Part 3 | Diabetes and feet toolkit advice for you

Funding and recruitment

To help meet this goal, a multi-million pound recruitment campaign (which has been in existence since 2018 to originally target the nursing sector) has now diversified to include allied health professionals. Called ‘We are the NHS’, this renewed campaign is fuelled by record funding that totals £39bn worth of investment over a three year period; partly delivered in response to the backlog brought about by the pandemic.

This funding includes:

• £1.5bn investment to retain and recruit a range of primary care staff, including podiatrists.
• An extra £520m to improve access and expand GP capacity.
• Extra student payments worth up to £3,000 a year for health professions that are struggling to recruit, or those with childcare responsibilities. This funding is expected to benefit around 100,000 students each year.

#1 What’s new in the infection guideline?

The Diabetes and feet toolkit says: ‘Diabetes-related foot ulcers (DFU) currently affect around 50,000 Australians, and up to 40% of these individuals can expect to have an associated infection in the first year after presentation. Best-practice adaptation of the 2019 International Working Group on the Diabetic Foot (IWGDF) Infection Guideline for the Australian national context was undertaken by an expert panel, leading to the development of the first multi-disciplinary, evidence-based Australian diabetes-related foot infection guidelines since 2011.’

What’s recommended for infection management?

This new infection guideline includes 35 recommendations and by implementing this guideline health professionals should:  

• Provide an evidence-based framework to ensure best management of individuals with diabetes-related foot infections.
• Help highlight infection considerations for implementation and monitoring. 
• Help improve outcomes for Australians living with diabetes-related foot infections. 

Different services may undertake different management processes, yet, the principles of best practice clinical management for diabetes-related foot infections should be similar for all services and include:

• Monitoring and evaluation forms a vital component of best-practice clinical management of diabetes-related foot infections.
• Services undertake an audit of patient outcomes every 12 months at a minimum.
• Minimum data should be collected on patients’ treatment approaches (including antibiotic and surgical management) and outcomes.
• Outcomes should be compared over time and to similar external units where possible.

This Diabetes and feet toolkit provides a practical and condensed overview of the Australian infection guideline designed to assist health professionals use the recommendations in daily practice. To learn more about each individual recommendation, please refer to the Australian guideline on management of diabetes-related foot infection.

#2 What’s new in the offloading guideline?

 The Diabetes and feet toolkit says: ‘Pressure offloading management is critical for healing DFU. Evidence-based guidelines have been developed over the years to weigh up the benefits, risks, quality of evidence and feasibility of different pressure offloading treatments to provide health professionals with best practice recommendations on how to provide optimal offloading treatment to people with DFU. However, substantial new offloading evidence has been published over the last decade. Many international evidence-based diabetes related disease (DFD) guidelines have taken this new evidence into account and recently been published, but their applicability to the Australian context is unclear. These guidelines have been systematically adapted from suitable international guidelines to the Australian context to become the new Australian evidence-based guideline on offloading management for people with DFU.’

What’s recommended for offloading management?

This new offloading guideline includes 13 recommendations. To optimise the uptake of these new recommendations into national clinical practice, the guidelines provide a comprehensive range of implementation considerations for health professionals. In addition to general implementation considerations for the Australian population, this guideline also provides specific implementation considerations for when treating people residing in geographically remote areas and Aboriginal and Torres Strait Islander Peoples, such as the impact of limited or infrequent access to DFU care, hot climates, dusty environments and cultural practices. All offloading recommendations have also been developed into a practical offloading pathway to optimise the implementation of recommendations.

To summarise the offloading recommendations:

• In Australia, we recommend a step-down offloading treatment approach for people with plantar DFU based on their contraindications and tolerance.
• We strongly recommend non-removable knee-high offloading devices as first line treatment, then removable knee-high offloading devices as second line, removable ankle-high offloading devices third, and medical grade footwear only as a last resort.
• We also recommend considering using felted foam in combination with the chosen offloading device or footwear to further reduce plantar pressure.
• For people with non-plantar DFU we recommend using a removable offloading device, felted foam, toe spacers or orthoses, or medical grade footwear depending on the type and location of the foot ulcer.
• If offloading device options fail to heal a person with plantar DFU, depending on the location, we recommend considering various surgical offloading procedures.

This Diabetes and feet toolkit provides a practical and condensed overview of the Australian offloading guideline designed to assist health professionals use the recommendations in daily practice. To learn more about each individual recommendation, please refer to the Australian guideline on offloading treatments for foot ulcers.

#3 What’s new in the wound healing intervention guideline?

 The Diabetes and feet toolkit says: ‘Diabetes-related foot ulceration is one of the most devastating complications of diabetes. It precedes up to 75% of amputations in people with diabetes and accounts for a significant proportion of the global disability burden. It is critical that interventions to enhance or facilitate healing of DFU are supported by strong evidence of benefit and cost-effectiveness, and all communities across Australia should have equitable access to these interventions. Implementing this guideline should help: 

• Guide health professionals on wound healing interventions to heal DFU 
• Provide implementation considerations to deliver a good standard of DFU care 
• Address the large burden and mitigate existing inequalities amongst Australians living with DFU’. 

All recommendations have also been developed into a practical wound healing interventions pathway to optimise the implementation of recommendations by the multiple health professionals and disciplines caring for Australians with DFU in secondary and tertiary health care settings in Australia.

What’s recommended in the wound healing interventions guideline?

There are 13 recommendations in the new Australian 2021 Wound healing guidelines compared with seven recommendations made in the previous 2011 Australian DFD Guidelines relating to wound healing interventions. There are multiple new recommendations made in this new guideline that reflect the new high-quality evidence gained in this field over the last decade. Of the 13 recommendations:

• Three relate to basic principles of wound care
• Five relate to adjunct therapies for use in specific wound types in addition to best standard of care
• Five relate to therapies that are recommended not for use.

The 5 adjunct therapies include the sucrose-octasulfate impregnated dressing, systemic hyperbaric oxygen therapy, negative pressure wound therapy, placental derived products, and the leucocyte platelet and fibrin dressing*. Larval therapy and skin replacement therapies (cultured skin equivalents and skin grafting) were recommended in the 2011 NHMRC Guidelines, but due to differences in methodology were not considered for inclusion in this guideline.

(*when available in Australia)

This Diabetes and feet toolkit provides a practical and condensed overview of the Australian wound healing interventions guideline designed to assist health professionals use the recommendations in daily practice. To learn more about each individual recommendation, please refer to the Australian guideline on wound healing interventions to enhance healing of foot ulcers.”