CG119 Diabetic foot problems
Mark Collier, lead nurse consultant for tissue viability at United Lincolnshire Hospitals NHS Trust discusses implementation of the guidance in clinical practice.
This podcast was added on 23 Mar 2011
Interviewer: Hello and welcome to the NICE podcast about the NICE guideline on the Inpatient Management of Diabetic Foot Problems. In particular this podcast will be focussing on implementing the recommendations in the guidance.
I am Jayne Rowney, implementation lead for this guidance, and with me is Mark Collier, lead nurse consultant for tissue viability at United Lincolnshire Hospitals NHS Trust, who was also a member of the guideline development group that developed this guideline.
This guideline relates to just one element of care that diabetic patients should receive. Why are diabetic foot problems an important concern? (00:09)
Mark Collier: Diabetes is one of the biggest health challenges in the UK today and it affects millions worldwide. In 2010, 2.3 million people in the United Kingdom 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 this condition. As the longevity of the population increases, i.e., we’re having a much more elderly population that are living longer, lots more co-morbidities, the incidence of diabetes related complications is therefore likely to increase and will be presenting all healthcare establishments wherever they may be. Among the main complications of diabetes are foot problems, which is what this guideline is particularly focussed on.
The guideline refers to a multidisciplinary foot care team, who do you envisage would be part of this team that is referred to in the guideline?
All the evidence suggests that if there is a multidisciplinary team involved in the patient’s care, irrespective of the make-up of that team, is that the patient’s outcomes are improved, and that goes across the whole range of specialities. I think it’s probably fair to say that up until now the patients with diabetic feet haven’t necessarily had multi-disciplinary team approach, particularly within secondary care, they’ve always been well served in primary care. So this guideline is really trying to focus that and help people establish, or give them the authority to establish a multi-disciplinary foot care team within their own areas. I would envisage that the leader of that team should be the diabetologist who is going to have the overall management responsibility for the patient, but then there will be various other specialists that should be actively involved. For example the vascular surgeon if there are any vascular problems that need to be sorted out. If there are any associated orthopaedic conditions, then of course the orthopaedic surgeon should be involved. The diabetic liaison nurse should be directly involved because obviously a complication suggests that control of the diabetes may not be as optimal as it should be, so there needs some further input there. From my own speciality, if the patient has a wound I would expect the tissue viability nurse to be involved in the management of that wound. And of course very importantly the podiatrist should be involved, if there is one available, as they have specialist skills that the other members of the team don’t have and can also provide a link and a conduit to the patient’s care in primary care and post discharge.
What are the main changes in practice that might be needed to implement the guideline?
I think one of the main changes is just the organisation of care, as in the setting up of the multidisciplinary team making it evident that throughout the establishment that it is actually in existence. In addition, it’s also the identification of someone who is going to be responsible for giving information to that patient. The guideline talks about the patient having a named contact, which may be a member of the multidisciplinary team but equally could be somebody else that the patient can directly relate to talk to, get meaningful information from and ensure that information is given to them from the healthcare setting in a consistent way in whatever format is right for the individual patient. So, taking into account differences in languages and ethnic groups, etcetera.
One of the conditions that the guideline recommends assessing for is Charcot arthropathy. Can you give an overview of what the condition is please and what signs and symptoms practitioners should be looking for?
Charcot’s arthropathy is very much a progressive muscular-skeletal condition which is characterised by joint dislocation, particularly of the ankle, fractures and deformities associated with the same in the foot. It is a progressive disease and can often lead to destruction of bone and soft tissue of weight bearing joints, as we have already pointed out, that therefore is logically going to most commonly affect the foot and ankle. Signs and symptoms will depend on the stage of the disease, when the patient presents to the medical professional or to the healthcare setting. And this can range from mild swelling to severe and moderate deformity of the foot. Inflammation, pain, erythema (i.e. redness) and increased skin temperature around the joint may be very noticeable, and although that is consistent with infection generally, in addition X-rays taken at the time may reveal that there is problem with the bone and that degenerative changes are clearly evident.
As well as making recommendations for what practitioners should do there are also some recommendations that relate to elements of care that might previously have been common practice but are now being advised against in this guideline. Can you tell us more about this and why these treatments are not being recommended?
Well in short, the treatments, although they were well-established treatments for other conditions and in different healthcare settings when we reviewed the evidence, the level of evidence was relatively poor if we are thinking about randomised controlled trials and metaanalysis of information that has been provided prior to that. There was lots of low level evidence but it was felt by the group, the guideline committee, that this evidence was not enough to support their recommendation and that the recommendation therefore should be that more research was undertaken with these particular treatments, and others, in relation specifically to management of the patient with a diabetic foot to try and identify a true correlation between the use of it and an improvement in their condition. So it’s not to say that those treatment modalities should not be used elsewhere it’s just in relation to this specific patient group that was a lack of evidence to support that practice currently.
The guideline has an identified care pathway for the management of patients admitted with diabetic foot problems. What are the main elements of this?
The care pathway clearly identifies two major phases of assessment and management of the patient. The first is within the first 24 hours. The pathway focuses very specifically on the initial assessment of the feet, and various investigations that should happen about that. And then following that after the 24 hour period the care pathway the leads on to more ongoing care which should obviously pre-empt and inform also the formal discharge pathway for the patient so that you get true continuity of care between healthcare settings.
What are the benefits of implementing this guideline?
The main benefits will actually be twofold. One to the NHS as a whole, but as importantly, to the patient. If diabetic foot problems aren’t picked up early and aren’t assessed and treated in an optimal manner then the diabetic foot problems can lead to increased outpatient costs to the NHS, increased bed occupancy and prolonged stays because of the complications associated with it such as infection. If these infections aren’t treated appropriately, it’s been identified by various authors that diabetic foot problems are the most common cause of non-traumatic limb amputations. So ultimately that has a massive effect on the patient’s quality of life, not least because they are now a limb short, but equally because of their ability to potentially work, their effects on the way that they socialise, their interactions with their family. So I think you can see that this particular guideline is very important for a whole lot of people, not least the NHS as a whole.
We hope that you have enjoyed this podcast and found the information useful and that it will help you when putting the guidance in practice. For more information about the guideline and for access to the implementation tools please visit the NICE website.
This resource should be used alongside the published guidance. The information does not supersede or replace the guidance itself.
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This page was last updated: 19 September 2012