Local responsibilities

The National Diabetes Footcare Audit (NDFA) lead is responsible for the coordination of this audit. The NDFA lead must ensure that there is a local process for:

We recommend following this process as part of a new ulcer presentation.  

At the presentation visit hand out the patient leaflet. The information can be handed out by clinic staff on arrival, so patients can have a look before they go into their consultation.

Provide a brief explanation of the audit in the clinic. If a person seems to be struggling to understand the NDFA, data submission and data linkage, you should ask some specific questions to clarify their difficulty. Such questions may include

• can you tell me what will happen if you agree to take part in this project?
• how might the NDFA project help you?
• how might this project not help you?
• do you have to take part in this project?
• what would you do if you decided to leave the project at a later date?
• What will happen if you decide not to be part of the project

This explanation should be extended to any family members so all of the potential participants will be given the opportunity to object if they want to.

For Wales

If following the assessment the adequate capacity to consent is not found, then surrogate consent for the patient should be recorded. This should ideally involve a family member but if this is unavailable it should be from another clinician. The person should be asked to sign the consent form on the behalf of the patient and the document should state their relationship to the patient. 

Record the consent when and if the person is willing. Note consent in section A on the NDFA collection form.   

This is a manual collection form and you will need to complete the form using a black pen in the boxes provided.

Do not write the patient’s name or address on the form.

Record Information for all three stages

1. Section A must be completed at first visit
2. Section B to be completed after 12 weeks. If the episode is not completed and the person has not yet been free from any active ulceration, Section B should also be completed at  24 weeks

Interval between first presentation to a health care professional and first assessment by your team.

Base your answer on the patient’s recall of the time between their first presentation with the current ulcer to any healthcare personnel (podiatrist, nurse, doctor) and their seeing you.

Location of Index (most severe) Ulcer

When at presentation there are multiple ulcers, record the location of only the most severe ulcer. This is the ulcer that should be scored using SINBAD (see below).

Current/Previous Charcot

The presence of an underlying Charcot foot may adversely affect healing. We need to know, therefore, whether the person has, or may possibly have, an active Charcot foot and if it affects the side of the index ulcer.

• no Charcot = no record of Charcot foot and no current features of Charcot foot
• possible Charcot Foot = signs suggesting the possibility, but without a formal diagnosis being confirmed. Generalised foot Swelling+/-Heat+/-Pain accompanying radiologist reported radiological features suggestive of Charcot neuro-arthropathy
• definite Charcot Foot = diagnosis based on standard clinical and radiological features history of, or current generalised foot Swelling+/-Heat+/-Pain, and radiologist reported radiological features typical of Charcot neuro-arthropathy

SINBAD scoring

SINBAD is an acronym for a simple yes/no scoring system that reliably assesses Ulcer Severity.

S = Site

• yes = Hindfoot =  includes the tarso-metatarsal joints and everything  proximal to them below the ankle
• no = Not the hindfoot (i.e. the forefoot)

I = Ischaemia

• yes = absent pulses +/- other  suggestive clinical signs

• no = intact pulses and no signs of ischaemia

N = Neuropathy

• yes = Evidence of sensory loss i.e. person cannot feel 10g monofilament, vibration or other stimulus used in routine  clinical practice
• No = No evidence of sensory loss

B = Bacterial Infection

• yes = clinical signs of infection (such as redness, swelling, heat, discharge)
• no = no clinical signs of infection

A = Area

• Yes = Area of 1cm² or more (assess using product of greatest diameters or other method)
• No = area less than 1cm²

D = Depth

• Yes = Ulcer penetrates to tendon or bone (assess by eye +/- sterile probe)
• No = Ulcer does not penetrate to tendon or bone

Each of the six items scores 0 (less severe) or 1 (more severe), and the SINBAD score is the sum of these individual item scores. Any lesion can therefore score from 1 (least severe) to 6 (most severe).

You will need to record if or not the patient is alive and whether they have an active ulcer at 12 weeks and 24 weeks after presentation. If the patient has been transferred to the care of another service it will be necessary to make contact with that service and ascertain answers to these questions.

At 12 weeks:

• if the patient has died tick No and submit the form.

• if the patient is alive, tick yes and answer whether they have an active ulcer and add the date.

• If they have no active ulceration, the form is now complete and ready for submission.
• if alive but continuing ulceration tick No and repeat at 24 weeks.

At 24 weeks:

If the patient had an active ulceration at 12 weeks, complete this section.

• if the patient has died tick No and submit the form.

• if the patient is alive, tick yes and answer whether they have an active ulcer and add the date. The form is now complete and ready for submission.

You will be able to check which patients are due for a 12 week and 24 week follow-up via the online submission tool. There is a reporting function built into the system which will list all the patients that are due for follow-up. You will also be able to download a CSV file.

Therefore, you will need to log on regularly to keep track of patients who are due for follow-up. 

Neuropathy

The term neuropathy is usually used to refer to the sensory peripheral neuropathy that frequently complicates diabetes. A person with neuropathy cannot perceive stimuli to the feet which could be potentially harmful. Sensory neuropathy is normally detected by clinical testing with a 10g monofilament, a sharp or a blunt object or standardised vibration. Rarely, a person may not be able to perceive potential trauma because of a disorder in the central nervous system. Such people with, for example, spinal injury or dementia, will have a similar increase in risk of foot ulcers to people with peripheral neuropathy - because they have decreased perception of pain. For the purposes of the NDA, such people should be recorded in SINBAD as having neuropathy.