Storyboard submission

Transcription

1 Storyboard submission Follow the detailed instructions in this template for writing a description of your storyboard. Type your information in each section below and save this completed storyboard document as a Microsoft Word file. Please spell check your storyboard before submission as it will be published on the NHS Wales Awards website. Please note: The storyboard should be between words maximum (including references but excluding headings, images or graphs) Submit your storyboard using the online submission system at by Friday 25 January Storyboard submission 1. Storyboard Title Amputation Rates fall, through implementation of a seamless integrated diabetic foot service across Cardiff and Vale UHB 2. Brief Outline of Context (Where this improvement work was done; what sort of unit/department; what staff/client groups were involved) The improvement was implemented across primary, community and secondary care services for patients with diabetes in Cardiff and Vale UHB. This was achieved through collaborative working between Gp practices, community Podiatry, Multi-disciplinary foot teams (MDFT) in secondary care, the artificial limb and appliance centre and engagement with diabetes patient reference groups. 3. Brief Outline of Problem (Statement of problem; how they set

2 out to tackle it; how it affected patient/client care) Diabetes UK s recent narrative stated that 80% of patients who had a foot ulcer or underwent an amputation died within 5 years (1) and with an increasing diabetic population projected at 1:10 patients having diabetes by 2030 (2) required a modernised service to tackle the potential epidemic of diabetic foot disease. In 2007 a service review was undertaken on diabetic foot management across the Cardiff and Vale Health Community and a new service delivery implemented. This required a competent workforce at all levels of care. Central to achieving this new service delivery was identifying Champions for each specialist profession to lead on new patient pathways, ensuring the patients saw the right person at the right time, in the right place (Figure 1). This provision of care closer to home did not detract from the level of care but ensured that timely and appropriate interventions, leading to better outcomes and patients experience. Figure 1 Scottish Diabetes Competency Framework for the prevention, treatment and management of Diabetic foot disease (2010): Draft consultation

3 4. Assessment of Problem and Analysis of its Causes (Quantified problem; staff involvement; assessment of the cause of problem; solutions/changes needed to make improvements) Problems: o Inappropriate referrals into Podiatry service of patients with diabetes with low risk to ulceration, this originating from primary care, requiring training from Podiatry into consistency of screening used to identify at risk feet. o Skill Gap in community Podiatry wound clinics to manage patients with diabetes holistically and closer to home, requiring a competent workforce through training needs. o Inequity of diabetic wound care across C&V Health Community for diabetic foot provision, identified through service review. o No disease specific pathways in the management of Diabetic foot complications needed Multi professional approach to design new pathways. o Need for Champions of each profession involved in Active foot disease to collaboratively work to-gether as part of a MDFT in developing these new pathways and formation of a bi monthly critical peer review clinic for the most compromised. o Increasing amputation rates for patients with Diabetes, required early screening and MDFT working to halt escalation of amputations. o Patients who had undergone amputation were at increased risk to losing contra lateral limb (3) but were unknown to foot protection teams figure 2, requiring repatriation to neighbouring Health s.

4 Figure Total Amputations Unknown Patients 0 C&V UHB CWM TAFF ABM ANEURIN BEVAN Increasing elderly population having amputations figure 3, with likelihood of rehabilitation decreased due to co-morbidities. Figure 3 age of Amputation 25% % 23% 80+ 8% 41-40% Figure 2 and 3 from Podiatry amputation and repatriation database 5. Strategy for Change (How the proposed change was implemented; clear client or staff group described; explain how they disseminated the results of the analysis and plans for change to the groups involved with/affected by the planned change; include a timetable for change)

5 2007 A working group was set up to review current service provision led by the Podiatry lead for diabetes and a new delivery plan drawn up The first MDFT critical analysis clinic took place for peer review of the most compromised. Figure 4 Delivery plan taken to Diabetes patient reference groups and endorsed by them as the particular direction they would like to see foot services being provided. Disease specific pathways developed and implemented for osteomyelitis and Charcot Gp educational sessions and training booklet provided by Podiatry Service. With ongoing training of Practice nurses on foundation courses for Diabetes Podiatrists commence Diplomas in primary care management of Diabetes and Diabetic foot modules ensuring competent workforce - ongoing 2009 Collaboration between Podiatry and CNS in ALAS to notifying neighbouring Health s of new amputees ongoing Podiatrist undertake non medical referring for x-rays and access to Bloods and Swabs to aid diagnostics C&V UHB now have 12 Diabetic wound clinics, 10 of these in the community adopting a step up step down service, seeing a competent professional at each stage of their care, with weekly rapid access to orthopaedic and vascular consultants alongside a bi monthly critical analysis clinic.

