In this issue of STRIDE we are sharing brief excerpts from the 2021 Australian evidence-based guidelines for diabetes-related foot disease and the companion Diabetes and feet toolkit, to try to encourage as many podiatrists as possible to refer to these resources.

The backstory

While you may be familiar with these resources, you may not yet be familiar with how the guidelines came about. Firstly, an expert multidisciplinary guideline working group was appointed to develop a guidelines protocol. Secondly, this was followed by the appointment of six multi-disciplinary national panels to enact the protocol and develop one guideline each specifically across six fields:

  • Prevention
  • Wound classification
  • Peripheral artery disease
  • Infection
  • Offloading
  • Wound healing interventions

Adapted from the 2019 International Working Group on the Diabetic Foot (IWGDF) Guidelines on the Prevention and Management of Diabetic Foot Disease, each guideline group included consumer and Aboriginal and Torres Strait Islander Peoples representatives for input on all guideline decisions and considerations. A key focus was the inclusion of implementation considerations in Australia, including specifically for geographically remote and Aboriginal and Torres Strait Islander Peoples.

The methodology used to develop these new guidelines was comprehensive (see page 6 here and page 8 here), and the public consultation process can be learned more about here.

The Diabetes and feet companion toolkit was then designed specifically to help busy multidisciplinary health professionals use guideline-recommended diabetes-related foot disease (DFD) care at any time and place and with the person with a diabetes-related foot ulcer (DFU) right there in front of them. This was funded by the National Diabetes Services Scheme (NDSS), an initiative of the Australian Government and administered by Diabetes Australia, and developed in collaboration with Diabetes Feet Australia and the Australian Diabetes Society.

The guidelines’ goal

The goal behind these updated guidelines is to ensure that health professionals in Australia – who care for people with DFD in secondary and tertiary health care settings – have access to consistent up-to-date evidence-based advice; including practical pathways and considerations for the Australian context. These guidelines will now serve as the national multidisciplinary best practice standards of DFD care in Australia and this is why it is so important all podiatrists familiarise themselves with these guidelines.

A sneak peek

To give you a sense of the information covered in these resources, further below are some excerpts from the Diabetes and feet companion toolkit covering the fields of prevention, wound classification and peripheral artery disease. We encourage you to head here to read the related information in full. 

Next month we’ll address the other fields covered which are infection, offloading and wound healing interventions.

#1 The power to create change

In Australia, it is estimated that 50,000 people are living with a DFU, while 300,000 people are considered at-risk of DFU. Aboriginal and Torres Strait Islander Peoples have disproportionately high rates of foot-related complications, with a three to six-fold increased likelihood of developing DFU and requiring amputation.

 

By following the 15 prevention guideline recommendations, it should encourage evidence-based consistency of care among health services and health professionals. This should in turn improve clinical pathways of care and reduce any confusion for health professionals and their patients at risk of DFU. It should also help guide and give confidence to clinicians who provide evidence-based DFU prevention strategies, as well as promote better prevention and overall outcomes for people living with DFU in Australia.

 

Key snapshot

A snapshot from the 15 prevention recommendations includes:

 

  • Screening all people with diabetes at increased risk of foot ulceration at intervals corresponding to the IWGDF risk ratings.
  • Providing structured education about foot protection, inspection, footwear, weight-bearing activities, and foot self-care.
  • Advice on self-monitoring of foot skin temperatures (contingent on validated user-friendly and affordable systems becoming approved and available in Australia).
  • Prescription of orthotic interventions and/or medical grade footwear.
  • Providing integrated foot care.
  • If the above recommended non-surgical treatments fails, we recommend considering the use of various surgical interventions for the prevention of DFU.

#2 Implementing the Wound classification guideline

Effective assessment, documentation and communication of clinical information and audit of patient outcomes is central to achieving optimal outcomes for people living with DFD.

 

Wound classification systems are useful tools to characterise DFU that support clinical assessment and aid effective communication between health professionals. They also assist with timely triage of referrals to specialist services such as interdisciplinary high-risk foot service, guide clinical decision making and prognosis in certain settings and support clinical audit and benchmarking.

 

In Australia, we recommend the use of the Site, Ischemia, Neuropathy, Bacterial Infection, and Depth (SINBAD) system as a minimum standard to document the characteristics of a DFU for the purposes of communication among health professionals and for regional/ national/ international audit. It is important that the individual components of SINBAD (rather than the total score) are used for the purposes of communication between health professionals.

 

For signs of ischaemia/peripheral artery disease we recommend use of the WIfI scoring system that generates a combined score across three areas: wound (depth of ulcer or gangrene extent), ischaemia (based on evaluation with ankle brachial index, ankle systolic pressure, toe pressure or transcutaneous oxygen pressure) and foot infection.

#3 What’s new in the Peripheral artery disease guideline

Peripheral artery disease (PAD) is estimated to be present in up to 50% of DFU and to be an independent risk factor in their development. PAD also contributes to delayed wound healing and increased risk of amputation, particularly when infection is present.

 

PAD commonly co-exists with systemic atherosclerosis and underlying generalised endothelial dysfunction due to vascular inflammation and an abnormal metabolic state. Together these changes increase the risk of cardiovascular morbidity and mortality significantly. When associated with diabetes, PAD is also more diffuse with increased involvement of tibial arteries, greater severity of the disease process, higher likelihood of distal ischaemic ulcers and extensive tissue loss, and increased risk of amputation.

 

Early diagnosis and treatment of PAD in people with DFU is critical due to the increased risk of non-healing, infection and amputation, as well as elevated rate of cardiovascular complications such as myocardial infarction and stroke, and a five-year mortality rate of more than 50%.

 

This new PAD guideline includes 17 recommendations with substantial new evidence relating to diagnosis, prognosis and management in the person with PAD and DFU including:

 

  • New evidence demonstrating the clinical challenge of diagnosing PAD in diabetes cohorts, particularly in relation to the limited capacity of clinical examination (including pulse palpation) and various bedside testing methods to rule out the presence of disease with no single or combination of tests yet to be found to be superior (recommendations 1 to 4, 6 to 8).
  • The validated WIfI classification system to estimate risk of amputation and potential benefit of revascularisation based on the ulcer characteristics, severity of ischaemia measured via non-invasive bedside testing, and infection severity (recommendation 5).
  • Additionally consider the recommendations in relation to specific subpopulations relevant to the Australian context including those in geographically remote circumstances, and for Aboriginal and Torres Strait Islander Peoples.

Next month: We’ll share more of these toolkit excerpts around infection, offloading and wound healing interventions.

 

© Copyright 2021 The Australian Podiatry Association

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