Saving limbs with good diabetic foot care
Quality screening, early diagnosis and timely referrals are key to preventing amputations in diabetes. Two experts shared their knowledge in an enlightening Primary Care Diabetes Europe webinar
Jane Diggle, a specialist diabetes nurse practitioner, set the scene with statistics demonstrating just how important it is to provide good diabetes foot care – one in three people with diabetes develop a foot ulcer in their lifetime; 84% of lower extremity amputations result from complications of a foot ulcer; there are about 100 amputations being performed every week in the UK as a result of diabetes; the financial burden is immense – cost of care for ulceration and amputation in diabetes in 2014/15 was estimated at almost £1 billion. And, of course, it has a devastating impact on a person’s quality of life, often leading to reduced independence, social isolation and psychological distress.
Improving those statistics is possible and the aim of the webinar was to improve competence in assessing foot health in people with diabetes, improve early recognition of potential and actual foot damage and ulcers in primary care, to better understand when to refer patients to specialist centres and to explore the therapeutic options. The webinar is a must-watch if you’re involved in diabetes foot care and it’s available on demand here: https://www.pcdeurope.org/webinar-diabetic-foot-ulcers/.
Jane explained why foot problems occur in people with diabetes, moving on to highlight that many amputations are avoidable if ulcers are either prevented or healed very quickly. Diabetic foot screening (when done well) is the cornerstone of good diabetic foot care and it can be done by any healthcare professional involved in a person’s care, providing they have the training and competence.
She then gave clear, concise and detailed guidance on how best to perform the three key aspects of foot screening – provide education (it’s the patient who sees their feet every day),take a history and perform an examination. She included the important reminder that ‘time is tissue’ – a break in the skin on Tuesday can result in an amputation on Friday, so prompt referrals can make all the difference.
The challenges of foot care during the COVID-19 pandemic were also covered, with advice on how to continue as effectively as possible when seeing patients remotely.
She finished with highlighting the Act Now! campaign, which aims to raise awareness of risk and when to seek help for both HCPs and people living with diabetes. The resources are available here: idealdiabetes.com/act-now-education-resources/.
Classifying and managing foot ulcers
Dr Judit Llussá Arboix, a family practitioner and associate professor at Universitat Autónoma de Barcelona, covered the classification and management of diabetic foot ulcers, and discussed the essential role that primary care practitioners play in early diagnosis and referral.
The classification of ulcers is important for many reasons, including individual prognosis, management of the ulcer and to inform decision-making around revascularisation. She directed participants to the classification guidelines issued by the International Working Group on the Diabetic Foot (IWGDF), which can be found here: iwgdfguidelines.org. All of its guidelines around the diabetic foot are also available on the site.
A superficial ulcer without ischaemia or infection can be treated in primary care, but all others require immediate referral. However, referral should also happen when the right assessment/treatment cannot be provided in primary care, so questions need to be asked about whether the cornerstones of good ulcer treatment, such as competent assessment and cleaning, debridement and offloading, are possible in the setting.
She talked through in detail how to test for ischaemia and infection, as well as treatment, including dressings and offloading devices. She also touched on prevention by looking at the patient holistically (metabolic control etc.) and treating co-morbidities.
Lastly, she echoed Jane’s message about timely referral – delay in referring patients from primary care is one of the most important risk factors for amputation and referring early greatly reduces the risk. It’s the responsibility of primary care practitioners to ensure this happens.
The views expressed in this article are those of the author, Dr Eleanor D Kennedy.