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NICE issues referral warning for foot ulcers in diabetes patients

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Diabetes patients with a foot problem that is deemed to be limb-threatening should be referred “immediately”, latest guidance states.

The National Institute for Health and Care Excellence has today published guidance on foot problems in diabetes patients – titled Diabetic foot problems: prevention and management – setting clear referral timelines and also promoting patient information.

 

The guidance follows recent warnings from the charity Diabetes UK on the need for regular foot checks and the growing cost of complications, including amputation.

NICE noted that foot complications were common in people with diabetes, with an estimated 10% of people with the condition having a diabetic foot ulcer at some point in their lives.

It highlighted that diabetic foot problems mainly occurred because of diabetic neuropathy or peripheral arterial disease, or both. 

It noted that nerve damage could mean that injuries like cuts went unnoticed and subsequently developed into an open sore – a diabetic foot ulcer – that could become infected and result in amputation.

NICE also warned that diabetes was the most common cause of non-traumatic limb amputation, with diabetic foot ulcers preceding more than 80% of amputations in people with diabetes.

In its latest guidance it recommended that if a patient had a limb-threatening or life-threatening diabetic foot problem, they should be referred immediately to acute services.

The local multi-disciplinary foot care service should also be informed so the patient could be assessed and a treatment plan put in place, it said.

NICE cited examples of limb-threatening and life-threatening diabetic foot problems as including ulceration with fever or any signs of sepsis or with poor blood supply to the limb, possible deep-seated soft tissue or bone infection, or gangrene.

For all other active diabetic foot problems, NICE said the patient should be referred within one working day to the multi-disciplinary foot care service or foot protection service for triage within one further working day.

“This guideline sets the standard for managing diabetic foot problems for all people with diabetes, including children and young people, in all NHS settings”

Rachel Berrington

In addition, it said information and “clear explanations” should be provided about the risk of developing a foot problem to patients or their carers when diabetes was “diagnosed, during assessments, and if problems arise”.

Such information should include basic foot care advice and the importance of foot care, foot emergencies and who to contact, footwear advice, and the person’s current individual risk of developing a foot problem, the guidance said.

Rachel Berrington, a diabetes specialist nurse and NICE guideline developer, said: “Diabetic foot problems are serious, and if not managed appropriately they can lead to minor or major amputations and even death.”

She highlighted that mortality rates after diabetic foot ulceration and amputation were high, with up to 70% of people dying within five years of having an amputation and around 50% dying within five years of developing a diabetic foot ulcer.

“This guideline sets the standard for managing diabetic foot problems for all people with diabetes, including children and young people, in all NHS settings,” she said. “For example the guideline identifies people who need immediate attention from the multi-disciplinary foot care service or acute services.”

She added: “The guideline also highlights the need for clear information and education for all people with diabetes about diabetic foot problems, so they know what care to expect, the importance of foot care and who to contact in an emergency.” 

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