All patients with diabetes should be screened to assess their risk of developing for foot disease (SIGN 116 section 11.2B), and as part of their review, trained personnel should examine patient’s feet to detect risk factors for ulceration.

A patient information leaflet on diabetic foot risk stratification and triage, produced by the Scottish Diabetes Foot Action Group, is available here.

Low risk

• No risk factors present e.g.
  • no loss of sensation
  • no signs of peripheral arterial disease
  • no significant callus
  • no significant structural deformity
  • able to self-care
  • eGFR >30
• In line with the Scottish government footcare policy: ‘For people who have been screened and assessed as low risk, it is acceptable and safe for them, their family, friends or carers to carry out personal foot care’ - no podiatry intervention is required
• Foot screening should be carried out every 2 years by a trained health care worker

Moderate risk

• One risk factor presents e.g.
  • loss of sensation
  • signs of peripheral arterial disease
  • significant callus
  • significant structural deformity
  • unable to or has no help to self-care
  • eGFR <30
• In line with the Scottish government footcare policy: ‘For people who have been screened and assessed as moderate risk, they or their family, friends or carers may still be able to carry out all or most of their personal footcare safely, following advice from the podiatrist’
• Foot screening should be carried out annually by a trained healthcare professional

In remission/high risk

• Previous ulceration, amputation, or consolidated Charcot
• More than one risk factor presents e.g. a combination of:
  • loss of sensation
  • signs of peripheral arterial disease
  • significant callus
  • significant structural deformity
  • unable to or has no help to self-care
  • eGFR <30
• These patients should be seen regularly by a Podiatrist
• For people who have been screened and assessed as high risk some of their personal footcare may still be carried out by themselves, their family, friends, or carers especially the checking their feet daily for any breaks in the skin or signs of any problems
• Foot screening is no longer required - this group of patients will always remain as in high risk or remission

Active

• Presence of active ulceration, infection, with or without ischaemia, gangrene, or unexplained hot, red, swollen foot with or without the presence of pain
• For people who have been assessed as suffering from Active Foot Disease rapid referral to a member of the multidisciplinary foot team or a multidisciplinary foot clinic is essential. Daily foot checks should still be carried out where possible by themselves, their family, friends, or carers for signs of any further problems.

Aim

To promote wound healing and prevent patients with ulceration from undergoing amputation.

Evidence

For a new foot ulcer, arrange urgent assessment by an appropriately trained health care professional (NICE 2004 grade D).

Refer to a multidisciplinary foot care team within 24 working hours if any of the following occur: new ulceration (wound), new swelling or new discolouration (redder, bluer, paler, blacker, over all or part of the foot) (NICE 2004 grade D).

The following need to be considered:

• debridement/wound preparation
• wound symptom management (e.g. infection/exudates)
• offloading the ulcer

Patients should be treated according to the diabetic foot antibiotic protocol.

Use the criteria below to choose the correct referral point for your patient. 

Note: e-referrals are requested.