Practice Guidelines

Inpatient management of diabetic foot problems: summary of NICE guidance

BMJ 2011; 342 doi: http://dx.doi.org/10.1136/bmj.d1280 (Published 23 March 2011) Cite this as: BMJ 2011;342:d1280
  1. T Tan, technical analyst1,
  2. E J Shaw, technical adviser1,
  3. F Siddiqui, assistant technical analyst1,
  4. P Kandaswamy, technical analyst, health economics1,
  5. P W Barry, consultant in paediatric intensive care2, honorary senior lecturer3,
  6. M Baker, consultant clinical adviser1
  7. on behalf of the Guideline Development Group
  1. 1Centre for Clinical Practice, National Institute for Health and Clinical Excellence, Manchester M1 4BD, UK
  2. 2University Hospitals of Leicester NHS Trust, Leicester LE5 4QF, UK
  3. 3Department of Child Health, University of Leicester, Leicester LE1 6TP
  1. Correspondence to: P W Barry pwb1{at}leicester.ac.uk

Foot problems that are related to diabetes (“diabetic foot” problems) affect a substantial number of people with diabetes, and 15% of people with diabetes will have a foot ulcer at some point in their lives. Diabetic foot ulcers precede more than 80% of amputations in people with diabetes and are the most common cause of non-traumatic limb amputation in the United Kingdom. Delays in diagnosis and management of diabetic foot problems increase morbidity and mortality, contribute to a higher amputation rate,1 and seriously affect patients’ quality of life—for example, by reducing mobility, leading to loss of employment, depression, and damage to or loss of limbs. Diabetic foot problems have a financial impact on the NHS through increased outpatient costs and bed occupancy and prolonged stays in hospital.

This article summarises the most recent recommendations in a short clinical guideline from the National Institute for Health and Clinical Excellence (NICE) on the management of diabetic foot problems in inpatients.2

Recommendations

NICE recommendations are based on systematic reviews of best available evidence and explicit consideration of cost effectiveness. When minimal evidence is available, recommendations are based on the Guideline Development Group’s experience and opinion of what constitutes good practice. Evidence levels for the recommendations are given in italic in square brackets.

Multidisciplinary foot care team

  • Each hospital should have a care pathway for patients with diabetic foot problems who need inpatient care. This care pathway is for people with diabetes who have (a) an ulcer, blister, or break in the skin of the foot; (b) inflammation or swelling of any part of the foot or any sign of infection; (c) unexplained pain in the foot; (d) fracture or dislocation in the foot, with no preceding history of substantial trauma; or (e) gangrene of all or part of the foot.3 The multidisciplinary foot care team should consist of healthcare professionals with the specialist skills and competencies necessary to deliver inpatient care to such patients. The team should normally include a diabetologist, a surgeon with the relevant expertise in managing diabetic foot problems, a diabetes nurse specialist, a podiatrist, and a tissue viability nurse, with access to other specialist services necessary for delivering the care outlined in the guideline. [Based on very low quality observational evidence and the experience and opinion of the Guideline Development Group (GDG)]

  • The role of the multidisciplinary foot care team is to:

    • -Assess and treat the patient’s diabetes, including interventions to minimise the patient’s risk of cardiovascular events, and any interventions for pre-existing chronic kidney disease or anaemia (refer to the NICE guidance on chronic kidney disease4 and on managing anaemia in people with chronic kidney disease5)

    • -Assess, review, and evaluate the patient’s response to initial medical, surgical, and diabetes management

    • -Assess the foot and determine the need for specialist wound care, debridement, pressure off-loading, and/or other surgical interventions

    • -Assess the patient’s pain and determine the need for treatment and access to specialist pain services

    • -Perform a vascular assessment to determine the need for further interventions

    • -Review the treatment of any infection

    • -Determine the need for interventions to prevent the deterioration and development of Achilles tendon contractures and other foot deformities

    • -Perform an orthotic assessment and treat to prevent recurrent disease of the foot

    • -Refer patients for physiotherapy where appropriate

    • -Arrange discharge planning, which should include arranging for the patient to be assessed and managed in primary and/or community care and followed up by specialist teams (refer to the NICE guidance on preventing and managing foot problems in type 2 diabetes6).

[Based on the experience and opinion of the GDG]

Information and support for patients

  • The patient should have a named contact—who may be a member of the multidisciplinary foot care team or someone with a specific role as an inpatient pathway coordinator—who will follow the inpatient care pathway and be responsible for:

    • -Offering patients information about their diagnosis, treatment, and the care and support they can expect

    • -Communicating relevant clinical information, including documentation before discharge, within and among hospitals and to primary and/or community care.

[Based on the experience and opinion of the GDG]

Initial examination and assessment

  • Remove the patient’s shoes, socks, bandages and dressings and examine their feet for evidence of the following and document any identified new and existing diabetic foot problems:

    • -Deformity

    • -Ulceration

    • -Inflammation and/or infection

    • -Ischaemia

    • -Neuropathy

    • -Charcot arthropathy.

[Based on very low quality observational evidence and the experience and opinion of the GDG]

  • Obtain urgent advice from an appropriate specialist if any of the following are present:

    • -Fever or any other signs or symptoms of systemic sepsis

    • -Clinical concern about possible deep seated infection (for example, palpable gas)

    • -Limb ischaemia.

