The National Diabetic Foot Audit Report

Key messages

The first cycle of the NDFA includes data on over 5,000 people presenting with a new diabetic foot ulcer episode between 14 July 2014 and 10 April 2015. Almost 130 clinical foot care teams participated and 129 Clinical Commissioning Groups (CCGs) and Local Health Boards (LHBs) contributed to the NDFA Structures Survey.

Although estimated case ascertainment is low (10 per cent), the data collected in the first nine months of the new audit has provided a valuable initial insight into the links between the structures and processes of care and the clinical outcomes of people with diabetic foot ulcers in England and Wales.

Key findings

Audit findings can be grouped by the three key questions posed at audit inception:

Structures Survey: are the nationally recommended care structures in place for the management of diabetic foot disease?

The current NICE guidelines recommend that commissioners and service providers ensure that there are robust protocols and clear local pathways for the continued and integrated care of people with diabetic foot disease across all settings. It is therefore necessary that:

1. Staff involved in the routine care of diabetes should be sufficiently skilled to undertake annual foot risk assessments and to refer those at increased risk of developing a diabetic foot ulcer to the foot protection service1.
2. A foot protection service is in existence for the assessment and continuing surveillance of those defined as being at increased risk in order to prevent diabetic foot ulcers, and to manage some of them in the community2.
3. A pathway for referral of people with diabetes with an active foot problem to a multidisciplinary foot care service or foot protection service within one working day and triaged within one further working day3.The audit found that the structures needed for the provision of such services were not universal.

• Almost 40 per cent of participating commissioning organisations were unable to give a definitive response (yes or no) to all of the NDFA Structures Survey questions.
• More than 40 per cent of localities who could respond to all three questions did not have all three of the basic NICE recommended systems for preventing and managing diabetic foot disease.Citations:
  • 1 NICE (2015) Diabetic foot problems: prevention and management. Recommendation 1.3.3-1.3.7http://www.nice.org.uk/guidance/ng192 NICE (2015) Diabetic foot problems: prevention and management. Recommendation 1.2.1

    http://www.nice.org.uk/guidance/ng19

    3 Ibid.

Processes: does the treatment of active diabetic foot disease comply with nationally recommended guidance?

1. Annualfootchecks
 The audit found that people with diabetes presenting with a foot ulcer are just as likely to have had a NICE recommended routine foot check4 in the preceding year as other people with diabetes (85 per cent in both groups).

At this stage it is not possible to conclude that the examination has no influence. Data quality concerns and variable referral pathways for people categorised as at an ‘increased’ or ‘high risk’ mean that further investigation is required.

2. People with a newly occurring foot ulcer should be referred and triaged within two days The audit found that:

• Almost 30 per cent of patients self-presented.
• Two fifths of patients who did not self-present were not seen by the foot careservice until two weeks or more after the first healthcare contact for the ulcer.
• More than one in 10 of those who did not self-present were not seen for twomonths or more from the first healthcare contact.
• The longer the delay before being seen by the diabetic foot care team, the more likely were the foot ulcers to be severe.Outcomes: are the outcomes of diabetic foot disease optimised?The audit found that:

• One half of all patients were ulcer free at 12 weeks from first expert assessment.
• Patients who self-presented or who were seen by the specialist foot care
  service within two weeks of first assessment by another healthcare professional had higher rates of ulcer healing than those seen later.
• Patients presenting with more severe ulcers were almost twice as likely not to be ulcer free at 12 weeks after first expert assessment.

Citations:

4 NICE (2015) Diabetic foot problems: prevention and management. Recommendation 1.4.2

http://www.nice.org.uk/guidance/ng19

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Recommendations

The following recommendations are made as a result of the findings of the audit.

Recommendations for people with diabetes

• People with diabetes should ensure that they have their feet checked at least once a year by a professional.
• People with diabetes should seek professional advice as soon as they notice any problems with their feet.Recommendations for healthcare professionals All healthcare professionals should be aware of the need for prompt expert assessment of newly occurring foot ulcers in people with diabetes and should know how this assessment can be arranged.

  Recommendations for commissioners

• Commissioners should ensure that NICE recommended diabetic foot care teams and pathways are in place.
• Commissioners should encourage all foot care services to register and submit details on as many as possible of their foot ulcer cases to the NDFA