NICE has today (23 March) published a new guideline for the care of people with diabetic foot problems in hospital.

Diabetes is becoming one of the UK's biggest health problems. In 2009, it was estimated that there were 2.3 million people in the UK with type 1 or type 2 diabetes1. With rising numbers of people affected by the condition, the incidence of complications is also on the rise. These include foot problems such as ulcerations2 and gangrene3, foot deformities, and infections which, if left untreated, can have a significant impact on a patient's quality of life. For example, by reducing a patient's mobility these problems can lead to loss of employment, depression, and damage to, or loss of, limbs. Each year in the UK, around 5,000 people with diabetes undergo leg, foot or toe amputations, equivalent to 100 a week4. Treating diabetic foot problems also has a considerable financial impact on the NHS through outpatient costs, increased bed occupancy, and longer hospital stays. Up to 20% (£600m) of the £3bn the NHS spends on diabetes each year goes on treating diabetic foot problems, and at least £252m of this is spent on amputation5.

There is currently some variation in practice in the management of patients with diabetic foot problems. This variation is due to a range of factors, including differences in the organisation of care between patients' admission to an acute care setting and discharge. This variability depends on geography, individual trusts, individual specialties (such as whether the service is managed by vascular surgery, general surgery, orthopaedics, diabetologists or general physicians) and the availability of podiatrists with expertise in diabetic foot disease.

The NICE guideline comprises a clear, authoritative source of information for NHS hospitals which will help overall management of diabetic foot problems, aiming to reduce variations in practice. It includes the following key recommendations:

- Each hospital should have a care pathway for diabetic foot problems in diabetic patients who require hospital care.

- A multidisciplinary foot care team should manage the care pathway

of patients with diabetic foot problems who require inpatient care. 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.

-- At the initial examination and assessment, the patients' feet should be examined for evidence of:

- Inflammation/infection
- Ulceration
- Deformity
- Neuropathy6
- Ischaemia7
- Charcot arthropathy8

-- Refer patients with diabetic foot problems 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.

-- When in hospital, patients with diabetic foot problems should have access to appropriate pressure reducing surfaces, to minimise the risk of pressure ulcer development on the affected limb.

Dr Fergus Macbeth, Centre for Clinical Practice Director at NICE, said: "Diabetes is one of the major health issues in the UK today, and each year more and more people are diagnosed with the condition. This increase in prevalence brings with it more diabetes-related complications such as foot problems, which are now the most common cause of non-traumatic limb amputation in the UK9. It's important, therefore, that the NHS is treating diabetic foot problems in the most clinically and cost effective way. This guideline provides clear, evidence-based recommendations for hospital staff treating patients (aged 18 years and above) who are admitted to hospital with diabetic foot problems or who develop them whilst in hospital. The guideline 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."

Dr Gerry Rayman, Consultant Physician and Head of Service, The Diabetes and Endocrine Centre and Diabetes Foot Clinic and Research Unit, Ipswich Hospital NHS Trust said:"I was pleased to be involved in the development of this guideline because I have seen first-hand the very serious problems that can result from diabetic foot complications. This guideline will be a useful aid to all those involved in the treatment of such patients in NHS hospitals, and will, I'm sure, result in better care for patients."

Kate Hill, patient/carer representative on the Guideline Development Group said: "Many people aren't aware that diabetes can also lead to foot problems, which can often be quite devastating. I'm confident that this new guideline will result in improved outcomes for patients with these problems."

References

[1] Diabetes UK.

[2] Ulcerationsare defined as foot wounds or open sores.

[3] Gangrene is the death of body tissue in a localised area due to loss of its blood supply.

[4] Diabetes UK.

[5] Diabetes UK.

[6] Neuropathy is the loss of full sensation in the nerves and is caused as a result of the complications from diabetes. Diabetic neuropathy is directly related to the length of time that nerve fibres are exposed to hyperglycaemia.

[7] Ischaemia is a lack of adequate blood flow from the heart to the foot, and causes a reduction in the amount of oxygen and nutrients needed for the cells to continue to function.

[8] Charcot arthropathy is a progressive musculoskeletal condition characterised by joint dislocation, fractures and deformities. It results in progressive destruction of bone and soft tissue of weight-bearing joints, often in the foot and ankle.

[9] J. Boulton, L. Vileikyte, G. Ragnarson-Tennvall, and J. Apelqvist (2005). The global burden of diabetic foot disease.

Notes

About the guideline

- The guideline is available from Wednesday 23 March

- A previous NICE clinical guideline on prevention and management of foot problems in type 2 diabetes (NICE clinical guideline 10, 2004) concentrated on the detection, general management and treatment of diabetic foot ulcers and the care pathway ends at referral to a multidisciplinary foot care team.

Source:
NICE