Diabetes is now the most significant health condition facing Australians. Overall, there are approximately 1.2 million Australians diagnosed with diabetes with another 500,000 estimated to be undiagnosed but at risk of complications (Diabetes Australia 2016).

In addition, the prevalence of diabetes increases with age, with men having higher rates of diagnosis than women. Diabetes is linked to a myriad of complications, impacting cardiovascular and kidney health, eye health and feet, with 13% of Australians with diabetes, experiencing nerve damage in their lower limbs associated with peripheral neuropathy and reduced circulation (Baker IDI Heart and Diabetes Institute 2012).

Diabetes – how it impacts on feet

Peripheral nerve damage and decreased peripheral circulation combined, are the leading cause of foot ulcers, infection and lower limb amputation. As discussed by Tal et al (2011), 15% of people with a diagnosis of diabetes go on to develop foot ulcers, with 80% of limb amputations associated directly with an initial foot ulcer.

Ensuring timely diagnosis and management of foot issues for patients with diabetes is crucial in decreasing poor health outcomes and related impact on quality of life. Recent guidelines (NICE 2016), provide the best source of evidence for diagnosis and management, with content developed from systematic review and expert opinions. Released in January 2016, the NICE guidelines for Diabetic foot care highlight key recommendations for health professionals to incorporate into their care and management of patients with diabetes, as outlined below.
Action within the first 24 hours of admission to hospital

The NICE guidelines (2016) specify that all patients with a diagnosis of diabetes with a foot problem, whether on admission or during an episode of care, should be placed on a care pathway to ensure their care is managed according to best practice principles.

Foot problems include:

• Ulcers, blisters, skin breaks
• Inflammation, swelling or signs of infection on the foot
• Complaints of a painful foot
• Presence of a fracture with no apparent trauma
• Gangrene present on the foot

Care across all settings

The role of a multidisciplinary team is to provide access to a range of evidence based care and protocols including:

• A complete assessment and review of the patient’s diabetes status, including interventions to reduce cardiovascular risk and kidney disease
• Specialist wound care and pain management
• Vascular assessment and access to appropriate interventions
• Antibiotic protocols for the treatment of infection
• Orthotic assessment
• Access to physiotherapy
• Discharge planning which includes referral to community based diabetes care.

Assessing the risk of developing a diabetic foot problem

The performance of a thorough foot assessment is a critical part of the NICE (2016) guidelines and needs to be performed diligently.

Key elements include:

• Mandatory foot checks to be performed upon diagnosis of diabetes, then annually;
• During a hospital stay, a foot check should be performed with any change in the patient’s status;
• A thorough foot examination should include having the patient remove their shoes and socks, and any dressings on both feet. The feet must be screened for any evidence of neuropathy, limb ischaemia, ulceration or callus formation, infection, deformity and gangrene and charcot arthropathy.

The results of a thorough foot assessment will then guide the clinician in determining the patient’s risk for developing a diabetic foot problem, with risk rated as low, medium, high or active. Interventions will then be guided as to the care and management for the patient.

Diabetic foot problems

Following assessment, a patient identified with an active foot problem which is considered limb or life threatening, requires immediate referral to an acute service. Examples include evidence of ulceration with signs of sepsis or limb ischaemia, indication of soft tissue or bone infection or gangrene.

Investigation and treatment

As detailed in the NICE Guidelines (2016), investigation and treatment of a diabetic foot ulcer requires the following steps:

• Assessment: Documentation of the size, depth and position of the ulcer. Use of a standardised protocol is also recommended with SINBAD (Site, Ischaemia, Neuropathy, Bacterial Infection, Area and Depth) a suggested technique.

• Treatment regimes include offloading, with the use of orthotics, management of ischaemia, wound debridement and dressings. Hyperbaric oxygen therapy is also included as a consideration within the guidelines.

• Diabetic foot infections need thorough investigation, with microbiological examination, if a wound is present, xray, to determine the extent or impact on soft tissue or bone, and the use of MRI to confirm the diagnosis if osteomyelitis is suspected.

• Charcot arthropathy, which leads to the progressive degeneration of the bones within the foot, requires investigation to confirm diagnosis by Xray, or MRI if xray results are normal, but the presence of Charcot arthropathy is highly likely.

• Treatment includes the use of offloading devices and ongoing management by the multidisciplinary foot service. With the high risk of ulceration, ongoing monitoring is a key requirement due to the increased risk for limb amputation (NICE 2016).

Patient information

Providing up to date information and individual treatment plans are essential in ensuring the patient can actively participate in their own care. The ability to monitor the condition of their feet, and identify any areas of concern before the development of infection or ulceration are crucial in reducing the risks of developing diabetes related foot problems.

Advice provided to the patient should include:

• Appropriate footwear
• General care of both feet and legs
• Wound care
• Who to contact for foot emergencies

Being alert to the risks associated with diabetes foot problems is an essential requirement of both health professionals and people diagnosed with diabetes. The development and implementation of guidelines and protocols within healthcare settings is intended to reduce the risk faced by this patient cohort.

The complications associated with diabetes foot problems should provide a forceful reminder that vigilance and access to specialist care are key requirements in reducing these risks.