Christine Wiebe

September 18, 2014

VIENNA — Clinicians should stop telling visually impaired patients with diabetes to "ask family and friends" to examine their feet, because "most people don't want…that," says one expert in the field.

While early detection of neuropathic disease is vital, especially in these high-risk patients, telling them to solicit the help of others for foot screenings is an "ineffective intervention," said Ann Williams, PhD, RN, research associate professor at the Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, Ohio.

Dr. Williams presented a poster detailing her research on this issue here at the European Association for the Study of Diabetes 2014 Meeting. She and her team conducted a pilot project aimed at teaching visually impaired patients with diabetes how to conduct their own foot exams.

In another poster session, UK researchers tried to identify the major barriers to diabetic-foot examination in their own hospital.

Although the United Kingdom's National Institute of Clinical Excellence (NICE) has recommended that all diabetic patients get a foot exam within 24 hours of any hospital admission, that actually happens in less than 38% of such cases, according to a 2013 national audit, reported Andrew J. Welch, MD, of Basingstoke Hospital, United Kingdom.

And in a survey at their own institution, Dr. Welch and colleagues were able to show an even lower rate, of just 13% of diabetic patients getting a foot exam within 24 hours. Following this, they implemented a series of interventions among hospital staff, such as reminder stickers and educational sessions, which resulted in improved rates of foot examination.

Pilot Project for Self Foot Examination in Visually Impaired

Patients often are embarrassed to ask others to touch their feet or are reluctant to ask yet another "favor" from people they already rely on for so much assistance, Dr. Williams explained. Hence, she designed her pilot project, in which a group of 52 visually impaired diabetic patients were randomly assigned to either an experimental or comparison foot-care group.

Both groups were given comprehensive self-management diabetes education, with an emphasis on foot care; they also were told to call a podiatrist involved in the study if they found new foot problems.

In addition, the experimental group was taught to conduct daily foot exams by themselves, relying on their own senses of touch and smell to try to identify cuts, swelling, warmth, or other changes, including unusual foot odors. The comparison group was instructed to ask someone else to visually inspect their feet every day (usual care).

After 6 months, both groups self-reported similar average numbers of foot exams per month, around 22. But the ability to follow the study guidance was very different for the 2 groups.

In the experimental group, most participants did conduct nonvisual exams on themselves on most days. But in the comparison group, many participants only rarely or never asked others to examine their feet. Instead, they did their own self-exams without having received any screening education.

Patients in the experimental group found more new foot problems — mostly early-stage disease, along with actual ulcers — compared with those in the other group. In addition, participants who were taught to self-screen reported finding the foot examinations highly acceptable.

During the poster presentation, some clinicians questioned whether diabetes patients who were already visually impaired would have sufficient tactile sensation to adequately examine their own feet. Dr. Williams said she screened out such patients for this pilot study, adding that the sense of smell still remained a powerful predictor of foot disease.

One patient, she said, detected a foul odor when removing a sock and immediately followed up with the podiatrist, who found a small but aggressive infection underneath her big toe. The patient's ability to recognize a potentially important problem, rather than simply trying to wash away the odor, may have prevented an amputation, she concluded.

Intervention, Regular Hospital-Based Teaching, Will Help

Meanwhile, in the United Kingdom, Dr. Welch and his team surveyed physicians and a few other healthcare workers at their hospital to identify barriers to foot exams. They had a 70% response rate: 51% of those who replied were doctors in training, 30% were consultants, and 9% medical students/diabetes nurses.

Of the respondents, 96% believed foot exams of diabetic patients were important, but only 56% said they conducted them routinely.

The survey identified a number of barriers to foot exams, including time constraints (86%), forgetting (68%), lack of training (56%), foot odor (16%), and foot phobia (11%).

On the survey, 69% admitted to examining less than half of their admissions and 94% examined less than half of patients' footwear. In addition, 10% of respondents indicated that examining patients' feet was not their responsibility.

The hospital staff also were asked what they considered the greatest risk factors for developing diabetic foot ulcers, and 80% identified poor blood sugar control as a cause. Other risk factors pinpointed in the survey were ill-fitting footwear (60%), peripheral neuropathy (54%), and peripheral vascular disease (49%).

Following the interventions that they implemented, compliance rose from just 13% of diabetic patients getting a foot exam within 24 hours to 53% getting one.

"Simple local interventions have the potential to significantly increase compliance with foot examinations. Regular hospital-based teaching should be made more widely available with refresher courses for consultants," they conclude.

European Association for the Study of Diabetes 2014 Meeting; September 17, 2014; Vienna, Austria. Abstract 1141, Abstract 1140

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