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Improving clinical and quality outcomes for people with diabetic foot disease

Diabetic Foot Australia (DFA) and the Australian Diabetes Society (ADS) recently endorsed the 2019 IWGDF Guidelines. With 87 evidence-based practice recommendations and 44 future research priorities across 8 chapters and 194 pages, the new 2019 international guidelines contain everything known to (wo)man on prevention, offloading, peripheral artery disease, infection, wound healing and ulcer classification.

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Improving clinical and quality outcomes for people with diabetic foot disease

Diabetic Foot Australia (DFA) and the Australian Diabetes Society (ADS) recently endorsed the 2019 IWGDF Guidelines. With 87 evidence-based practice recommendations and 44 future research priorities across 8 chapters and 194 pages, the new 2019 international guidelines contain everything known to (wo)man on prevention, offloading, peripheral artery disease, infection, wound healing and ulcer classification.

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the national problem

Diabetes-related foot disease is defined as ulceration, infection, ischaemia or neuro-arthropathy of the foot in people with diabetes. People at-risk of diabetes-related foot disease are defined as those with diabetes who have developed peripheral neuropathy, peripheral arterial disease or have a history of previous foot disease.

Diabetes-related foot disease (DFD) is globally-recognised as the leading cause of diabetes-related hospitalisations and amputation, with mortality rates comparable to many cancers. It poses a major burden on an individual’s quality of life, significant risks to their morbidity and mortality, and increases their healthcare costs.

 

In 2019 on any given day in Australia

0

Australians are living with diabetic foot disease

0

Australians are living with a diabetes-related amputation

0

Australians will undergo a diabetes-related amputation

Foot Care in Practice

Clinical recommendations for improving diabetic foot ulcer patient outcomes

Foot problems in diabetes are among the most serious complications of diabetes mellitus. Foot problems are a source of major suffering and costs for the patient, and they also place a considerable financial burden on healthcare and society in general. Foot care in practice needs a strategy that includes prevention, patient and staff education, multi-disciplinary treatment of foot ulcers, and close monitoring of people’s feet. Such practice may prevent diabetic foot ulcers and their sequelae like amputation or prolonged hospitalization.

 

Pathophysiology

Diabetic foot ulcers frequently result from a patient simultaneously having two or more risk factors, with diabetic peripheral neuropathy playing a central role. This neuropathy leads to an insensitive and sometimes deformed foot, often causing an abnormal walking pattern. In people with neuropathy, minor trauma (e.g., from ill- fitting shoes, walking barefoot or an acute injury) can precipitate ulceration of the foot. Loss of sensation, foot deformities, and limited joint mobility can result in abnormal biomechanical loading of the foot. This produces high pressure in some areas, to which the body responds with thickened skin (callus). This leads to a further increase of the abnormal loading, often with subcutaneous haemorrhage and eventually ulceration. Whatever the primary cause, if the patient continues walking on the insensitive foot it impairs wound healing.

 

 

Prevention

There are five key elements that underpin prevention of foot problems:

1.     Assess all people with diabetes and stratify their risk of developing foot complications

2.     Regular inspection and examination of the at-risk foot

3.     Education of patient, family and healthcare providers

4.     Routine wearing of appropriate footwear

5.     Treatment of pre-ulcerative signs

 

Diabetic Foot Ulcer Treatment

Foot ulcers will heal in the majority of patients if the clinician bases treatment on the principles outlined below. However, even optimum wound care cannot compensate for continuing trauma to the wound bed, or for inadequately treated ischemia or infection. Patients with an ulcer deeper than the subcutaneous tissues often require intensive treatment, and, depending on their social situation, local resources and infrastructure, they may need to be hospitalised.

There are seven key elements that underpin treatment of diabetic foot ulcers, whereby it is needed for these elements to be delivered by a multidisciplinary foot care team.

1.     Relief of pressure and protection of the ulcer

2.     Restoration of skin perfusion

3.     Treatment of infection

4.     Metabolic control and treatment of co-morbidity

5.     Local wound care

6.     Education for patient and relatives

7.     Prevention of recurrence

2018 Australian Guideline

on footwear for people

with diabetes

Published in the Journal of Foot and Ankle Research, this guideline contains 10 key recommendations to guide health professionals in selecting the most appropriate footwear to meet the specific foot risk needs of an individual with diabetes. This footwear guideline updates the 2013 Australian practical guideline on the provision of footwear for people with diabetes.

for all people with diabetes

Female nurse helping senior patient to get up from bed
Wear appropriate footwear that fits, protects and accommodates the shape of their feet
This includes having adequate length, width, and depth (and consequently adequate girth, i.e. adequate volume).  A particular emphasis may need to be placed on the toe box of the shoe that should be consistent with the shape of the forefoot and toes of the person. An enclosed heel with a stabilising heel counter is recommended. Openheel footwear can result in direct trauma injury to the heel and may require a person to claw their toes in order to keep the footwear fixed to their feet, further increasing the repetitive stress under their forefoot, and in turn the risk of ulceration. 
Female nurse helping senior patient to get up from bed
Wear Socks to reduce shear and friction 
People with diabetes should be advised to always wear socks within their footwear, to reduce shear and friction. Further, advise people with diabetes to wear socks made of mostly natural materials (to prevent undue moisture accumulation), that are seamless (to prevent undue repetitive stresses) and do not have elasticated cuffs (to prevent undue oedema).
Female nurse helping senior patient to get up from bed
Educate on the importance of wearing appropriate footwear
People with diabetes, their relatives and caregivers should also be educated on the importance of appropriate footwear to prevent foot ulceration, and the importance of adherence to wearing it. Also, the importance of annual foot screens to assess their risk of foot ulceration, and to return for further footwear advice if their foot risk status increases should be emphasised.

