Evidence categories (I-IV) and recommendation grades (A-D) are defined at the end of the "Major Recommendations" field.
In addition to these evidence-based recommendations, the guideline development group also identifies recommendations drawn from the National Institute for Clinical Excellence (NICE) 2003 technology appraisal of patient education models for diabetes.
Foot Care in Diabetes
Foot Care: General Management Approach
D - Effective care involves a partnership between patients and professionals, and all decision making should be shared.
D - The role that any informal carers of the person with diabetes have in providing care and receiving information to allow them to fulfill this role should be discussed with the person with diabetes, and any decisions about this should be that of the person with diabetes.
A - Arrange recall and annual review as part of ongoing care.
D - Healthcare professionals and other personnel involved in the assessment of diabetic feet should receive adequate training.
A - As part of annual review, trained personnel should examine patients' feet to detect risk factors for ulceration.
B - To improve knowledge, encourage beneficial self-care, and minimise inadvertent self-harm, healthcare professionals should discuss and agree with patients a management plan that includes appropriate foot care education. (Refer to Appendix 26 of the original guideline document about issues and topics that might be covered in patient education.)
C - Extra vigilance should be used for people who are older (over 70 years of age), have had diabetes for a long time, have poor vision, have poor footwear, smoke, are socially deprived, or live alone.
D - Healthcare professionals may need to discuss, agree, and make special arrangements for people who are housebound or living in care or nursing homes to ensure equality of access to foot care assessments and treatments.
NICE 2003 - Structured patient education should be made available to all people with diabetes at the time of initial diagnosis, and then as required on an ongoing basis, based on a formal, regular assessment of need.
A - Offer patient education on an ongoing basis. (Refer to Appendix 26 of the original guideline document for issues and topics that might be covered in patient education.)
B - Use different patient education approaches until optimal methods appear to be identified in terms of desired outcomes.
Foot Examination and Monitoring
A - Regular (at least annual) visual inspection of patients' feet, assessment of foot sensation, and palpation of foot pulses by trained personnel is important for the detection of risk factors for ulceration.
A - Examination of patients' feet should include:
- Testing of foot sensation using a 10 gram monofilament or vibration (using biothesiometer or calibrated tuning fork)
- Palpation of foot pulses
- Inspection for any foot deformity
- Inspection of footwear
C - Monofilaments should not be used to test more than ten patients in one session and should be left for at least 24 hours to "recover" (buckling strength) between sessions.
C - Classify foot risk as:
- Low current risk (normal sensation, palpable pulses)
- At increased risk (neuropathy or absent pulses or other risk factor)
- At high risk (neuropathy or absent pulses plus deformity or skin changes or previous ulcer)
- Ulcerated foot
D - Self-monitoring and inspection of feet by people with diabetes should be encouraged.
Care of People at Low Current Risk of Foot Ulcers (Normal Sensation, Palpable Pulses)
B - To improve knowledge, encourage beneficial self-care, and minimise inadvertent self-harm, healthcare professionals should discuss and agree with patients a management plan that includes appropriate foot care education (Refer to Appendix 26 of the original guideline document for issues and topics that might be covered in patient education.)
Care of People at Increased Risk of Foot Ulcer (Neuropathy or Absent Pulses or Other Risk Factor)
D - Patients with risk factors for ulceration should be referred to a foot protection team (a team with expertise in protecting the foot; typically, members of the team include podiatrists, orthotists, and foot care specialists).
D - Arrange regular review, 3 to 6 monthly, by a foot protection team.
D - At each review:
- Inspect patient's feet.
- Review need for vascular assessment.
- Evaluate footwear.
- Enhance foot care education. (Refer to appendix 26 for information about issues and topics that might be covered in patient education.)
Care of People at High Risk of Foot Ulcers (Neuropathy or Absent Pulses Plus Deformity or Skin Changes or Previous Ulcer)
A - Patients at high risk for ulceration should be referred to a foot protection team.
D - Arrange frequent review, 1 to 3 monthly, by a foot protection team.
At each review:
- A - Inspect patient's feet.
- D - Review need for vascular assessment.
- D - Evaluate provision and provide appropriate:
- Intensified foot care education
- Specialist footwear and insoles
- Skin and nail care
D - Ensure special arrangements for access to the foot protection team for those people with disabilities or immobility.
Care of People with Foot Ulcers
D - For a new foot ulcer, urgent (within 24 hours) assessment by an appropriately trained health professional should be arranged.
D - Ongoing care of an individual with an ulcerated foot should be undertaken without delay by a multidisciplinary foot care team.
D - The multidisciplinary foot care team should comprise highly trained specialist podiatrists and orthotists, nurses with training in dressing of diabetic foot wounds, and diabetologists with expertise in lower limb complications. They should have unhindered access to suites for managing major wounds, urgent inpatient facilities, antibiotic administration, community nursing, microbiology diagnostic and advisory services, orthopaedic/podiatric surgery, vascular surgery, radiology, and orthotics.
D - Patients who may benefit from revascularisation should be referred promptly.
C - Patients with non-healing or progressive ulcers with clinical signs of active infection (redness, pain, swelling, or discharge) should receive intensive, systemic antibiotic therapy.
D - In the absence of strong evidence of clinical or cost effectiveness, healthcare professionals should use wound dressings that best match clinical experience, patient preference, and the site of the wound, and consider the cost of the dressings.
D - Wounds should be closely monitored and dressings changed regularly.
B - Dead tissue should be carefully removed from foot ulcers to facilitate healing, unless revascularisation is required.
B - Total contact casting may be considered for people with foot ulcers unless there is severe ischaemia.
D - Currently, there is a lack of trial evidence on the use of the following interventions in the treatment of foot ulcers and they are not recommended: cultured human dermis (or equivalent), hyperbaric oxygen therapy, topical ketanserin, or growth factors.
B - For patients with foot ulcers or previous amputation, healthcare professionals could consider offering graphic visualisations of the sequelae of disease and providing clear, repeated reminders about foot care.
Care of People with Charcot Osteoarthropathy
D - People with suspected or diagnosed Charcot osteoarthropathy should be referred immediately to a multidisciplinary foot care team for immobilisation of the affected joint(s) and for long-term management of offloading to prevent ulceration.
Emergency Referral
D - Refer patients to a multidisciplinary foot care team within 24 hours if any of the following occur:
- New ulceration (wound)
- New swelling
- New discolouration (redder, bluer, paler, blacker, over part or all of foot).
Definitions
Evidence Categories
- Evidence from:
- meta-analysis of randomised controlled trials, or
- at least one randomised controlled trial
- Evidence from:
- at least one controlled study without randomization, or
- at least one other type of quasiexperimental study
- Evidence from non-experimental descriptive studies, such as comparative studies, correlation studies, and case-control studies
- Evidence from expert committee reports or opinions and/or clinical experience of respected authorities
Recommendation Grades
- Directly based on category I evidence
- Directly based on:
- Category II evidence, or
- Extrapolated recommendation from category I evidence
- Directly based on:
- Category III evidence, or
- Extrapolated recommendation from category I or II evidence
- Directly based on:
- Category IV evidence, or
- Extrapolated recommendation from category I, II or III evidence
