Insights for Diabetes Excellence, Access and Learning

 A joint D-Foot and iDEAL initiative.

Delay in reaching specialist care and how to reduce it.

Amputations can be avoided if foot ulcers are effectively detected, assessed, referred and rapidly treated. 

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Delay in reaching specialist care and how to reduce it.

Michael Edmonds, Jayne Robbie, Anne Phillips and Marco Meloni

Amputations can be avoided if foot ulcers are effectively detected, assessed, referred and rapidly treated. 

Poor symptom recognition, and a lack of knowledge, or failure to understand the severity of a foot problem in a person with diabetes can result in a delay in reaching specialist care. Both persons with diabetes and health care professionals may not appreciate the warning signs that precede the need for an amputation. Even after persons with have reached a health care professional, there may be delay in referring to specialised care because of a failure to make a diagnosis.  Health care professionals may not recognise infection or ischaemia in the absence of pain because of concomitant neuropathy and even after recognition of the seriousness of foot disease, the importance of specialised care may not be appreciated by some health care professionals due to inaccurate health care assessments. 

In order to promote urgent referral to specialist care, the iDEAL group (a multi-disciplinary team of specialists with a key interest in improving diabetes care outcomes across the UK) has devised the acronym ACT NOW! with direct input from a person with diabetes. This will enable both people with diabetes and their carers to recognise the warning signs which may result in amputation.

The acronym is:

Accident: Has there been a recent accident or trauma to the foot?
Change: Is there any new swelling, redness or change of shape of the foot?
Temperature: Is there is a change in temperature? Could this be an infection or possible Charcot?
New pain: Is there new pain present? Is it localised or generalised throughout the foot?
Oozing: Is there any discharge from the foot?
Wound: Is there a blister or break in the skin?

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The identification of these symptoms and signs should give persons with diabetes permission and confidence to seek urgent help and to activate rapid referral to specialised care. It has been designed to be easy to use, effective and reliable, and is particularly relevant during these times of the COVID-19 pandemic with remote digital consultations, social distancing and with reduced numbers of diabetes foot care checks being undertaken.

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It is also important that health care professionals should be aware of the ACT NOW! Tool.

This consists of the ACT NOW! acronym and also a Checklist which enables people with diabetes, their carers and health care professionals to enquire and document the ACT NOW!  symptoms or signs and to take possible further information such as a digital photo. 

The Checklist can then be used as a referral document to specialist care. 

Alternatively, the Checklist can be used when people with diabetes present for routine assessment with their health care professionals.

Adopting and using the ACT NOW! acronym and  Checklist will have the potential to make a profound impact and to help people with diabetes to access timely assessment and referral.


We hope that D-Foot International might share the ACT NOW!  Acronym amongst its individual and constituent members and this would contribute to its mission of ending avoidable lower-limb amputations due to diabetes worldwide.

Resources:  iDEAL has downloadable ACT NOW! resources and educational material which can be accessed from the website at