Quality standard

Quality statement 5: Assessing the risk of diabetic foot problems on admission to hospital

Quality statement 5: Assessing the risk of diabetic foot problems on admission to hospital

Quality statement

Adults with type 1 diabetes admitted to hospital have an assessment of their risk of developing a diabetic foot problem. [new 2023]

Rationale

Assessing the risk of developing a diabetic foot problem and timely care during a hospital admission for any reason, by skilled healthcare professionals such as members of the foot care service, decreases the probability of developing diabetic foot problems for adults with type 1 diabetes.

Quality measures

The following measures can be used to assess the quality of care or service provision specified in the statement. They are examples of how the statement can be measured, and can be adapted and used flexibly.

Structure

a) Evidence of local systems to identify all adults with type 1 diabetes when they are admitted to hospital.

Data source: The National Diabetes Audit's inpatient safety audit includes data on the number of providers that have a robust system to identify all people with diabetes on admission to hospital.

b) Evidence of local arrangements to ensure that foot assessments for adults with type 1 diabetes are performed by appropriately trained healthcare professionals.

Data source: No routinely collected national data for this measure has been identified. Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example from training records, competency assessment and records of continuous professional development.

Process

Proportion of adults with type 1 diabetes admitted to hospital who have an assessment of their risk of developing a diabetic foot problem.

Numerator – the number in the denominator who have an assessment of their risk of developing a diabetic foot problem.

Denominator – the number of adults with type 1 diabetes admitted to hospital.

Data source: No routinely collected national data for this measure has been identified. Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example from patient records.

Outcome

a) Incidence of diabetic foot ulcer identified on hospital admission in adults with type 1 diabetes.

Data source: No routinely collected national data for this measure has been identified. Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example from patient records.

b) Rate of diabetic foot ulcer in adults with type 1 diabetes during a hospital admission.

Data source: The National Diabetes Audit's inpatient safety audit includes data on the number, frequency and rate per 100,000 bed days of inpatient harms, including diabetic foot ulcer.

What the quality statement means for different audiences

Service providers (secondary care services) ensure that a foot care service is available within hospitals to provide foot assessments to adults with type 1 diabetes when they are admitted to hospital. They ensure that a multidisciplinary foot care team is available for management of any high-risk and active foot problems that are identified.

Healthcare professionals (members of the foot care service, nurses, doctors and podiatrists) are trained to provide foot assessments to adults with type 1 diabetes when they are admitted to hospital. They can refer to and work with the multidisciplinary foot protection service if any foot problems are identified on assessment.

Integrated care systems ensure that multidisciplinary foot care services and foot protection services are available to provide management of foot problems, including high-risk and active foot problems identified from foot assessments, for adults with type 1 diabetes when they are admitted to hospital.

Adults with type 1 diabetes who are admitted to hospital have a check of their feet for any problems that may be related to their diabetes.

Source guidance

Diabetic foot problems: prevention and management. NICE guideline NG19 (2015, updated 2019), recommendation 1.3.3

Definitions of terms used in this quality statement

Assessment of their risk of developing a diabetic foot problem

Adults with type 1 diabetes should remove their shoes, socks, bandages and dressings for the assessment. Their feet should be examined for the following risk factors:

  • neuropathy (using a 10 g monofilament as part of a foot sensory examination)

  • limb ischaemia (palpation of foot pulses as part of a vascular assessment)

  • ulceration

  • callus

  • infection or inflammation

  • deformity

  • gangrene

  • Charcot arthropathy or an unexplained hot, swollen foot with or without pain

  • ankle brachial pressure index.

The risk of developing a diabetic foot problem can be assessed using the following risk stratification:

  • Low risk:

    • no risk factors present except callus alone.

  • Moderate risk:

    • deformity or

    • neuropathy or

    • peripheral arterial disease.

  • High risk:

    • previous ulceration or

    • previous amputation or

    • on renal replacement therapy or

    • neuropathy and peripheral arterial disease together or

    • neuropathy in combination with callus, deformity or both, or

    • peripheral arterial disease in combination with callus, deformity or both.

  • Active diabetic foot problem:

    • ulceration or

    • infection or

    • chronic limb-threatening ischaemia or

    • gangrene or

    • suspicion of an acute Charcot arthropathy, or an unexplained hot, swollen foot with a change in colour, with or without pain.

[Adapted from NICE's guideline on diabetic foot problems, recommendations 1.3.4 to 1.3.6 and expert opinion]