CLINICAL RISK REDUCTION


The forgotten foot


Professor Graham Leese looks at pitfalls in identifying diabetics at risk of lower limb complications leading to amputation


T


HE national prevalence of diabetes is over five per cent, and recent studies indicate that about 20 per cent of all hospital in-patients


and nursing home residents have diabetes. Tis means that all involved in healthcare need to know something about diabetes, and in particular which patients with diabetes are “at risk” of coming to harm in the short-term. Diabetes is the commonest cause of lower


extremity amputation in the UK, usually as a result of the combination of two lower limb complications: neuropathy and peripheral vascular disease. Patients with neuropathy have numb feet and frequently do not notice or complain of problems. Several cases have been highlighted in the press over recent years involving individuals who developed foot ulceration whilst being an in-patient or in a nursing home and then went on to require a major amputation. Tis has oſten been a tragic sequelae to otherwise exemplary and successful in-patient care for some other condition. It is equally tragic in that it is oſten avoidable given a little knowledge, thought and some straightforward action. If diabetes features low in the medical “problem


list” this can potentially result in a greater risk for the individual patient, as clinicians may be distracted by other seemingly more important issues. In 85 per cent of cases, amputations start with a foot ulcer and the vast majority of these are preventable. However, which patients with diabetes are at greatest risk?


Identifying risk By far the strongest predictor of foot ulceration and amputation (see table) in a patient with diabetes is a history of a prior ulcer1


. Nearly all


patients are able to recall reliably whether they have had an ulcer or not – and it is very easy to ask! Other key risk factors include assessing whether the patient has neuropathy, absent foot pulses and nephropathy. Tis takes more effort but is relatively straightforward. Neuropathy is usually assessed by detecting


16


sensation to tuning fork vibration or 10g monofilaments. However, it is well recognised that these are oſten difficult to find on a busy ward. Although it is probably not as well validated as the aforementioned tests, a new test called “touch the toes”(http://goo.gl/M4086F) has been shown to be useful for detecting neuropathy (developed by Gerry Rayman and a team at Ipswich Hospital). Tis involves lightly touching the first and fiſth toe of the right and then leſt foot and then lightly touching the middle toe on each foot. If the patient cannot feel two or more toes being touched, they are deemed as having neuropathy. Research has found that the test correlates fairly well with monofilament testing and other neuropathy assessments and is easy and convenient for ward use. Asking the patient if they have had a previous


ulcer, and examination for neuropathy (aſter excluding existing ulcers) will identify most of the patients at high risk of developing foot ulcers and amputations. About four per cent of people with diabetes have had a previous ulcer, and about 20 per cent have numb feet in the community2


,


although this proportion is probably higher in the diabetes population found within a hospital setting. How well do we actually do in practice? An audit


in November 2013 of 1,040 patients in hospital with diabetes across nearly every health board in Scotland was not impressive3


. Of all in-patients on


any ward in Scottish hospitals only 44 per cent of patients had had their feet checked, and of those checked 36 per cent had neuropathy and were thus “at risk” of hospital-acquired ulceration. Of


SUMMONS


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