incorporating the guidance into practice.
Finally, we will end the presentation with further information about the support provided by NICE.
Slides are also provided which summarise NICE Quality Standards and show the Diabetes statement and measures relating to the “at-risk” diabetic foot

3. Background
Diabetes is one of the biggest health challenges facing the UK today
Diabetic foot problems are the most common cause of non- traumatic limb amputation
Diabetic foot problems have a significant financial impact on the NHS and a significant impact on patients’ quality of life.
NOTES FOR PRESENTERS:
Key points to raise:
The feet of people with diabetes can be affected by neuropathy, peripheral arterial disease, foot deformity, infections, ulcers and gangrene.
The costs to the NHS relate to outpatient costs, increased bed occupancy and prolonged stays in hospital.
Quality of life may be affected by reduced mobility that may lead to loss of employment, depression and damage to or loss of limbs.
Diabetic foot problems require urgent attention. A delay in diagnosis and management increases morbidity and mortality and contributes to a higher amputation rate.
The primary objective in managing diabetic foot problems is to promote mobilisation. This involves managing both medical and surgical problems and involving a range of medical experts in related fields.
Additional information:
Various strategies have been published for the management and prevention of diabetic foot problems in hospital, including 'Putting feet first', Diabetes UK 2009 and 'Improving emergency and inpatient care for people with diabetes', Department of Health 2008.
There is an associated Quality Standard for diabetes, published March 31st 2011.
Image of neuroischaemic foot reproduced with kind permission of Dr Tony Coll, University of Cambridge.
All Images in this presentation are reproduced with kind permission off Dr. Tony Coll, University of Cambridge

4. Epidemiology
In 2010, 2.3 million people were registered as having diabetes
Life expectancy can be reduced by up to 15 years for people with diabetes
15% of people with diabetes will have a foot ulcer at some point in their lives
Diabetes is the most common cause of non-traumatic limb amputation.
NOTES FOR PRESENTERS:
Key points to raise:
In 2010, 2.3 million people in the UK were registered as having diabetes, while the number of people estimated as having either type 1 or type 2 diabetes was 3.1 million.
By 2030 it is estimated that more than 4.6 million people will have diabetes.
Type 2 diabetes is up to six times more common in people of South Asian descent, and up to three times more common in people of African and African-Caribbean origin.
The life expectancy of people with diabetes is shortened by up to 15 years, and 75% die of macrovascular complications.
The annual incidence of diabetic foot ulceration in the UK varies from 1.0 to 3.6%, with a prevalence of 5%.
Recent studies suggest that lifetime risk of diabetic foot ulcer may be as high as 25%
Diabetic foot ulcers precede more than 80% of amputations in people with diabetes.
After a first amputation, people with diabetes are twice as likely to have a subsequent amputation as people without diabetes.
Mortality rates after diabetic foot ulceration and amputation are high, with up to 70% of people dying within 5 years of having an amputation.

5. Scope
Key components and organisation of patient hospital care for diabetic foot problems from hospital admission to discharge planning
Assessment and investigation of diabetic foot problems
Clinical and cost-effectiveness of treatments for diabetic foot problems.
NOTES FOR PRESENTERS:
Key points to raise:
The scope of this guideline covers advice for adults (18 years and older) with diabetic foot problems, admitted to hospital. This could be secondary or tertiary care.
It also covers the care of those who have diabetic foot problems diagnosed while in hospital.

6. Multidisciplinary foot care team
Each hospital should have a care pathway for patients with diabetic foot problems who require inpatient care
The multidisciplinary foot care team should consist of healthcare professionals with the specialist skills and competencies necessary to deliver inpatient care for patients with diabetic foot problems.
NOTES FOR PRESENTERS:
Key points to raise:
The multidisciplinary foot care team should normally include a diabetologist, a surgeon with the relevant expertise in managing diabetic foot problems, a diabetes nurse specialist, a podiatrist and a tissue viability nurse, and the team should have access to other specialist services required to deliver the care outlined in this guideline.
The multidisciplinary foot care team should:
assess and treat the patient’s diabetes , which should include interventions to minimise the patient’s risk of cardiovascular events, and any interventions for pre-existing chronic kidney disease or anaemia (please refer to ‘Chronic kidney disease’ [NICE clinical guideline 73] and ‘Anaemia management in people with chronic kidney disease’ [NICE clinical guideline 114])
assess, review and evaluate the patient’s response to initial medical, surgical and diabetes management
assess the foot, and determine the need for specialist wound care, debridement, pressure off-loading and/or other surgical interventions
assess the patient’s pain and determine the need for treatment and access to specialist pain services
perform a vascular assessment to determine the need for further interventions
review the treatment of any infection
determine the need for interventions to prevent the deterioration and development of Achilles tendon contractures and other foot deformities
perform an orthotic assessment and treat to prevent recurrent disease of the foot
have access to physiotherapy
arrange discharge planning, which should include making arrangements for the patient to be assessed and their care managed in primary and/or community care, and followed up by specialist teams. [Please refer to ‘Type 2 diabetes: prevention and management of foot problems’ (NICE clinical guideline 10).] [1.2.5]

