Diabetic Foot ProblemsImplementing NICE guidance

March 2011

NICE clinical guideline 119

What this presentation covers

Background

Epidemiology

Scope

Priorities for implementation

Costs and savings

Discussion

Find out more

NICE Quality Standard

Background

• Diabetes is one of the biggest health challenges facing the UK today

• Diabetic foot problems are the most common cause of non-traumatic limb amputation

• Diabetic foot problems have a significant financial impact on the NHS and a significant impact on patients’ quality of life. All Images in this presentation are reproduced

with kind permission off Dr. Tony Coll, University of Cambridge

Epidemiology

• In 2010, 2.3 million people were registered as having diabetes

• Life expectancy can be reduced by up to 15 years for people with diabetes

• 15% of people with diabetes will have a foot ulcer at some point in their lives

• Diabetes is the most common cause of non-traumatic limb amputation.

Scope

• Key components and organisation of patient hospital care for diabetic foot problems from hospital admission to discharge planning

• Assessment and investigation of diabetic foot problems

• Clinical and cost-effectiveness of treatments for diabetic foot problems.

• Each hospital should have a care pathway for patients with diabetic foot problems who require inpatient care

• The multidisciplinary foot care team should consist of healthcare professionals with the specialist skills and competencies necessary to deliver inpatient care for patients with diabetic foot problems.

Multidisciplinary foot care team

The patient should have a named contact to follow the inpatient care pathway and be responsible for:

– offering patients information about their diagnosis and treatment, and the care and support that they can expect

– communicating relevant clinical information, including documentation prior to discharge, within and between hospitals and to primary and/or community care.

Patient information and support

• Remove the patient’s shoes, socks, bandages and dressings and examine their feet

• If the following are present, obtain urgent advice from an appropriate specialist:

– Charcot arthropathy (which should be considered if deformity, redness or warmth are present)

– systemic sepsis – deep seated infection – limb ischaemia

Initial examination and assessment

• Refer the patient to the multidisciplinary foot care team.

• 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.

Care within 24 hours

• If osteomyelitis is suspected and initial X-ray does not confirm its presence, use magnetic resonance imaging (MRI)

• If MRI is contraindicated, white blood cell (WBC) scanning may be performed instead.

Investigation of suspected diabetic foot infection

Management of diabetic foot infection

• Each hospital should have antibiotic guidelines for the management of diabetic foot infections.

• When choosing wound dressings take into account:

– clinical assessment of the wound – patient preference – clinical circumstances– which wound dressing has the

lowest acquisition cost.

Management of diabetic foot ulcers

Costs and savings

The guideline on the inpatient management of diabetic foot problems is unlikely to result in a significant change in resource use in the NHS. However, recommendations in the following areas may result in additional costs/savings depending on local circumstances:

• Multidisciplinary foot care team• Care within 24 hours • Investigation of suspected diabetic foot infection• Management of diabetic foot ulcers

Discussion

• To what extent do local arrangements compare with the guideline recommendations?

• What should we stop doing as a result of this guideline?

• What are the training implications for staff to support implementation of this guideline?

• What are the local cost implications of implementing the guideline?

Find out more

Visit www.nice.org.uk/guidance/CG119 for:

•the guideline •the quick reference guide•‘Understanding NICE guidance’•costing statement•audit support

NICE Quality Standard

Diabetes – Statement 10

Quality standards

A quality standard is a set of specific, concise statements that:

• act as markers of high-quality, cost-effective patient care across a pathway or clinical area, covering treatment or prevention

• are derived from the best available evidence and produced collaboratively with the NHS and social care, along with their partners and service users.

Diabetes quality standard

• The management of diabetes draws on many areas of healthcare management.

• The quality standard describes markers of high-quality, cost-effective care that, when delivered collectively, should contribute to improving the effectiveness, safety and experience and of care for adults diabetes.

• The quality standard consists of 13 quality statements.

Quality statement 10: ‘At risk’ foot

Each of the quality statements may be of interest to service providers, healthcare professionals, commissioners and people with diabetes.

Quality statement 10: ‘At risk’ foot

Quality statement:

People with diabetes with or at risk of foot ulceration receive regular review by a foot protection team in accordance with NICE guidance, and those with a foot problem requiring urgent medical attention are referred to and treated by a multidisciplinary foot care team within 24 hours.

Quality statement 10: ‘At risk’ foot

Quality measure:

•Evidence of local arrangements to ensure that people with diabetes with or at risk of foot ulceration receive regular review by a foot protection team in accordance with NICE guidance.

•Evidence of local arrangements to ensure that people with diabetes with a foot problem requiring medical attention are treated by a multidisciplinary foot care team within 24 hours.

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