For people at intermediate or high-risk of foot ulceration

Female nurse helping senior patient to get up from bed
Obtain Footwear from trained professionals 
Due to the complexities in accommodating the foot and the importance of preventing foot ulceration, people with diabetes should be instructed to obtain their footwear from an appropriately trained professional with demonstrated competencies in footwear fitting for this population, to ensure the footwear meets all requirements. People who develop diabetic peripheral neuropathy lose protective sensation and their ability to feel pressure and pain. Thus, they may have a tendency to purchase poorly fitting footwear in an attempt to stimulate some sensory feedback. They also do not feel abnormally high repetitive stress (pressure or shear) caused by inappropriate footwear or walking barefoot and are more likely to develop pre-ulcerative lesions (e.g. callus or blisters) that subsequently lead to ulceration.
Female nurse helping senior patient to get up from bed
Wear appropriate footwear at all times both indoors and outdoors
Because of their increased risk, people with diabetes at intermediate- or high-risk of foot ulceration should be motivated to wear their footwear at all times, both indoors and outdoors.  The indoor footwear should meet the same requirements with regard to adequacy of fit and offloading, but compromises might be made in the materials used in manufacture, as it is likely to experience less “wear-and-tear” compared to footwear used outdoors.
Female nurse helping senior patient to get up from bed
Check footwear before wearing and check feet after wearing shoes
People with peripheral neuropathy have lost the ability to feel pressure, pain or foreign objects. They, or their relatives and caregivers, need to be motivated to check their footwear each time before they are put on, to ensure that there are no foreign objects in the footwear or penetrating the soles. Furthermore, they should also check their feet each time their footwear is removed, to ensure that there are no signs of abnormal pressure, shear, trauma or ulceration.

For people with a foot deformity or previous diabetic foot ulceration

Female nurse helping senior patient to get up from bed
For a foot deformity consider prescribing medical grade footwear
When a foot deformity, pre-ulcerative lesion is present, off-the-shelf footwear is not likely to be appropriate. Prescribing medical grade footwear (pre-fabricated or custom-made needs to be considered, to accommodate the altered biomechanics.
Female nurse helping senior patient to get up from bed
For a healed plantar ulcer prescribe medical grade footwear that reduces plantar pressure
For people with a healed plantar foot ulcer, off-the-shelf footwear is most unlikely to be sufficient. Medical grade footwear (pre-fabricated or custom-made) with a demonstrated plantar pressure reducing effect at high-risk areas, including the previous ulcer location, needs to be prescribed.
Female nurse helping senior patient to get up from bed
Review prescribed footwear every 3 months
Both the foot and the footwear change shape over time. Prescribed footwear, and custom-made orthoses or insoles, should be reviewed every three months to ensure it still fits, protects and supports the foot.

For people with a foot deformity or previous diabetic foot ulceration

Female nurse helping senior patient to get up from bed
Prescribe appropriate offloading devices - not footwear
Footwear is not specifically recommended to treat a plantar diabetic foot ulcer in the IWGDF guidelines; in contrast offloading devices are recommended and necessary to heal these ulcers. We strongly recommend that any health professional treating a patient with a plantar diabetic foot ulcer ensures their patient has an appropriate offloading device.
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Tackling

the

National

Burden

Diabetic Foot Australia has established the Australia Diabetes-Related Foot Disease Strategy 2018-2022 to guide Australia’s efforts toward reducing the burden of Diabetic foot disease in this country by prioritising:

  • Access to affordable and effective care

  • Provision of safe quality care

  • Research and development to improve patient outcomes

Written by Diabetic Foot Australia with input from various national and state peak bodies, interdisciplinary foot disease services and individual experts from the Australian diabetic foot disease (DFD) community, the aggregated feedback and DFA’s response can be found here

The following nine goals are formulated within these priorities, each with their potential areas for action and measures to keep track of their progress. We look forward to the uptake of this strategy, and monitoring the positive steps the Australian DFD community will take on the pathway towards ending avoidable amputations in a generation.

Female nurse helping senior patient to get up from bed

All people with diabetes should have access to annual DFD screening and understand their risk of developing diabetes-related foot disease.

Female nurse helping senior patient to get up from bed

All people at-risk of diabetes-related foot disease should have access to preventative evidence-based healthcare from appropriately trained health professionals.

Female nurse helping senior patient to get up from bed

All people with diabetes-related foot disease should have access to evidence-based
healthcare from specialised interdisciplinary foot disease services.

Female nurse helping senior patient to get up from bed

All health professionals and specialised interdisciplinary foot disease services caring for people with, or at-risk of, diabetes-related foot disease should demonstrate they meet minimum Australian evidence-based standards.

Female nurse helping senior patient to get up from bed

All health service regions should report their diabetes-related foot disease outcomes annually to monitor progress towards ending avoidable amputations.

Female nurse helping senior patient to get up from bed

Australian national diabetes-related foot disease guidelines should continually reflect the most up-to-date robust evidence to guide standards for healthcare provision and outcome reporting.

Female nurse helping senior patient to get up from bed

An “Australian Research Agenda for Diabetes-Related Foot Disease” should be developed and endorsed to guide national research priorities.

Female nurse helping senior patient to get up from bed

An “Australian Diabetes-Related Foot Disease Clinical Trials Network” should be established to provide national research support and leadership.

Female nurse helping senior patient to get up from bed

Investments in research and development for diabetes-related foot disease should be
proportionate to the national health burden caused by the disease.

Arming your patients with knowledge

For people with diabetes, feet are often over-looked as the management of other aspects of diabetes takes higher priority. With over 50,000 Australians living with diabetic foot disease every day, Diabetic Foot Australia has developed the handy Daily Foot Checklist for people with diabetes to incorporate into their daily lives.

 

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