7. Patient information and support
The patient should have a named contact to follow the inpatient care pathway and be responsible for:
offering patients information about their diagnosis and treatment, and the care and support that they can expect
communicating relevant clinical information, including documentation prior to discharge, within and between hospitals and to primary and/or community care.
NOTES FOR PRESENTERS:
Key points to raise:
Patients should be offered information, explanations and opportunities to discuss issues and ask questions.
The named contact may be a member of the multidisciplinary foot care team or someone with a specific role as an inpatient pathway coordinator.
Recommendation in full:
The patient should have a named contact* to follow the inpatient care pathway and be responsible for:
- offering patients information about their diagnosis and treatment, and the care and support that they can expect
- communicating relevant clinical information, including documentation prior to discharge, within and between hospitals and to primary and/or community care. [1.2.7]
*This may be a member of the multidisciplinary foot care team or someone with a specific role as an inpatient pathway coordinator.

8. Initial examination and assessment
Remove the patient’s shoes, socks, bandages and dressings and examine their feet
If the following are present, obtain urgent advice from an appropriate specialist:
Charcot arthropathy (which should be considered if deformity, redness or warmth are present)
systemic sepsis
deep seated infection
limb ischaemia
NOTES FOR PRESENTERS:
Key points to raise:
Feet should be examined for any signs of neuropathy, ischaemia, ulceration, inflammation and/or infection, deformity or Charcot arthropathy.
Document any identified new and/or existing diabetic foot problems
If suspected, diagnosis of Charcot arthropathy should be confirmed by an appropriately trained specialist.
Signs and symptoms of systemic sepsis include fever, tachycardia, hypotension, reduced consciousness or altered cognitive state.
A deep seated infection may be suspected if there is palpable gas in the foot.
If limb ischaemia is suspected, inspect the limb for colour and temperature, gangrene or tissue loss and presence or absence of a peripheral pulse.
Recommendations in full:
Remove the patient’s shoes, socks, bandages and dressings and examine their feet for evidence of:
neuropathy
ischaemia
ulceration
inflammation and/or infection
deformity
Charcot arthropathy.
Document any identified new and/or existing diabetic foot problems. [1.2.11]
Obtain urgent advice from an appropriate specialist if any of the following are present:
Fever or any other signs or symptoms of systemic sepsis.
Clinical concern that there is a deep-seated infection (for example palpable gas).
Limb ischaemia. [1.2.16]
Image of X-ray showing Charcot arthropathy reproduced with kind permission of Dr Tony Coll, University of Cambridge.

9. Care within 24 hours
Refer the patient to the multidisciplinary foot care team.
Transfer the responsibility of care to a consultant member of the multidisciplinary foot care team if a diabetic foot problem is the dominant clinical factor for inpatient care.
NOTES FOR PRESENTERS:
This recommendation relates to the care that should be undertaken within 24 hours of a patient with diabetic foot problems being admitted to hospital, or the detection of diabetic foot problems (if the patient is already in hospital)
Key points to raise:
The overall care pathway should consist of providing care within 24 hours of admission or detection of a foot problem, and further investigation and management of specific diabetic foot problems.
A named consultant should be accountable for the care of the patient and for ensuring that healthcare professionals provide timely care.
Recommendation in full:
Refer the patient to the multidisciplinary foot care team within 24 hours of the initial examination of the patient’s feet. Transfer the responsibility of care to a consultant member of the multidisciplinary foot care team if a diabetic foot problem is the dominant clinical factor for inpatient care. [1.2.9]

