Quality statement 6: Referral for urgent diabetic foot problems

Quality statement

Adults with a limb-threatening or life-threatening diabetic foot problem are referred immediately for specialist assessment and treatment. [2011, updated 2016]

Rationale

Rapid referral to specialist services for adults with a limb-threatening or life-threatening diabetic foot problem, so that they can be assessed and an individualised treatment plan put in place, can reduce the risk of amputation and death.

Quality measures

Structure

Evidence of local arrangements to ensure that adults with a limb-threatening or life-threatening diabetic foot problem are referred immediately for specialist assessment and treatment.

Data source: Local data collection.

Process

a) Proportion of presentations of limb-threatening or life-threatening diabetic foot problems that are referred immediately for specialist assessment and treatment.

Numerator – the number in the denominator that are referred immediately for specialist assessment and treatment.

Denominator – the number of presentations of limb-threatening or life-threatening diabetic foot problems.

Data source: Local data collection.

b) Proportion of presentations of limb-threatening or life-threatening diabetic foot problems in which the multidisciplinary foot care service is informed.

Numerator – the number in the denominator in which the multidisciplinary foot care service is informed.

Denominator – the number of presentations of limb-threatening or life-threatening diabetic foot problems.

Data source: Local data collection.

Outcome

Incidence of foot and lower limb amputations in people with diabetes.

Data source: The National Diabetes Audit collects information on minor and major amputations in people with diabetes.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (such as foot protection services, GPs and community services) ensure that systems are in place so that adults with a limb-threatening or life-threatening diabetic foot problem are referred immediately for specialist assessment and treatment, and the multidisciplinary foot care service is informed.

Health and social care practitioners (such as podiatrists, GPs, practice nurses and district nurses) ensure that they refer adults with a limb-threatening or life-threatening diabetic foot problem immediately for specialist assessment and treatment, and inform the multidisciplinary foot care service.

Commissioners (clinical commissioning groups and NHS England) ensure that they commission services in which adults with a limb-threatening or life-threatening diabetic foot problem are referred immediately for specialist assessment and treatment, and the multidisciplinary foot care service is informed.

What the quality statement means for patients, service users and carers

Adults with diabetes who have a serious foot problem are sent to hospital immediately, so that they can be assessed and treated straight away. Serious foot problems are those that might result in amputation or even death, and include a diabetic foot ulcer with a fever or any other symptoms of blood poisoning (the medical name for this is sepsis), a problem with the blood supply to the foot, gangrene, or a severe foot or bone infection.

Source guidance

Definitions of terms used in this quality statement

Limb-threatening or life-threatening diabetic foot problem

Limb-threatening and life-threatening diabetic foot problems include:

  • ulceration with fever or any signs of sepsis

  • ulceration with limb ischaemia (see the NICE guideline on lower limb peripheral arterial disease)

  • clinical concern that there is a deep-seated soft tissue or bone infection (with or without ulceration)

  • gangrene (with or without ulceration).

[Adapted from NICE's guideline on Diabetic foot problems: prevention and management, recommendation 1.4.1]

Specialist assessment and treatment

The specialist service should be the multidisciplinary foot care service wherever possible. However, if the multidisciplinary foot care service is not available (for example, if the person presents out of hours) then, in order to avoid any delay in treatment, the person should be referred immediately to acute services and the multidisciplinary foot care service informed.

The multidisciplinary foot care service should be led by a named healthcare professional, and consist of specialists with skills in the following areas:

  • diabetology

  • podiatry

  • diabetes specialist nursing

  • vascular surgery

  • microbiology

  • orthopaedic surgery

  • biomechanics and orthoses

  • interventional radiology

  • casting

  • wound care.

The multidisciplinary foot care service should have access to rehabilitation services, plastic surgery, psychological services and nutritional services.

[Adapted from NICE's guideline on Diabetic foot problems: prevention and management, recommendations 1.2.3 and 1.2.4, and expert opinion]