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NICE guidance

How to manage the diabetic foot

Diabetes-related complications have a major financial impact on the NHS. A guideline offers advice on managing patients in acute settings

Diabetes is one of the biggest health challenges facing the UK. In 2010, 2.3 million people in the UK were registered as having diabetes, while an estimated 3.1 million have either type 1 or type 2 diabetes. By 2030, more than 4.6 million people could have the condition.

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As the longevity of the population increases, so does the incidence of diabetes-related complications (Anderson and Roukis, 2007). These include foot problems, the most common cause of non-traumatic limb amputation (Boulton et al, 2005).

Diabetic foot problems include neuropathy, peripheral arterial disease, deformity, infections, ulcers and gangrene. They can have a major financial impact on the NHS through increased bed occupancy, prolonged stays in hospital and outpatient costs. They can also have a considerable impact on patients’ quality of life, for example, damage to or loss of limbs can lead to reduced mobility that can result in loss of employment and depression.

This new National Institute for Health and Clinical Excellence guideline provides recommendations on the essential components of inpatient care of people with diabetic foot problems from hospital admission onwards.

Implications for nursing practice

The guideline recognises the importance of effectively managing diabetic foot problems. It provides evidence-based recommendations to ensure optimum treatment for patients in acute healthcare setting, and suggests a coordinated and systematic approach to patient care, to minimise the risk of complications.

A key recommendation is that hospitals should have a care pathway in place for patients with diabetic foot problems who require inpatient care, and that this should be managed by a multidisciplinary foot care team. This 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. The role of the tissue viability nurse is acknowledged, but importantly as an addition to, rather than a replacement, for the podiatrist. Whenever possible a podiatrist should be involved with an acute foot care team, as they often provide an important link between practitioners involved in the acute and primary healthcare settings.

The guideline recognises the importance of treating diabetic foot problems as an emergency and of offering support for patients while they are in hospital. It recommends: “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 before discharge, within and between hospitals and to primary and/or community care.”

Recommendations for appropriate patient management are given within a framework of two main phases of care: within the first 24 hours; and ongoing management.

The guideline considers specific adjunctive therapies, which it recommends are used only as part of a clinical trial. These therapies comprise: dermal or skin substitutes, electrical stimulation therapy, autologous platelet-rich plasma gel, regenerative wound matrices and deltaparin. They also include growth factors (granulocyte colony-stimulating factor, platelet-derived growth factor, epidermal growth factor and transforming growth factor beta) and hyperbaric oxygen therapy, or as part of a clinical trial or as rescue therapy (negative pressure wound therapy).

The clinical and cost effectiveness of negative pressure wound therapy and hyperbaric oxygen therapy are recommended as areas for further research. This is needed before these treatments can be adopted as evidence-based practice. 

Conclusion

This guideline gives an overview of the importance of effective management of patients with diabetic foot problems while in acute healthcare settings, and provides evidence-based recommendations for managing them. It aims to help nurses assess their patients, be actively involved in providing appropriate treatment, and give tailored information as required. It also aims to reduce variations in the level of care that patients receive when they are in hospital, leading to fewer amputations, a better quality of life for those affected and lower NHS costs. NT

The guideline, Diabetic Foot Problems: Inpatient Management of Diabetic Foot Problems and other implementation resources are available for download at www.nice.org.uk/guidance/CG119

Mark Collieris lead nurse/consultant, tissue viability, United Lincolnshire Hospitals NHS Trust, and a member of the NICE guideline development group

Readers' comments (1)

  • I am unsure if the RN's in the UK are aware of the expanded role for nurses in preventive care. The nurses in Canada and the US are now providing preventive diabetic foot care; i.e. nail trimming, callus reduction. There is a certification available now internationally.. CFCN, certified foot care nurse. I have been providing these types of services for 17 years and am now dedicating a great deal of my time and energy in spreading the word to all nurses that we can and should be providing these services. If anyone is interested in learning more about the role of the nurse in preventive foot care, please feel free to contact me. Nurses are an untapped resource in the war against preventable amputations!!
    Laura Roehrick RN, CFCN
    roehrickrn@gmail.com

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