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School of Health and Related Research (ScHARR), University of Sheffield. Clinical Guidelines for Type 2 Diabetes: Prevention and Management of Foot Problems [Internet]. Sheffield (UK): University of Sheffield; 2003. (NICE Clinical Guidelines, No. 10.)

  • This publication is provided for historical reference only and the information may be out of date.

This publication is provided for historical reference only and the information may be out of date.

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Clinical Guidelines for Type 2 Diabetes: Prevention and Management of Foot Problems [Internet].

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Appendix 21Scope

Guideline title

Management of type 2 diabetes: prevention and management of foot problems(update)

Short title

Type 2 diabetes – foot care (update)

Background

The National Institute for Clinical Excellence (‘NICE’ or ‘the Institute’) has commissioned the National Collaborating Centre for Primary Care to review recent evidence on the prevention and management of foot problems in people with type 2 diabetes, and update the existing guideline Clinical Guidelines and Evidence Review for Type 2 Diabetes: Prevention and Management of Foot Problems (Royal College of General Practitioners, 2000) for use in the NHS in England and Wales. The updated guideline will provide recommendations for good practice that are based on the best and most recently available evidence of clinical and cost effectiveness. This guideline will be relevant only to patients with Type 2 diabetes, as the management of foot problems for patients with Type 1 diabetes will be incorporated into the NICE guideline currently under development, Type 1 diabetes: diagnosis and management of type 1 diabetes in primary and secondary care, scheduled for publication in January 2004.

The Institute’s clinical guidelines will support the implementation of National Service Frameworks (NSFs) in those aspects of care where a Framework has been published. The statements in each NSF reflect the evidence that was used at the time the Framework was prepared. The clinical guidelines and technology appraisals published by the Institute after an NSF has been issued will have the effect of updating the Framework.

Clinical need for the guideline

  1. Type 2 diabetes (non-insulin dependent diabetes mellitus) is a common and chronic disease with a high risk of a number of serious complications. About 1.3 million people are currently diagnosed with diabetes. This means that in 100,000 people, about 2,000–3,000 will have diabetes. Type 2 diabetes accounts for about 85% of these cases and many more people may have Type 2 diabetes as yet undiagnosed.1 It has been estimated that diabetes may be responsible for at least 5% of healthcare expenditure in the UK and up to 10% of hospital inpatient resources are used for the care of people with diabetes 1,2
  2. Foot complications are common in diabetes. Overall, 20–40% of people with diabetes are estimated to have neuropathy (depending on how it is defined and measured) and about 5% have a foot ulcer.3,4,5
  3. The St Vincent declaration called for a 50% reduction in amputation from diabetic gangrene, reflecting the belief that much morbidity is preventable by better patient management.6 A retrospective survey of people with diabetes in Newcastle upon Tyne (UK) undergoing non-traumatic* amputation, found that of the patients receiving hospital care, only half had complete foot evaluations in the year preceding initial ulceration or gangrene.7 Another retrospective study investigated causal pathways to amputation in a series of 80 people with diabetic lower-extremity amputations. A causal sequence of minor trauma, cutaneous ulceration and wound-healing failure applied to 72% of amputations.8 The aim of the guideline will help improve standards of care and outcomes.

The guideline

  1. The guideline development process is described in detail in three booklets that are available from the NICE website (see ‘Further information’). The Guideline Development Process – Information for Stakeholders describes how organisations can become involved in the development of a guideline.
  2. This document is the scope. It defines exactly what this guideline will (and will not) examine, and what the guideline developers will consider.
  3. The areas that will be addressed by the guideline are described in the following sections.

Population

Groups that will be covered

Adults and children with diagnosed type 2 diabetes.

Groups that will not be covered

  1. The guideline will not address identification of undiagnosed diabetes, general management of people with diabetes (other than aspects that relate to the prevention of foot complications).
  2. The guideline will not cover people with foot problems who do not have Type 2 diabetes.

Healthcare setting

  1. The guideline will cover the care received from primary and secondary healthcare professionals who are involved in the care of people with type 2 diabetes.
  2. This is an NHS guideline and although it will also be relevant to practice within residential and nursing homes, social services and the voluntary sector, it will not make recommendations regarding services exclusive to these sectors.

Clinical management

The guideline will include recommendations on the following areas.

  1. Patient and carer education regarding prevention and management of foot and lower limb problems associated with diabetes.
  2. The definition of increased risk of foot complications, the identification of those at risk and the management and prevention of foot complications.
  3. Diagnosis of the foot with complications
    • Type of ulceration
    • Infection
    • Charcot neuroarthropathy
    • Critical ischaemia
  4. Management of the ulcerated foot including
    • Off-loading ¥.
    • Dressings
    • Debridement
    • Pharmacological interventions including antibiotics and analgesics
    • Skin replacements
    • Physical therapies
    • Growth factors
  5. Primary prevention, and prevention of recurrence
  6. Indications for referral to specialist services including:
    • Specialist foot teams/clinic
    • Those with responsibility for assessment and provision of (specialist) footwear
    • Podiatry and Orthotics
    • Surgery and Interventional radiology,
    • Mobility assessment.
    • Pain management
  7. Aspects of clinical management that will not be covered in the guideline are:

Audit support within guideline

The guideline will be accompanied by audit review criteria and advice.

References

1.
Department of Health. National Service Framework for Diabetes. 2001.
2.
Laing W, Williams R. Diabetes: a model for health care management. 2. London: Office of Health Economics; 1989.
3.
Kumar S, Ashe HA, Parnell LN, et al. The prevalence of foot ulceration and its correlates in Type 2 diabetic patients: a population based study. Diabetic Medicine. 1994;11:480–4. [PubMed: 8088127]
4.
Neil HAW, Thompson AV, Thorogood M, et al. Diabetes in the elderly: the Oxford community diabetes study. Diabetic Medicine. 1989;6:608–13. [PubMed: 2527702]
5.
Walters DA, Gatling W, Mullee MA, Hill RD. The distribution and severity of diabetic foot disease: a community based study with comparison to a non-diabetic group. Diabetic Medicine. 1992;9:354–8. [PubMed: 1600707]
6.
World Health Organization (Europe) and International Diabetes Federation (Europe). Diabetes care and research in Europe: the St Vincent Declaration. Diabetic Medicine. 1990;7:360. [PubMed: 2140091]
7.
Deerochanawong C, Home PD, Alberti KGMM. A survey of lower limb amputation in diabetic patients. Diabetic Medicine. 1992;9:942–6. [PubMed: 1478041]
8.
Pecoraro RE, Reiber GE, Burgess EM. Pathways to diabetic limb amputation: basis for prevention. Diabetes Care. 1990;13:513. [PubMed: 2351029]

Footnotes

Nerve damage

*

These are amputations that are not due to an accident.

¥

Offloading is a system that facilitates wound healing by re-distributing plantar foot pressure e.g. bed-rest, in-shoes orthoses, special footwear, walking caste etc

Copyright © 2003, School of Health and Related Research (ScHARR), University of Sheffield.
Bookshelf ID: NBK51726

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