Reducing amputations: how to save limbs during the pandemic and beyond
Nearly all ulcers are preventable, which is why foot care and education is such a vital part of looking after diabetes patients - and took centre stage at one of the sessions of this year’s Diabetes UK Professional Conference.
There are over 7000 diabetes-related amputations in England each year and 80% are preceded by foot ulceration. These two sobering statistics were highlighted by Jayne Robbie, Senior Lecturer at Birmingham City University, in her talk about the importance of diagnosing infection. She went on to add that amputation and ulceration are associated with high mortality – only around 50% of patients survive for two years after a major amputation in diabetes.
Infection is an important cause of tissue destruction and she showed images demonstrating that infection of both soft tissue and/or bone is common across all types of ulceration. It spreads rapidly, so it is vitally important to make an early diagnosis and enable early referral and treatment. Signs of a red, hot, swollen foot should not be ignored, she said, because progression from minor injury to unsalvageable tissue can happen in as little 48 hours.
An extraordinary statistic from an audit done in Birmingham in 2020 showed that 47% of patients hospitalised for severe soft tissue infection from an outpatient podiatry clinic had simply turned up for routine podiatry appointments. They hadn’t realised that they were unwell, highlighting the need for foot care education.
During the pandemic, an innovative multi-disciplinary hot clinic was set up in Birmingham to reduce hospital admissions – a one-stop shop for patients with diabetes presenting with acute foot problems. The advent of specialist foot clinics all over the world have clearly demonstrated an improvement in clinical outcomes for patients presenting with ulcerations. However, clear referral pathways are needed to prevent late presentations and one of the resources she drew attention to was the ‘Fast-track Pathway for Diabetic Foot Ulceration During COVID-19 and Beyond’, which is available at https://d-foot.org/projects/fast-track-pathway-for-diabetic-foot-ulceration.
The role of the podiatrist in COVID-19 and beyond
Dr Paul Chadwick, clinical director at the College of Podiatry, gave further insight into changes in podiatry practice that occurred during the pandemic and what the discipline can take forwards from those experiences.
During the first wave, there was a reduction in health-seeking behaviour – patients cancelled appointments for fear of catching COVID-19 and, despite the fact that podiatrists continued to provide care, many didn’t realise hospital foot clinics were still running. Data showed a spike in severe ulceration admissions in May/June 2020 as the first wave started to subside.
One of the most important things that happened during the first wave was that, realisising patients were staying away, so many in the profession contributed to CPD webinars and other resources to help non-specialists, such as the emergency guidance issued by Foot In Diabetes UK: ‘The Lower Limb Amputation Prevention Guidance’was created to help identify and manage people with critical/limb-threatening ischaemia or infection. It’s available here: https://www.wounds-uk.com/resources/details/lower-limb-amputation-prevention-guidance.
Podiatrists also provided key support to the NHS during a difficult time. It was quickly recognised that they have transferable skills and many were redeployed while still supporting diabetic foot care, undertaking tasks such as supporting wound care across the body, home IV therapy, treating lower limb fractures, catheterisation, cannulating, working in urgent care centres, supporting district nurses in home visits and suturing. Some became the lead on triaging foot and lower limb conditions. Podiatrists are also independent prescribers, which helped to reduce further visits to the doctor.
Dr Chadwick finished with the positives that can be taken away from the changes in practice during the pandemic, such as the value of integrated virtual clinics (use of video clinics was especially useful for care homes in the most recent wave) and the need for increasing podiatric prescribing - not just for the foot and lower limb but possibly for other conditions too. It also laid bare the need for investment in the National Wound Care Strategy Programme to aid a more joined-up approach to wound care post-pandemic.
Accessing specialist care in good time
Finally, Professor Michael Edmonds, consultant diabetologist at King's College Hospital, covered why there is often a delay in people getting the specialist care they need and the role of the ACT NOW campaign in reducing it.
COVID-19 obviously impacted access to care, but even outside of the pandemic, delay can happen because of people with diabetes seeking help too late (sometimes due to poor education on warning signs) and inaccurate assessments/poor symptom recognition from healthcare professionals or not referring quickly enough because they don’t realise the severity of the problem. And even when a referral is made in a timely fashion, there can be issues with accessing care because of factors such as poor communication or lack of multi-disciplinary foot teams.
To address awareness among diabetes patients and HCPs, the iDEAL group (a multi-disciplinary team of diabetes specialists) created the ACT NOW checklist and toolkit, which can be downloaded from the iDEAL website (https://idealdiabetes.com/).
The acronym stands for:
Accident: Recent or history of an accident or trauma?
Change: Is there any new swelling, redness or change of shape of the foot?
Temperature: Is there is a change in temperature present? Could this be an infection or possible Charcot?
New pain: Is there pain present? Is it localised or generalised throughout the foot?
Oozing: What colour is any exudate? Is there an odour?
Wound: Can you document the size, shape and position of the wound in the foot affected?
Any of these would necessitate referral to a specialist.
The IDEAL campaign aims to reduce amputation by 50% over five years.
The views expressed in this article are those of the author, Dr Eleanor D Kennedy.