10. Investigation of suspected diabetic foot infection
If osteomyelitis is suspected and initial X-ray does not confirm its presence, use magnetic resonance imaging (MRI)
If MRI is contraindicated, white blood cell (WBC) scanning may be performed instead.
NOTES FOR PRESENTERS:
Key points to raise:
Osteomyelitis should not be excluded on the basis of X-rays alone. X-rays should be used for alternative diagnoses, such as Charcot arthropathy.
If osteomyelitis is suspected, do not delay the commencement of a course of antibiotics pending the results of an MRI scan.
Recommendation in full:
If osteomyelitis is suspected and initial X-ray does not confirm the presence of osteomyelitis, use magnetic resonance imaging (MRI). If MRI is contraindicated, white blood cell (WBC) scanning may be performed instead. [1.2.19]
Image of widespread osteomyelitis reproduced with kind permission of Dr Tony Coll, University of Cambridge.

11. Management of diabetic foot infection
Each hospital should have antibiotic guidelines for the management of diabetic foot infections.
NOTES FOR PRESENTERS:
Key points to raise:
For mild infections, offer oral antibiotics with activity against Gram-positive organisms.
For moderate and severe infections, offer antibiotics with activity against Gram-positive and Gram-negative organisms, including anaerobic bacteria.
For moderate infections use oral or intravenous route of administration; for severe infections start with intravenous route of administration and then reassess.
Recommendation in full:
Each hospital should have antibiotic guidelines for the management of diabetic foot infections. [1.2.23]
Image of osteomyelitis, presenting late due to lack of pain, reproduced with kind permission of Dr Tony Coll, University of Cambridge.

12. Management of diabetic foot ulcers
When choosing wound dressings take into account:
clinical assessment of the wound
patient preference
clinical circumstances
which wound dressing has the lowest acquisition cost.
NOTES FOR PRESENTERS:
Key points to raise:
Pressure-relieving support surfaces and strategies should be used in line with NICE clinical guideline 29.
Additional information:
The guideline also features information on treatments that should not be used routinely.
Negative pressure wound therapy should not be routinely used to treat diabetic foot problems, but may be considered in the context of a clinical trial or as rescue therapy (when the only other option is amputation).
Dermal or skin substitutes, electrical stimulation therapy, autologous platelet-rich plasma gel, regenerative wound matrices and deltaparin, growth factors and hyperbaric oxygen therapies should also not be used unless in the context of a clinical trial.
Recommendation in full:
When choosing wound dressings, healthcare professionals from the multidisciplinary foot care team should take into account their clinical assessment of the wound, patient preference and the clinical circumstances, and should use wound dressings with the lowest acquisition cost. [1.2.32]
Image of painless neuropathic ulcer under 1st metatarsal head reproduced with kind permission of Dr Tony Coll, University of Cambridge.

13. Costs and savings
The guideline on the inpatient management of diabetic foot problems is unlikely to result in a significant change in resource use in the NHS. However, recommendations in the following areas may result in additional costs/savings depending on local circumstances:
Multidisciplinary foot care team
Care within 24 hours
Investigation of suspected diabetic foot infection
Management of diabetic foot ulcers
NOTES FOR PRESENTERS:
NICE has found that implementing this guideline is unlikely to result in any significant changes in resource use, based on national assumptions. Organisations should evaluate their own practices against the recommendations in the NICE guideline and assess costs locally.
These recommendations are:
Multidisciplinary foot care team [recommendations 1.2.1–1.2.5]
Comments from consultation suggested that some trusts are not replacing diabetes specialists’ posts (including diabetes specialist nurses and consultants). Therefore cost implications could be higher if trusts need to either establish or re-establish multidisciplinary foot care teams. There will also be additional costs to provide training and ongoing education for hospital professionals.
Care: within 24 hours [ recommendation ]
Where there is a need to improve the timing of service delivery there might be additional costs; this will need to be assessed locally.
Magnetic resonance imaging (MRI) or, if contraindicated, white blood cell (WBC) scanning, to confirm osteomyelitis where initial X-ray has not confirmed its presence. [recommendation ].
Clinical opinion suggests many units currently use repeated X-rays. Therefore, this change in practice might result in additional MRI or WBC costs.
Not using specific bone scans to diagnose osteomyelitis [recommendation ]
Clinical opinion suggests there is very limited use of these scans currently. Organisations should review their services and assess locally any potential savings that might result from stopping them.
Not routinely using negative pressure wound therapy (NPWT) [recommendation ]
Clinical opinion suggests that NPWT is commonly used in practice. Organisations should review their services and estimate any potential savings locally.
Not offering dermal or skin substitutes, electrical stimulation therapy, autologous platelet-rich plasma gel, regenerative wound matrices, deltaparin, hyperbaric oxygen therapies or growth factors, unless as part of a clinical trial [recommendation ]
Feedback from clinicians suggests that such adjuvant treatments are rarely used in practice. Organisations should review local practices to ensure compliance with this recommendation, and estimate any potential savings locally.

