DIABETES FOOT REFERRAL PATHWAY Portsmouth and South East Hampshire

Revised Jan 2010

Refer to Podiatry Diabetes and Foot Ulcer Clinic, Paulsgrove Healthy Living Centre

For assessment by advanced practitioner and onward referral to specialist MDT Portsmouth City Patients:Versajet assessment and consider community IV antibiotics

Referral by letter / fax / telephone as indicated by the patient’s condition

Tel: 023 92381093 Fax: 023 92683013

For patients who are unable to attend clinic contact the local Podiatry Rapid Response

Vascular Team Rapid access clinic runs weekly on Friday am

for urgent cases Vascular Surgeons – Mr Payne, Mr Pemberton,

WC Whitbread, Mr Gibbs Referral by letter / fax / telephone as indicated by

the patient’s condition Tel: 023 92286400 Fax:023 92286263

Surgical Assessment Unit, Queen Alexandra Hospital

Contact SAU Coordinator for

admission to SAU Tel: 023 92286000

Bleep:0050

Patient systemically well:

• Initiate Empirical antibiotics (see over)

• Deep wound swab • Review Response to

antibiotics within 4-7

NON Infected

Patient systemically unwell • spreading

infection despite antibiotics

• deep abscess

Review response to treatment, refer accordingly to Vascular / Joint Medical Clinic / SAU

Refer to Podiatry Service

For individual assessment and management plan in line with NICE guideline.

Joint Medical / Podiatry clinic via the Diabetes Centre, Queen Alexandra Hospital (weekly Wed pm)

Referral by letter / fax to Dr Meeking from GP/Podiatry for: • Neuropathic non-healing ulcers (not requiring urgent

surgical opinion) • Foot condition requiring medical/glycaemic management • Suspected Charcot

Tel: 023 92286260 Fax: 023 92286791

INFECTED

PRIMARY CARE ANNUAL DIABETES FOOT ASSESSMENT

(DFA) • Diabetes Foot Assessment score of 10 or above • i.e if loss of 10g monofilament <8/10 each foot OR absent foot pulses OR history of foot ulcer

CRITICAL ISCHAEMIA Features include the following: • Discoloration of toes (pale,

dusky, black) • Signs of necrosis • Pain at rest (often at night) • Cold • Diminished / absent pulses

FOOT ULCERATION

HOT SWOLLEN NEUROPATHIC FOOT

(CHARCOT) Features may include: • Pain on walking when

usually neuropathic • Adequate blood supply • Recent minor trauma Treat as suspected Charcot joint – urgent referral to Podiatry & Joint medical clinic. See over for info

Diabetic Foot Infection management The full guideline is available from: Portsmouth Hospitals Intranet: http://pharmweb/MedicinesInformation/Guidelines/alpha.aspx Porstmouth PCT intranet: http://pct/pro/adu/podiatry/default.aspx Portsmouth Diabetes Care website: www.portsmouthdiabetes.co.uk Mild Infection: Presence of 2 or more clinical signs of inflammation but cellulitis/erythema extends no more than 2cm from the ulcer and infection is limited to superficial tissues Prescribe Empirical Oral Antibiotics for 7-14 days: Flucloxacillin 500mg qds If penicillin allergic clarithromycin 500mg bd If MRSA positive from any site in previous year doxycycline 200mg od Review response and onward referral as per guideline Moderate Infection: As above in a patient who is systemically well and metabolically stable but also has 1 or more of: cellulitis extending more than 2cm, lymphatic streaking, spread beneath the superficial fascia, deep tissue abscess, gangrene and involvement of muscle, tendon, joint or bone. Requires referral for MD assessment and consider IV antibiotics Monitor WCC and CRP to assess response Convert to oral therapy when clinically stable and sensitivities available Flucloxacillin 500mg – 1g qds If penicillin allergic Clindamycin 300mg qds Severe Infection: As above but patient is systemically unwell – admit to hospital for medical management

Charcot Alert

Hot, swollen, neuropathic, diabetic foot? Think Charcot until proven otherwise. Advise to non-weight bear and refer urgently following the pathway. Commonly mistaken for: cellulitis, acute gout, sprain/strain, DVT An example of early Charcot:

Additional information: NICE Type 2 Diabetes: prevention and management of foot problems 2004 http://guidance.nice.org.uk/CG10 Portsmouth Diabetes and Endocrine Centre: http://www.porthosp.nhs.uk/diabetes-foot-service.htm Diabetes Foot Assessment information: http://www.portsmouthdiabetes.co.uk/index2.php?nav_id=1954