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High-risk foot (Vascular)

ADULT

If any of the following are present or suspected, please refer the patient to the emergency department (via ambulance if necessary) or seek emergent medical advice if in a remote region.


  • Crescendo or multiple recent TIA (Transient Ischemic Attack) / amaurosis fugax
  • Acute stroke
  • Acute aortic dissection
  • Ruptured AAA
  • Symptomatic AAA (abdominal/back pain/tenderness, compressive symptoms, distal embolisation)
  • Axillary vein thrombosis, iliofemoral DVT
  • Acute DVT
  • Active infection in leg with peripheral arterial disease
  • Diabetic foot infection (refer to high-risk foot pathway)
  • Acute arterial ischemia/threatened limb
  • Ischaemic changes and/or threatened limb (ulcer, gangrene, rest pain)
  • Active infection in leg with peripheral arterial disease
  • Diabetic foot infection (refer to high-risk foot Healthpathway)
  • Foot ulcer with infection and systemically unwell or febrile, invasive infection or rapidly spreading cellulitis (defined by peripheral redness around the wound >2cm), acute ischaemia, wet gangrene, acute or suspected Charcot - A
  • Thrombosed AVF (refer to vascular registrar on call or the renal access nurse)
  • Refer to HealthPathways or local guidelines
  • Diabetic foot ulcer: High-risk foot clinic (referral via podiatry and access via telehealth available –- Statewide Diabetes Clinical Network will provide details)
  • For adults with diabetes, assess their risk of developing a diabetic foot problem at the following times:
    • when diabetes is diagnosed, and at least annually thereafter
    • if any foot problems arise
    • on any admission to hospital, and if there is any change in their status while they are in hospital.
  • For low risk of developing a diabetic foot problem, continue to carry out annual foot assessments, emphasise the importance of foot care, and advise they could progress to moderate or high risk
  • Basic foot care advice and the importance of foot care
  • ATSI people with diabetes are considered to be at high risk of developing foot complications until adequately assessed otherwise
  • Commence antibiotics as per therapeutic guidelines https://tgldcdp.tg.org.au/etgAccess
    Off-loading https://www.sdc.qld.edu.au/courses/176
  • Renal impairment increases the risk of amputation for people with diabetes who experience amputation rates 11 times that of the general diabetic population, which in turn is 15 times the rate in people without diabetes

Examine both feet for evidence of the following risk factors:

  • Neuropathy (use a 10g monofilament as part of a foot sensory examination)
  • Limb ischaemia (see CPC on peripheral arterial disease)
  • Ulceration
  • Callus
  • Infection and/or inflammation
  • Deformity
  • Gangrene
  • Charcot arthropathy

 

Minimum Referral Criteria

  • Category 1
    (appointment within 30 calendar days)
    • Foot ulcer or pressure injury with mild to moderate infection <2cm around wound. - B
    • Necrosis/dry gangrene (with or without ulceration) - B
    • Non-infected foot ulcer - B

    Urgent cases – (refer to key below)

    A - client to present to emergency department immediately
    B - client to present to diabetes specialist service within 24 hours.  If no specialist service is available, present to an emergency department.

  • Category 2
    (appointment within 90 calendar days)
    • Diabetic with high-risk foot*

     

    *High-risk foot has 2 or more of the following:

    • Peripheral neuropathy (PN),
    • Peripheral arterial disease (PAD),
    • Foot deformity
    • Or a history of:
      • previous amputation or
      • previous foot ulceration
  • Category 3
    (appointment within 365 calendar days)
    • Peripheral arterial disease, peripheral neuropathy or foot deformity in the absence of adequate community resources

1. Reason for request Indicate on the referral

  • To establish a diagnosis
  • For treatment or intervention
  • For advice and management
  • For specialist to take over management
  • Reassurance for GP/second opinion
  • For a specified test/investigation the GP can't order, or the patient can't afford or access
  • Reassurance for the patient/family
  • For other reason (e.g. rapidly accelerating disease progression)
  • Clinical judgement indicates a referral for specialist review is necessary

2. Essential referral information Referral will be returned without this

  • Details of all treatments offered and efficacy
  • Peripheral pulses, femoral/popliteal/foot
  • Is the ulcer neuropathic or ischaemic (or both) in origin?

3. Additional referral information Useful for processing the referral

  • Is there active infection? Consider deep wound swab/pathology for culture, ESR CRP FBC
  • Is there invasive infection with spreading cellulitis around the wound?
  • Is there bony infection? XR if required.
  • If suspected arterial disease –Doppler Ankle Brachial Pressure Index (ABPI), toe pressures, duplex scan etc
  • Appropriate medical history including claudication distance, rest pain, ischaemic changes and risk factors
  • Results of depression screening (PHQ-2)
    • over the last 2 weeks, how often have you been bothered by any of the following problems?
      • little interest or pleasure in doing things?
      • feeling down, depressed, or hopeless?

4. Request

Patient's Demographic Details

  • Full name (including aliases)
  • Date of birth
  • Residential and postal address
  • Telephone contact number/s – home, mobile and alternative
  • Medicare number (where eligible)
  • Name of the parent or caregiver (if appropriate)
  • Preferred language and interpreter requirements
  • Identifies as Aboriginal and/or Torres Strait Islander

Referring Practitioner Details

  • Full name
  • Full address
  • Contact details – telephone, fax, email
  • Provider number
  • Date of referral
  • Signature

Relevant clinical information about the condition

  • Presenting symptoms (evolution and duration)
  • Physical findings
  • Details of previous treatment (including systemic and topical medications prescribed) including the course and outcome of the treatment
  • Body mass index (BMI)
  • Details of any associated medical conditions which may affect the condition or its treatment (e.g. diabetes), noting these must be stable and controlled prior to referral
  • Current medications and dosages
  • Drug allergies
  • Alcohol, tobacco and other drugs use

Reason for request

  • To establish a diagnosis
  • For treatment or intervention
  • For advice and management
  • For specialist to take over management
  • Reassurance for GP/second opinion
  • For a specified test/investigation the GP can't order, or the patient can't afford or access
  • Reassurance for the patient/family
  • For other reason (e.g. rapidly accelerating disease progression)
  • Clinical judgement indicates a referral for specialist review is necessary

Clinical modifiers

  • Impact on employment
  • Impact on education
  • Impact on home
  • Impact on activities of daily living
  • Impact on ability to care for others
  • Impact on personal frailty or safety
  • Identifies as Aboriginal and/or Torres Strait Islander

Other relevant information

  • Willingness to have surgery (where surgery is a likely intervention)
  • Choice to be treated as a public or private patient
  • Compensable status (e.g. DVA, Work Cover, Motor Vehicle Insurance, etc.)
  • Please note that where appropriate and where available, the referral may be streamed to an associated public allied health and/or nursing service.  Access to some specific services may include initial assessment and management by associated public allied health and/or nursing, which may either facilitate or negate the need to see the public medical specialist.

  • A change in patient circumstance (such as condition deteriorating, or becoming pregnant) may affect the urgency categorisation and should be communicated as soon as possible.

  • Please indicate in the referral if the patient is unable to access mandatory tests or investigations as they incur a cost or are unavailable locally.