14. Discussion
To what extent do local arrangements compare with the guideline recommendations?
What should we stop doing as a result of this guideline?
What are the training implications for staff to support implementation of this guideline?
What are the local cost implications of implementing the guideline?
NOTES FOR PRESENTERS:
These questions are suggestions that have been developed to help provide a prompt for a discussion at the end of your presentation – please edit and adapt these to suit your local situation.

15. Find out more Visit www.nice.org.uk/guidance/CG119 for: the guideline
the quick reference guide
‘Understanding NICE guidance’
costing statement
audit support
NOTES FOR PRESENTERS:
You can download the guidance documents from the NICE website.
The NICE guideline – all the recommendations.
A quick reference guide – a summary of the recommendations for healthcare professionals.
‘Understanding NICE guidance’ – information for patients and carers.
The full guideline – all the recommendations, details of how they were developed, and reviews of the evidence they were based on.
For printed copies of the quick reference guide or ‘Understanding NICE guidance’, phone NICE publications on or and quote reference numbers N2467 (quick reference guide) and/or N2468(‘Understanding NICE guidance’).
NICE has developed tools to help organisations implement this guideline, which can be found on the NICE website.
Costing statement – details of the likely costs and savings when the cost impact of the guideline is not considered to be significant.
Audit support – for monitoring local practice.

16. NICE Quality Standard Diabetes – Statement 10 NOTES FOR PRESENTERS:
Key points to raise:
The following slides give additional information, with regards to the NICE Diabetes Quality Standard. In particular, they refer to quality statement 10, which focuses on the ‘at risk’ foot.

17. Quality standards
A quality standard is a set of specific, concise statements that:
• act as markers of high-quality, cost-effective patient care across a pathway or clinical area, covering treatment or prevention
• are derived from the best available evidence and produced collaboratively with the NHS and social care, along with their partners and service users.
NOTES FOR PRESENTERS:
Key points to raise:
There are two components to a quality standard: qualitative statements and quantitative measures.
Qualitative statements are descriptive statements of the key infrastructure and clinical requirements for high quality care, as well as the desirable or expected outcomes.
The qualitative measures set up the expected degree of achievement as ‘quality indicators’.
Commissioners will be interested in quality standards as markers of high quality care and patients and the public will see clear statements of what they can expect to receive from services.

18. Diabetes quality standard
The management of diabetes draws on many areas of healthcare management.
The quality standard describes markers of high-quality, cost-effective care that, when delivered collectively, should contribute to improving the effectiveness, safety and experience and of care for adults diabetes.
The quality standard consists of 13 quality statements.
NOTES FOR PRESENTERS:
Key points to raise:
There are multiple vascular risk factors and wide-ranging complications associated with diabetes.
The quality standard aims to improve the outcomes of care by:
Preventing people from dying prematurely.
Enhancing quality of life for people with long-term conditions.
Helping people to recover from episodes of ill health or following injury.
Ensuring that people have a positive experience of care.
Treating and caring for people in a safe environment and protecting them from avoidable harm.
The diabetes quality standard covers care for adults with diabetes, and excludes children, young people and pregnant women.
Additional information:
Recommendations from -
‘Diabetic foot problems: inpatient management of diabetic foot problems’ (NICE clinical guideline 119),
‘Type 2 diabetes: the management of type 2 diabetes’ (NICE clinical guideline 87),
’Diabetes in pregnancy: management of diabetes and its complications from pre-conception to the postnatal period’ (NICE clinical guideline 63),
‘Type 1 diabetes: diagnosis and management of type 1 diabetes in children, young people and adults’ (NICE clinical guideline 15),
‘Type 2 diabetes: prevention and management of foot problems’ (NICE clinical guideline 10)
Joint Department of Health and Diabetes UK Care Planning Working Group (2006) Care planning in diabetes document
- were developed by the Topic Expert Group (TEG) into 13 quality statements included in the quality standard.

