Quality Standards for Diabetes Care Toolkit

Implementation advice

Refer to SIGN (2010) Management of Diabetes section 11 Management of Diabetic Foot Disease.
Access to foot care services is the basic expected care for people with diabetes.
Annual foot screening to ascertain risk is the basis of an integrated foot protection programme. SIGN suggests at least annual screening from diagnosis of diabetes is appropriate. Additionally they suggest foot screening data should be entered into an online screening tool to provide automatic risk stratification and a recommended management plan, including patient information. Refer to the Diabetes Foot Screening and Risk Stratification Tool developed by NZSSD – PodSIG (2014).
The BPAC NZ (2010) screening table suggests the following regarding the recommended frequency of examination for diabetic foot complications:

confirmed diabetes – as soon as possible after diagnosis and annually thereafter

first signs of foot problems identified or patient at high risk – every three to six months

active ulceration and infection or very high risk – regular podiatry and multidisciplinary team assessment until active problems are resolved and then every one to three months.

A clear pathway of care should be in place from screening, through to general podiatry care and monitoring in the community, to accessing specialist podiatry care in the hospital setting. Wrap-around services including vascular, orthopaedic, nursing and allied health should be included in this pathway. Patients seen through an emergency department (ED) and or ward admissions with foot ulceration should have a referral to specialist podiatry services. Access can be via medical practices and/or community podiatry with patients being graded and referred as appropriate.
Funding should be in place for individuals to receive targeted foot care including:

assessment and provision of services by a podiatrist on referral from a GP practice if a need is identified at an annual foot check (using screening tool)

ongoing podiatry care and assessment where a need is identified by a podiatrist (access to Tier 3 service for active foot problems)

access to ongoing podiatry care and assessment on discharge from Tier 3 service post active foot condition where deemed appropriate by the podiatrist

access to footwear and offloading devices is important and needs to be timely.

Individuals identified with ‘high risk’ feet require ongoing access to funded podiatry services. Individuals who are identified as having ‘high risk’ feet via the screening tool need access to funded podiatry services on an ongoing basis, because as time progresses they often require more intensive input. Individuals with ‘high risk’ feet do not have isolated episodes of care, but require more intensive and lifelong management (Rice et al 2014).
All individuals with diabetes should receive written and oral advice about:

how diabetes can affect feet

why it is important to assess foot risk and regularly screen feet

how to care for feet and when to seek help (SIGN 2010).

People with active foot disease should be referred to a MDT (Tier 3 service) – podiatrist, diabetes physician, orthotist, diabetes nurse specialist, vascular surgeon, orthopaedic surgeon, radiologist, wound specialist nurse, occupational therapist, etc.
Refer to the tool developed by NZSSD – PodSIG (2014). This paper also provides a good general overview of an in-depth foot assessment (Boulton et al 2008).
Refer to Ministry of Health DHB Allied health services podiatry for people with at risk/high risk feet tier level 3 service specification (and tiers 1 and 2).
Many referral processes are in place via Health Navigation tools available in medical practices.
Refer to SIGN (2010) section 11 Management of diabetic foot disease: www.sign.ac.uk/pdf/sign116.pdf