CLINICAL RISK REDUCTION


patients with neuropathy, in only 41 per cent had some effort been made to protect the foot. Of patients with current foot ulcers, 35 per cent had not been referred for treatment and 2.4 per cent of all foot ulcers had developed whilst the patient was in hospital. Similar findings were identified in an ongoing in-patient audit in English hospitals. Tere is clearly a need to improve on this. Frailty, malnutrition and foot deformity are also


important risk factors to consider for a hospital in-patient. Tis is particularly important if the patient has neuropathy. Although the whole foot is vulnerable, the heel is particularly susceptible for poorly mobile patients. Unfortunately, heel ulcers are the most difficult to resolve, and thus prevention is best.


What action to take Once patients at risk have been identified, what can be done about it? Within Scotland an initiative entitled CPR for feet has been developed to try and help healthcare professionals reduce the risk of patients developing foot ulceration. Tis involves checking (C) patients for visible problems and neuropathy, providing protection (P) for those at risk, and referring (R) those with active problems, such as ulcers or gangrene (see figure right). Checking the feet for problems includes removing all dressings, as this is frequently not undertaken. Dressings oſten cover a major problem, which usually gets worse if not attended to. A number of pressure-


relieving devices are available to avoid heel complications for


patients at risk. Tese include heel pillows, heel protection boots, repose


devices, PODUS boots, PRAFO or LEEDer splints and many more, which are usually available at orthotic departments. Pressure-relieving mattresses are another approach which may help. However, specific devices are usually preferable for patients at high risk of foot ulcers, although the two can be combined and may be especially useful for the frail patient who is also at risk of pressure sores. In summary, nearly all wards and residential or


nursing homes will have patients with diabetes who are at risk of amputation. Tis will be the case for about a third of all in-patients, and they are easily identified by asking them if they have had a previous foot ulcer, checking their feet for ulcers (including under any dressing) and looking to see if they have numb feet, e.g. by using the touch the toes test. “At risk” patients should be provided with pressure relieving devices, and such patients should have their feet checked regularly. It sounds simple but frequently these measures are not taken in


SPRING 2015 References


1. Leese GP, Cochrane L, Mackie AD, Stang D, Brown K, Green V. Measuring the accuracy of different ways to identify the ‘at risk’ foot in routine clinical practice Diab Med 2011; 28: 747-754.


2. Abbott CA, Carrington AL, Ashe H, Bath S, Every LC, Griffiths J, et al. The North West Diabetes Care Foot study: incidence of, risk factors for, new diabetic foot ulceration in a community- based cohort Diab Med 2002; 19: 377-84


3. National audit of foot care in Scotland (2014). Diabetes in Scotland http:// diabetesinscotland.org.uk/ Default.aspx


Patients with diabetes at greatest risk of foot ulceration and amputation


MAJOR RISKS


• Patients who have had previous ulcers or amputations


• Patients with neuropathy


Although prior ulcer and neuropathy are both risk factors, in most studies history of a prior ulcer predicts the onset of foot ulcer 10 times greater than the presence of neuropathy


OTHER RISKS


• Patients with absent pulses


• Patients with structural foot abnormality


• Patients with nephropathy or other renal disease


• Frail patients


practice, thus putting patients at risk of unnecessary amputations and clinicians at risk of unnecessary litigation.


Key points • About 20 per cent of hospital in-patients and nursing home residents have diabetes.


• Around a third of these will have neuropathy and be at risk of foot ulceration and amputation.


• History of prior ulcer is the strongest predictor of future ulcer – so ask!


• Always look under a dressing for the presence of a current ulcer.


• A number of pressure-relieving devices are available for those at risk.


17


FiGurE PuBliSHED WiTH kiND PErMiSSioN oF THE ScoTTiSH GovErNMENT


Page 1  |  Page 2  |  Page 3  |  Page 4  |  Page 5  |  Page 6  |  Page 7  |  Page 8  |  Page 9  |  Page 10  |  Page 11  |  Page 12  |  Page 13  |  Page 14  |  Page 15  |  Page 16  |  Page 17  |  Page 18  |  Page 19  |  Page 20  |  Page 21  |  Page 22  |  Page 23  |  Page 24