The Diabetic Foot

For all people with diabetes, use the ‘CPR for Feet’ approach:

C- Check

1. Is there an active wound?
2. Is skin integrity at risk (immobility, oedema, infection etc.)?
3. Does the person have neuropathy? (see ‘Testing for neuropathy’ below)
4. Does the person have evidence of ischaemia or absent foot pulses?
5. Has the person had a previous ulcer or amputation?

P- Protect

1. Protect feet that are increased risk of injury.
2. Consider inflatable (Repose™) boots to reduce pressure on heels. NB These are designed for use in bed only, not whilst mobilising
3. Check footwear is appropriate and discourage mobilising barefoot
4. Educate patient and inform nursing colleagues that patient is at increased risk of pressure injury and encourage changes in position/avoidance of pressure e.g. from end of bed or bed side rails
5. Check feet regularly and seek advice if injury occurs

R- Refer

1. Refer all patients with diabetes and an active foot wound to Podiatry for further assessment by emailing:  [email protected]/Tel: 01387 220031 (Mon-Fri)
2. Consider using the SINBAD scoring system to aid triage of referrals (Highest Score = 6):

Refer urgently to Vascular team at University Hospital Hairmyres (see Vascular section) if:

1. Suspected acute diabetic foot sepsis
2. Acute digital or limb ischaemia
3. Acute on chronic limb-threatening ischaemia (increasing rest pain, worsening gangrene/necrosis or ulceration)
4. See Vascular Referrals Page for more information

Acute Diabetic Foot Sepsis

1. Consider acute diabetic foot sepsis in a person with diabetes who has new or deteriorating foot wounds associated with systemic illness, deterioration or failure to clinically improve as expected. This is a potentially limb and life threatening emergency which requires urgent senior Vascular referral and review.
2. Admit under care of General Surgery for assessment by Surgical middle grade.
3. Discuss with the on-call Vascular service at University Hospital Hairmyres (Consultant or SPR) via switchboard 01355 585000. Clinical photographs (with patient consent) are extremely useful in triaging referrals and monitoring progress
4. Collect blood and wound cultures and commence IV antibiotics as soon as possible prior to urgent transfer
   • Refer to the Sepsis bundle for additional guidance regarding management of sepsis
   • Refer to the NHS D&G Antimicrobial Handbook for antimicrobial advice: NHSD&G Empirical Antibiotic Guideline
5. If UHH Vascular team advises that the patient does not require immediate transfer:
   • Continue on appropriate antibiotics after blood and wound cultures
   • Refer to the local Vascular team (if available-limited cover) or continue liaising with UHH Vascular team as appropriate
   • Advise Podiatry team of admission on [email protected] or 01387 220031 (Mon-Fri)
   • Consider MR scanning to identify collection/abscess or osteomyelitis
   • Consider assessment of arterial sufficiency if not undertaken within last 6 months (Arterial Duplex or CT angiography).

Chronic Diabetic Foot infection

1. In most cases these patients will be treated and followed up as outpatients through the Diabetes Foot Clinic and associated Multidisciplinary Diabetic Foot Team meeting.
2. Patients may be admitted semi-electively for intravenous antibiotic therapy if unsuitable for OPAT; these patients will usually be admitted under the care of the Diabetes team.
3. Refer new patients with diabetes and an active foot wound to Podiatry/Diabetes Foot Clinic for further assessment as above, by emailing:  [email protected]/Tel: 01387 220031 (Mon-Fri)
4. Consider clinical photographs (with patient consent) and use the SINBAD scoring system to aid triage of referrals (see above).

Testing for Neuropathy in a Person with Diabetes

1. Ideally, testing should be undertaken using a 10g monofilament, if available:
2. Explain what you are going to do, and why
3. Apply the monofilament to a sensitive area of skin, e.g. the inside of the forearm or wrist, so the person is aware of the sensation they are supposed to feel
4. Test 5 sites on both feet
   • Plantar surface of the hallux and third toe
   • Plantar surfaces of 1st, 3rd and 5th metatarsal heads
5. Ask the person to close their eyes and say “yes” every time they feel pressure from the 10g monofilament on their foot
6. Place the monofilament at 90 degrees to the skin surface
7. Slowly push the monofilament until it has bent ~1cm (don’t jab)
8. Hold the monofilament in place for 1-2 seconds then slowly remove
9. If the patient does not respond, repeat twice, and if still no response, score as a negative response
10. A person with intact sensation should be able to detect at least 8 of the ten sites tested.      A score of 7 or less indicates peripheral neuropathy and loss of protective sensation.