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Wounds on the High-Risk Foot

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.


Wounds of traumatic aetiology

  • Systemic inflammatory response symptoms (SIRS) or clinically unwell
  • Wounds with complex foreign body involvement and significant damage to associated surrounding structures including blood vessels, nerves, muscles, joints and tendons. 
  • Wounds with associated compound fractures
  • Persistent significant bleeding not controlled with usual measures 
  • Worsening pain and/or pain not in keeping with mechanism of injury
  • Initial acute burns should be managed as per ANZBA guidelines
  • Refer to Vascular High Risk Foot CPC or Diabetic High Risk Foot CPC 

Arterial/ischaemic ulcer

  • Systemic inflammatory response symptoms (SIRS) or clinically unwell
  • Worsening pain and/or pain not in keeping with progression of the wound/ulcer
  • Sepsis or acutely unwell due to infection3
  • Acute or critical limb ischaemia with necrosis
  • Rapidly deteriorating ulceration or necrosis.3
  • Ulcers or wounds in a limb with markedly compromised circulation

Wounds on the High-Risk Foot

  • Systemic inflammatory response symptoms (SIRS) or clinically unwell
  • Worsening pain and/or pain not in keeping with progression of the wound/ulcer
  • Progressive cellulitis despite initial treatment
  • Acute or critical limb ischaemia with necrosis
  • Acute Charcot arthropathy if access to podiatry is not accessible within 48 hours

Stoma related wounds

  • Systemic inflammatory response symptoms (SIRS) or clinically unwell
  • Worsening pain and/or pain not in keeping with progression of the wound
  • Progressive cellulitis despite initial treatment
  • Suspected incarcerated hernia or underlying abscess
  • Suspected bowel obstruction resulting in non-functioning stoma
  • Persistent significant bleeding not controlled with usual measures 
  • Stomal change in colour from red / pink to blue or black
  • Stomal prolapse causing circulatory compromise
  • Bleeding peristomal varices
  • Ongoing high output stoma and signs of dehydration

NB: If the problem is with the stomal appliance the patient can self-refer to stomal therapy nurse.  Patients not in contact with regular stomal therapy nurse/service can be referred by GP.

Pressure injury

  • Systemic inflammatory response symptoms (SIRS) or clinically unwell
  • Worsening pain and/or pain not in keeping with progression of the wound/ulcer
  • Pressure injury if causing systemic infection
  • Patients with spinal injuries should be referred to Spinal Outreach Team (SPOT)

Post-operative wound/dehiscence

  • Systemic inflammatory response symptoms (SIRS) or clinically unwell
  • Worsening pain and/or pain not in keeping with progression of the wound/ulcer
  • Prosthesis / metal work is on view
  • Purulent discharge with associated fevers

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

Refer to HealthPathways or local guidelines

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

Diabetic foot Australia

Minimum Referral Criteria

  • Category 1
    (appointment within 30 calendar days)
    • Foot ulcer or pressure injury with mild to moderate infection <2cm around wound*
    • Necrosis/dry gangrene (with or without ulceration) *
    • Non-infected foot ulcer.  For optimal care, a patient with an ulcer will be reviewed within 48 hours by a specialist High Risk Foot Service
    • Foot wound with known peripheral arterial disease, peripheral neuropathy, or foot deformity in the absence of adequate community resources

    *client to present to High Risk Foot Service within 48 hours.  If no High-Risk Foot service is available, consult with a specialist service via telehealth, or present to an emergency department.

  • Category 2
    (appointment within 90 calendar days)
    • No category 2 criteria
  • Category 3
    (appointment within 365 calendar days)
    • No category 3 criteria

Please insert the below information and minimum referral criteria into referral

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

  • Co-morbidities and past medical history 
  • Details of all treatments offered, and efficacy to date e.g. type of dressings used, date of commencement of any antibiotics with dose prescribed.

3. Additional referral information Useful for processing the referral

  • Relevant clinical history / vascular referrals including previous history of Charcot arthropathy
  • History of allergies and list of current medications
  • Current podiatry treatment/dressing regimen, toe pressures if available 
  • Relevant pathology (as clinically indicated)
  • Recent vascular imaging (duplex studies, ABPI if already completed)
  • Relevant medical imaging results if available –i.e. x-ray, ultrasound 
  • Clinical photograph – with patient’s consent, where secure image transfer, identification and storage is possible

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.

 

Version: 3
Last updated: 11 June 2021

© State of Queensland (Queensland Health) 2021

Except as permitted under the Copyright Act 1968, no part of this work may be reproduced, communicated or adapted without permission from Queensland Health. To request permission email ip_officer@health.qld.gov.au.

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