Chapter VIII

MINIMUM CARE PROTOCOL

FOR DIABETIC FOOT

THE PROCESS OF DEVELOPMENT DEVELOPMENT OF PROTOCOL FOR

o Examination of diabetic footo Assessment of ulcerso Laboratory assessment o Treatment and o Prevention

NNEF and a number of recognized experts in diabetes foot care in India have worked closely since December 1999. A consistent effort through well structured Diabetic Foot Care workshops has been made to bring about professional awareness in India, with the help of the experts, coordinated and supported by NNEF till date. A major offshoot of these efforts was the formation of National Foot Group in Chennai in December 1999 which later evolved formally as Diabetic Foot Society of India.

A meeting of National Foot Group was held in Bangalore on July 22nd, 2001 for review the developments brought about by the NNEF - Experts combine and to make an attempt to develop a consensus on “Minimum Care Protocol for Diabetic Foot.” 40 members of the National Foot Group attended the meeting. This document is the outcome of the recommendations for these members of National Foot Group.

The Process of Development of the Protocol:TThe assembled members were explained the idea of Minimum Care Protocol For Diabetic Foot by Dr. Ashok Kumar Das, Convener and Chairman of the National Foot Group. Dr. Das emphasized the need for a uniform minimum standard the professionals who take care of diabetic foot should follow. This endeavor also allows for the outcome analysis of treatment and could throw light on the areas that need greater concentration, Dr. Das explained. According to specific area for consideration the group was divided as shown below with the leader.

1. Prevention Group - Dr. A K Das

2. Foot Examination - Dr. Sharad Pendsey

3. Foot Ulcer Assessment - Dr. Arun Bal

4. Laboratory Assessment - Dr. Vijay Vishwanathan

5. Treatment - Dr. K R Suresh

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Each group agreed upon the minimum care protocol required to be followed in their area for consideration. The recommendations were recorded on OHP sheets, presented by a group member, were discussed by all and then accepted with suggestions at few places.

Minimum Care Protocol For Diabetic FootGroup 1Prevention of Diabetic Foot Development and / or complications

The group emphasized the lack of standards in diabetes foot care and felt that this document should be practical, as widely applicable as possible and should be affordable to all concerned.

In order to prevent the development of diabetic foot and / or its complications we need to -

Highlight the diabetes foot problem in practice.

Highlight the same in the context of diabetes disorder.

Emphasis on the Indian socio-economic conditions that may lead to diabetic foot, further complicated by customs beliefs and practices among Indians.

Emphasis on examination for neuropathy since that forms the bulk of the problem.

Address equally the city and village population with diabetes also, as the latter are highly vulnerable to injury and ulceration .

Emphasis on not “walking bare foot”.

Self examination of foot taught to persons with diabetes.

Reporting symptoms early to prevent serious complications patient education necessary.

Avoiding Tobacco particularly among persons with diabetes.

Examination of footwear.

Control of hypertension, diabetes, lipids.

Investigations to identify foot at risk.

Monofilament testing.

Doppler for AB index.

Other vascular studies if available.

Audio visual aids to explain the patients risks.

Advising on as ideal a foot wear as possible.

Educational materials:

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Easy to read, pictorial and in regional languages. Step by Step approach to foot care educations should be reached to all involved in

diabetes and foot care in particular. Revised as necessary. Documentation of work there from draw lessons in own practice.

Standard Formats to document care: Measuring outcomes. Publication/complication in Indian context to be used as a guide for all.

SLOGAN: “Save Diabetes Foot Reduce Economic Burdens”.Group 2EXAMINATION OF FOOT:History:Parasthesias ClaudicationH/o Diabetes Mellitus Injury by Thermal ExposureMassage Shoe bitePast h/o ulcer

Examination:Inspection Skin texture Colour - Pale, Red, Blue, Black Loss of Sweating

Palpation Warmth, Tenderness Calluses, Fissures, Bony prominences Deformity, Web spaces, Nails Joint movement

Foot Pulses Dorsalis Pedis, Posterior Tibial, Prominent veins Vascular Examination and Risk Assessment: A/B Index Doppler

Foot Pressure measurement: Ink Pad, Harris Mat, PodoTrack Footwear inspection for foot impressions.

Risk Assessment: Protective sensation- Pinprick for pain, Cotton wool for touch Temperature, Vibration by Tuning Fork or vibration threshold measuring

instruments, Touch and Pressure Monofilament l Joint sensation limitation Subtalar/ big toe

Joint movement limitation Reflexes and Jerks

RISK CATEGORY:

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Group 3FOOT ULCER ASSESSMENT IN DIABETES MELLITUS:H/o duration, trauma, bare foot or incorrect walking, foot wear, varicose veins, previous ulcer

H/o occupation, profession

H/o tobacco, alcohol

Examination of the Ulcer: Site, Size, Edge, Shape and Base of the Ulcer Slough, Discharge, Exposure of bone, tendon Surrounding Tissue, Warmth

Examination of the Foot: Deformity Pulsation Edema over foot

Investigation: X ray foot, Bacterial swab

Treatment of specialist when: Ulcer with Discharge Surrounding tissue oedema Cellulitis Lymphangitis

Group 4 AIM TO INDENTIFY THE HIGH RISK FEET LABORATORY INVESTIGATION:

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Lab test On first Once every Once every Once every Acute examination 12 months 6 months 3 months infection Risk 0

Risk 1 Risk 2 Risk 3 A SENSATION + + + + +B VASCULATURE + + + + +C PRESSURE AND + + + + +MOBILITYD RADIOLOGY +(If swelling + + + + is present)E METABOLIC According to + + + + usual guidelinesF MICROBIOLOGY – – – – –

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Group 5PRIMARY LINE OF TREATMENT 1. Wound assessment, '3D' assessment

Mapping with a plastic sheet as guideMapping every 2 weeksPhotographic evidence digital photographyGrading “Depth Ischemia Scale”-Wagner's classification

2. Primary Neuropathic woundsMarking on chappalsNoting corns and callusesTherapy-Shaving calluses and modifying footwear

3. Infection:Warmth, discharge, unhealthy baseNo improvement in three days-refer to specialist earlier if patient worsensCulture and sensitivityPenicillin and clavulinic acid (Sulbactum)

4. Circulation Palpation of pulses(Venous filling time, Capillary filling time)