[Based on the experience and opinion of the GDG]

Initial care (within 24 hours)

  • For a patient with diabetic foot problems being admitted to hospital or already in hospital but with newly detected diabetic foot problems, refer to the multidisciplinary foot care team within 24 hours of the initial examination of the patient’s feet. 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. [Based on very low quality observational evidence and the experience and opinion of the GDG]

Investigation of suspected diabetic foot infection

  • If osteomyelitis is suspected and initial radiography does not confirm the presence of osteomyelitis, use magnetic resonance imaging (if this is contraindicated, consider white blood cell scanning instead. [Based on moderate to low quality observational evidence]

Management of diabetic foot infection

  • Each hospital should have antibiotic guidelines for management of diabetic foot infection. [Based on the experience and opinion of the GDG]

Management of diabetic foot ulcers

  • When choosing wound dressings, the multidisciplinary foot care team should take into account their clinical assessment of the wound, the patient’s preference, and the clinical circumstances, and they should use wound dressings with the lowest acquisition cost. [Based on moderate to low quality evidence and the experience and opinion of the GDG]

  • Do not routinely use negative pressure wound therapy, but consider this in the context of a clinical trial or as rescue therapy (when the only other option is amputation).

  • Do not offer the following treatments for inpatient management, unless as part of a clinical trial:

    • -Dermal or skin substitutes

    • -Electrical stimulation therapy, autologous platelet-rich plasma gel, regenerative wound matrices, and deltaparin

    • -Growth factors (granulocyte colony stimulating factor, platelet derived growth factor, epidermal growth factor, and transforming growth factor β)

    • -Hyperbaric oxygen therapy.

[Based on moderate to low quality evidence]

Overcoming barriers

No agreed treatment pathways or service models exist for management of diabetic foot problems in inpatients. Current practice is thought to vary considerably, owing to a range of factors, including differences in the organisation of care from the time of acute care admission to discharge. However, prompt identification of diabetic foot problems, with appropriate treatment and referral, can reduce associated morbidity (including rates of amputation) and mortality.1

The NICE recommendations should facilitate the provision of timely and coordinated care for people with diabetic foot problems who are admitted to hospital (either for the primary diabetic foot problem or for other reasons but who also have a diabetic foot problems). They outline what care should be provided and how this should be organised, specifying key functions and members of the multidisciplinary team.

Further information on the guidance

This guideline was developed as a short clinical guideline. Short clinical guidelines give recommendations on part of a care pathway and are intended to allow rapid guideline development (over nine to 11 months) for areas of care for which the NHS needs urgent guidance. Short clinical guidelines are developed by the NICE technical team using the same methods as the existing standard NICE guidelines developed by the National Collaborating Centres (www.nice.org.uk).

As part of this process, the NICE technical team conducted a systematic search of the literature, assessed the quality of included studies, and synthesised and presented the evidence using the modified GRADE system (Grading of Recommendations Assessment, Development, and Evaluation). Cost effectiveness analyses were also conducted and considered as part of the evidence base. The Guideline Development Group (comprising patient and carer members and healthcare professionals in related fields, including diabetes, orthopaedic and vascular surgery, and podiatry) then discussed the evidence and drew up recommendations. The draft guideline underwent a rigorous validation process, which included inviting comments from stakeholder organisations. The development group took into consideration all comments when producing the final version of the guideline.

NICE has produced three different versions of the guideline: a full version containing all the evidence, the process undertaken to develop the recommendations, and all the recommendations; a quick reference guide; and a version for patients and the public. All these versions are available from the NICE website (http://guidance.nice.org.uk/CG119). Further updates of the guidance will be produced as part of NICE’s guideline development programme.

Future research/remaining uncertainties
  • What is the optimum environment for wound healing, and what is the optimum dressing to treat diabetic foot ulcers?

  • Is total contact foot casting clinically effective and cost effective compared with other forms of reducing pressure (off-loading) in patients with neuropathic ulcers?

  • What is the clinical and cost effectiveness of negative pressure wound treatment for diabetic foot problems?

  • What is the clinical and cost effectiveness of hyperbaric oxygen therapy for diabetic foot problems?

Notes

Cite this as: BMJ 2011;342:d1280

Footnotes

  • This is one of a series of BMJ summaries of new guidelines based on the best available evidence; they highlight important recommendations for clinical practice, especially where uncertainty or controversy exists.

  • The Guideline Development Group comprised Amanda Adler, Peter Barry (chair), Anthony Berendt, Mark Collier, Sunil Dhar, Nirupam Goenka, Katherine Hill, Gerry Rayman, Clifford Shearman, Louise Stuart, Gloria Travers. The NICE Short Clinical Guideline Technical Team comprised Lynda Ayiku, Mark Baker, Nicole Elliott, Michael Heath, Kim Jeong, Prashanth Kandaswamy, Victoria Kelly, Yaminah Rajput, Beth Shaw, Faisal Siddiqui, and Toni Tan.

  • Contributors: EJS drafted the summary, and TT, FS, PK, PWB, and MB reviewed the content. All authors approved the final version. PWB is the guarantor.

  • Funding: The Centre for Clinical Practice (Short Clinical Guidelines Technical Team), part of the National Institute for Health and Clinical Excellence, wrote this summary.

  • Competing interests: All authors have completed the Unified Competing Interest form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

  • Provenance and peer review: Commissioned; not externally peer reviewed.

References