The Diabetic Foot Risk Stratification and Triage chart below has been developed from the NICE guideline [NG19]: Diabetic foot problems: prevention and management, using a format taken from the SIGN 116 guidelines. Following the foot screening process the patient should be assigned and informed of their risk category and a treatment and management plan introduced according to the chart if required.
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Low risk
Definition
No risk factors present except callus e.g. no loss of sensation, no signs of peripheral vascular disease and no other risk factors.
Action
Annual screening by a suitably trained Health Care Worker. Tell people that they are at low risk of foot ulceration and agree a self-management plan. Provide written and verbal information about diabetes and the importance of blood glucose control, basic foot care and footwear. Advise them that they could progress to moderate or high risk. Provide information about foot emergencies and who to contact.
Moderate risk
Definition
One risk factor present e.g. loss of sensation or signs of peripheral vascular disease without callus or deformity.
Action
Tell people that they are at moderate risk of foot ulceration and refer to the foot protection service for first assessment (within 6-8 weeks). The foot protection service should; assess the feet every 3-6 months, give advice about and provide skin and nail care of the feet. Assess foot biomechanics, give footwear advice and consider providing insoles and specialist footwear. Assess lower limb vascular status. Liaise with other healthcare professionals about diabetes management and reducing the risk of cardiovascular disease. Provide information about foot emergencies and who to contact. People in hospital should be given a device to offload heel pressure.
High risk
Definition
Previous ulceration or previous amputation or on renal replacement therapy or neuropathy and non-critical limb ischaemia together or neuropathy in combination with callus and or deformity or non-critical limb ischaemia in combination with callus and /or deformity.
Action
Tell people that they are at high risk of foot ulceration and refer to the foot protection service for first assessment (within 2-4 weeks). The foot protection service should; assess the feet and give advice and care (as detailed below), frequently (1-2 months) or very frequently (1-2 weeks) where there is immediate concern. People in hospital should be given a device to offload heel pressure.
Active foot disease
Definition
Presence of active ulceration or unexplained hot red swollen foot with or without the presence of pain.
Action
Tell people they have active foot problem. Provide written and verbal information about the foot problem and emergency contact number. Assess and document size, depth and position of the ulcer if present. According to training and skill, and where appropriate, offer 1 or more of the following: offloading, control of infection, control of ischaemia, wound debridement and wound dressing. Refer to the Multidisciplinary Diabetic Foot Clinic or Foot Protection Service (according to local protocols) within 1 working day for triage within 1 further working day.
Definition
Presence of a limb-threatening or life-threatening diabetic foot problem; Ulceration with fever or signs of sepsis or limb ischaemia, clinical concern of a deep-seated soft tissue of bone infection (with/without ulceration), gangrene (with/without ulceration).
Action
Manage as above. Tell people that they have a foot emergency, refer immediately to acute hospital services (e.g Trauma Unit) and inform the Multidisciplinary Diabetic Foot Clinic (according to local protocols).
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