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Diabetes-related foot amputations: a preventable disaster

You don't have to be an expert in diabetes to help save patient's limb. Better training of non-specialists and improved foot care in all settings could turn back the rising tide of amputations.
diabetes

You don't have to be an expert in diabetes to help save a patient's limb. Better training of non-specialists and improved foot care in all settings could turn back the rising tide of amputations.

When Ruth Miller looks at the latest figures on diabetes-related foot amputations, she admits that her heart sinks a little. As Poole NHS Foundation Trusts lead diabetes nurse, she knows the devastation the disease can wreak on peoples feet. Yet this message doesnt seem to be getting through.

There are some hospitals with very good services, and others less good, she says. And the same goes for GP practices. I know services are stretched, but people should have their feet checked.

Its important for the

...

You don't have to be an expert in diabetes to help save a patient's limb. Better training of non-specialists and improved foot care in all settings could turn back the rising tide of amputations.


People with diabetes should have an annual foot check, and about a third should
receive preventative and protective foot care. Picture: Science Photo Library

When Ruth Miller looks at the latest figures on diabetes-related foot amputations, she admits that her heart sinks a little. As Poole NHS Foundation Trust’s lead diabetes nurse, she knows the devastation the disease can wreak on people’s feet. Yet this message doesn’t seem to be getting through.

‘There are some hospitals with very good services, and others less good,’ she says. ‘And the same goes for GP practices. I know services are stretched, but people should have their feet checked.

‘It’s important for the individual – complications can affect people’s family relationships and ability to work. But it also makes sense for the NHS and the wider economy.’

Preventable 

A recent Diabetes UK analysis of Public Health England data shows that around 20 foot amputations take place each day, and that numbers are increasing. The charity estimates that 4 in 5 of these amputations are preventable, but that people don’t have access to services such as a multidisciplinary specialist foot team.

There has been some improvement since Diabetes UK launched its Putting Feet First campaign in 2012, says the charity’s policy manager Nikki Joule. The rate of major amputations has fallen and more areas have introduced a proper diabetes care pathway, with a focus on feet. But this is far from universal, and access remains patchy.

Vital role 

About a third of hospitals still don’t have a multidisciplinary foot team, says Ms Joule. ‘People with diabetes should get an annual foot check, and about a third should be getting preventative and protective foot care, such as seeing a podiatrist regularly. But that doesn’t exist in a lot of areas.'

She adds: ‘The number of amputations has risen, which isn’t surprising as the number of people with diabetes is increasing.’

Ms Miller says this is a problem that requires action at all levels – and nurses have a vital role to play. 

‘The challenge is that care for the most complex patients with diabetes isn’t delivered by specialists,’ she says. ‘We’re not asking everyone to become an expert. But we are demanding that they have basic care competencies.’

Ms Miller has focused on diabetes care, including foot care, at her trust. So far, about 1,000 acute staff, including physiotherapists, occupational therapists, doctors and nurses, have been trained in the basics of diabetes care, along with community nurses.

Training includes using the Ipswich Touch Test, which determines whether people have reduced sensation in their feet and provides information on what to do and where and when to refer on. There is also a version for patients to do at home, available on the Diabetes UK website.

Keeping it simple 

The Poole Trust’s project also involves a 10-point training sheet, which gives a basic run-down of what staff need to know about diabetes, including foot care.

Qualitative research suggests the project has triggered a big improvement in staff confidence in looking after people with diabetes. Early indications from the trust’s latest inpatient care audit are that there are fewer medication and adverse events, and the number of foot checks have increased. ‘When we crunch the numbers we’ll have quantitative evidence too,’ says Ms Miller.

‘What we’re trying to do is turn a small light on in a dark room, to keep it simple, but to train people in what they need to know.

Support from the top

‘We want people to look at patients’ feet, whether it’s in the emergency department in the community or in GP practices.

‘We want everyone to know, for example, that if someone who has diabetes is admitted to hospital, and they have a foot problem, they are at high risk of developing ulcers.’

Having moved to Dorset from the Royal Free in London, where she was also instrumental in improving diabetes foot care, Ms Miller has been impressed with the support she has received since starting at the smaller trust.

‘We’ve been asked to present to the board of directors and there’s real buy-in from the top of the organisation,’ she says. 

Despite progress, preventable complications of diabetes are still an issue. ‘I saw a young man with retinopathy yesterday,’ she says. ‘It was caused by high blood pressure and blood sugar. We got him stabilised, but he was at risk of serious problems with his sight. It’s the same with foot care.’

Ms Joule has a simple message for all nurses. ‘We want people to think diabetes, think feet,’ she says. ‘It’s everyone’s business, and it really matters.’

Case study: ‘Foot problems messed up my retirement’

Retired civil servant Robert Carew Hunt was diagnosed with type 2 diabetes in 2002. A blood glucose test ordered by a vigilant practice nurse found his blood glucose levels were extremely high.

At the time he already had an ulcer on his big toe, which later had to be amputated, as did another toe on the same foot.

Despite excellent care from the podiatry clinic at St George’s Hospital, Tooting, Mr Carew Hunt continued to have problems with both feet and this year made the difficult decision to have his left leg amputated below the knee.

‘I’d had problems with my right foot, and my left foot had always been my good foot,’ he says. ‘But I continued to get ulcers, and bouts of cellulitis, which as well as being very painful meant that I lost any progress I’d made with the foot.

‘By the time I decided to have the operation, it didn’t really feel like a foot, it was a swollen lump. The decision was a no-brainer, as I felt I’d be able to get about again.’

For the 3 years before the operation, Mr Carew Hunt's mobility was severely restricted. He describes his foot problems as having ‘messed up his retirement.’

‘Living with foot problems like this is very difficult, but I’ve been lucky with the care I’ve had,’ he says. ‘I know other people with diabetes who don’t even have access to specialist podiatry. It’s a real postcode lottery, and I don’t think that’s right.’

After the operation, rehabilitation and the fitting of a prosthetic leg, Mr Carew Hunt is making good progress. ‘I hope this will give me a new lease of life,’ he says.

Facts on diabetes
  • According to the latest analysis by Diabetes UK, the number of diabetes-related foot amputations in England has reached an all-time high of 20 per day.
  • Public Health England figures show that the number of diabetes-related foot amputations is now 7,370 a year compared to the previous figure of 7,042, and the variation between the best and worst performing areas continues to widen.
  • Diabetic foot disease remains the most common cause of diabetes-related hospital admission.
  • Diabetes UK says that 4 out of 5 of diabetes-related foot amputations are preventable.
  • The Putting Feet First campaign has 3 main aims: that people with diabetes know how to look after their feet and what to expect from their health service; local health services provide an integrated footcare pathway; and healthcare professionals are more aware of the risk of diabetic foot disease and the need for annual checks.
  • There are 3.5 million people diagnosed with diabetes in the UK and an estimated 549,000 have the condition but don’t know it. Most of these have type 2 diabetes.

 


Jennifer Trueland is a freelance health writer

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