Diabetic foot protocol (circle, tick, cross, or record)

General principles

• If severe, take swabs and 2 sets of blood cultures, page ID registrar (#323)
• If not severe, avoid antibiotics prior to surgery
• Don’t wait for histology before deciding on discharge
• Readmit under vascular unit if fails on TACT
• Print this form to use as checklist in file (add sticker; tick-off as you go)

 Vascular JMO

• Document clinical assessement
  • Presence, size ____ (mm) and depth ____ (mm) of ulcer(s)
  • Features of simple infection (Purulence; Erythema; Pain; Tenderness; Warmth; Induration)
  • Features of advanced infection (Cellulitis > 2cm; Lymphangitis; Deep tissue involvement; Abscess; Gangrene; Systemically unwell)
  • Arterial and Venous status (including results of studies)
  • Neuropathic status (including pin prick level)
• Document routine investigations
  • FBE (WCC ____), U/E+Creat ____ (umol/L), CRP ____ (mg/L), HBA1C ____ (%), Xray
  • Swabs of ulcers
• Routine referrals
  • ID JMO (#158) or BPT (#191)
  • Diabetes CNC (#244)
  • Written referral for ID consultant
    • Including: Relevant investigation results and clinical assessment (as above); Surgical plan
• If 2 or more features of advanced infection present (see above)
  • Blood cultures (2 sets) and MRI
  • Referral to endocrine registrar (#363 or #177)
• Referral to PICC nurse (for day 1 post-op) if obvious and/or advised by ID
• Referral to TACT as advised by ID
• Discharge planning not complete until:
  • Patient has been seen post-op by vascular surgery registrar / consultant
  • Outpatient wound management planned
  • Surgical review booked
  • Discharge summary includes all co-morbidities and complications no matter how minor (e.g., hypokalemia, hypoglycaemia)

Vascular registrar (operative management)

• Send deep soft tissue for culture and histology
• If bone definitely (or possibly) involved
  • Send bone from affected area and proximal margin (using new and separate scalpels / bone cutters) for culture and histology
• SEND SPECIMENS FRESH IN SEPARATE JARS; NOT IN FORMALIN
  • Label origin and type very clearly (e.g., left 3^rd metatarsal bone)
• Document condition of remaining bone / tissue in op notes
  • Including LIKELIHOOD and EXTENT of persistent osteomyelitis

Infectious diseases JMO (or BPT if unavailable)

• Assist vascular JMO in ticking off all their boxes
• Document clinical assessment
  • Likelihood of osteomyelitis based on probe to bone test and investigations (as above)
  • Suitability and patient agreement for TACT
    • If unclear, ask TACT nurse to review on ward
• Discuss and review with ID registrar then consultant
  • Co-ordinate antibiotic plan (inpatient/outpatient; IV/oral; duration)
  • Facilitate early discharge to TACT if meets following criteria: First presentation; No prolonged prior antibiotics; No MRSA, MRGN, VRE
    • Otherwise, choose TACT antibiotics based on tissue cultures
    • NB: TWH pharmacy can often make first 1-2 days antibiotics
• Liaise directly with TACT to ensure they’re clear about plan
• Book for BPT / JMO clinic within 2 weeks through IMACS (ext. 5898)

Consensus protocol for Huber / Villalba patients managed in collaboration with Infectious Diseases unit