19. Quality statement 10: ‘At risk’ foot
Each of the quality statements may be of interest to service providers, healthcare professionals, commissioners and people with diabetes.
NOTES FOR PRESENTERS:
Key points to raise:
Service providers ensure access to appropriate treatment and review by a foot protection team for people with diabetes with or at risk of foot ulceration in accordance with NICE guidance and ensure adequate systems and services are in place for referring people with diabetes who have a foot problem requiring urgent medical attention from primary care to a multidisciplinary foot care team within 24 hours.
Healthcare professionals ensure they identify and manage people with diabetes with or at risk of foot ulceration in accordance with NICE guidance, and ensure they are aware of local arrangements for accessing a multidisciplinary foot care team within 24 hours for people with diabetes who have a foot problem requiring urgent medical attention.
Commissioners ensure they commission services that provide access to regular review by a foot protection team for people with diabetes with or at risk of foot ulceration in accordance with NICE guidance, and that provide access to a multidisciplinary foot care team for people with diabetes who have a foot problem requiring urgent medical attention within 24 hours.
People with diabetes who have foot ulcers, or are at risk of developing foot ulcers, have regular check-ups from a team specialising in foot protection, and are seen and treated by a specialist healthcare team within 24 hours if they have foot problems needing urgent medical attention.

20. Quality statement 10: ‘At risk’ foot
People with diabetes with or at risk of foot ulceration receive regular review by a foot protection team in accordance with NICE guidance, and those with a foot problem requiring urgent medical attention are referred to and treated by a multidisciplinary foot care team within 24 hours.
NOTES FOR PRESENTERS:
Key points to raise:
This quality statement was developed from recommendations in ‘Type 2 diabetes – foot care’ (NICE clinical guideline 10) and ‘Diabetic foot problems’ (NICE clinical guideline 119).
While other quality statements within the diabetes quality standard may be relevant for patients with diabetic foot problems, this quality statement specifically addresses the patient with or at risk of ulceration in addition to those with foot problems requiring urgent medical attention.

21. Quality statement 10: ‘At risk’ foot
Quality measure:
Evidence of local arrangements to ensure that people with diabetes with or at risk of foot ulceration receive regular review by a foot protection team in accordance with NICE guidance.
Evidence of local arrangements to ensure that people with diabetes with a foot problem requiring medical attention are treated by a multidisciplinary foot care team within 24 hours.
NOTES FOR PRESENTERS:
Key points to raise:
The focus of the quality measure is on improving the processes of care that are considered to be linked to health outcomes.
The processes stated for this quality statement are:
Proportion of people with diabetes with foot ulceration who receive regular review by a foot protection team in accordance with NICE guidance
Numerator – the number of people in the denominator who receive regular review by a foot protection team in accordance with NICE guidance
Denominator – the number of people with diabetes with foot ulceration.
Proportion of people with diabetes at risk of foot ulceration who receive regular review by a foot protection team in accordance with NICE guidance
Denominator – the number of people with diabetes at risk of foot ulceration.
Proportion of people with diabetes with a foot problem requiring urgent medical attention referred to and treated by a multidisciplinary foot care team within 24 hours.
Numerator – the number of people in the denominator referred to and treated by a multidisciplinary foot care team within 24 hours.
Denominator – the number of people with diabetes with a foot problem requiring urgent medical attention.
Proportion of people with diabetes with an urgent foot problem referred to a multidisciplinary foot care team who are treated in accordance with NICE guidance
Numerator – the number of people in the denominator treated in accordance with NICE guidance .
Denominator – the number of people with diabetes with an urgent foot problem referred to a multidisciplinary foot care team.

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NOTES FOR PRESENTERS:
Additional information:
This final slide is not intended to be part of the presentation, it asks for feedback on whether this implementation tool meets your requirements and whether it will help you to put this NICE guidance into practice - your opinion would be appreciated.
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