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7 6. Measurement of Improvement (Details of how the effects of the planned changes were measured) Prevention is the ultimate aim with early identification of those at risk to foot ulcerations being referred on. The Quality Outcome Framework implemented into Primary care had diabetes dimension with foot screening being an indicator of measure. General practitioners in C&V UHB consistently achieve in excess of 90% available points for each indicator (figure 4), with Podiatry supported educational sessions giving some consistency to this screening. Figure 4 Quality Outcome Framework data Health Cardiff & Vale ULHB DM10 DM10 % DM29 DM29 % Number of Numerator Denominator Numerator Denominator Practices 67 18,500 19, ,922 19, DM 10. The percentage of patients with diabetes with a record of neuropathy testing in the previous 15 months DM 29. The percentage of patients with diabetes with a record of a foot examination and risk classification: 1) low risk (normal sensation, palpable pulses), 2) increased risk (neuropathy or absent pulses) 3) high risk (neuropathy or absent pulses plus deformity or skin changes in previous ulcer) 4) ulcerated foot within the preceding 15 months The Welsh Government is using Results Based accountability in the new Diabetes service delivery post National Service Framework for diabetes 2013 with amputation rates being an outcome measure. This hard end point is seen as an indication of service provision and figure 5 would appear to reflect this new integrated foot service as successful in reducing amputation rates. There was a 48% reduction in Major limb amputation rates between and a further 31% in years with no real increase in minor amputation rates in these years either. Figure 5 Amputation rates of patients who are resident in Wales and are treated in NHS hospitals in Wales and England. Operation Rates per Ten Thousand Diabetes Population¹ for Calendar Year 2009.

8 Local_Health_ Abertawe Bro Morgannwg University Local Health Aneurin Bevan Local Health Betsi Cadwaladr University Local Health Cardiff and Vale University Local Health Cwm Taf Local Health Hywel Dda Local Health Powys Teaching Local Health Operation Rates per Ten Thousand Diabetes Population¹ for Calendar Year 2010 Abertawe Bro Morgannwg University Local Health Aneurin Bevan Local Health Betsi Cadwaladr University Local Health Cardiff and Vale University Local Health Cwm Taf Local Health Hywel Dda Local Health Powys Teaching Local Health Operation Rates per Ten Thousand Diabetes Population¹ for Calendar Year 2011 Abertawe Bro Morgannwg University Local Health Aneurin Bevan Local Health Betsi Cadwaladr University Local Health Cardiff and Vale University Local Health Cwm Taf Local Health Hywel Dda Local Health Powys Teaching Local Health Footnotes Amputation Rates for Patients Diagnosed with Diabetes. Resident-based figures include episodes of patients who are resident in Wales and are treated in NHS hospitals in Wales and England. Calendar Years Date Extracted: 06/11/2012 Source: Patient Episode Database for Wales (PEDW), NHS Wales Informatics Service (NWIS). AMPUTATION OF LEG AMPUTATION OF TOE

9 7. Effects of Changes (Statement of the effects of the change; how far these changes resolve the problem that triggered the work; how this improved patient/client care; the problems encountered with the process of changes or with the changes) The introduction of an integrated service has provided equity of care across C&V UHB with a competent workforce available at the point of need. Working within pathways has ensured rapid access and in the case of the critical analysis clinic has seen the orthopaedic surgeon offering 20% of patients seen for early surgical correction and intervention, which reduce risks of future amputation. The peer support that has come from collaboratively working has led to an increased awareness of each other s scope of practice that not only gives better outcomes for patients but supports the professionals as well. The concept of peer support has proved vital allowing professionals to work in an environment of shared knowledge in an open honest manner. To-day 100% of patients who undergo amputations are repatriated into foot protection programmes within their own Health. Initially liaising with 3 other Health s proved difficult and was supported by C&V UHB with no funding, but this has improved communications between Health boards and has allowed them to review current service provision as why some of these patients were not under a Foot Protection team. 8. Lessons Learnt (Statement of lessons learnt from the work; what would be done differently next time) Being aware that all previous providers of care are informed and involved from the outset. Certainly having Champions from each profession taking responsibility, with enthusiasm and support was central to this success ensuring they represented their specialist group for continuation and succession planning 9. Message for Others (Statement of the main message they would like to convey to others, based on the experience described) Health care Professionals are patient focused and it s re-assuring to know that when asked you had Champions willing to spend time and effort for the patients benefit, just ask.

10 References 1. Derived from DUK narrative foot campaign 2012 Source: Office of National Statistics (2010). Cancer survival in England: one year and five year survival for 21 common cancers, by sex and age. Moulik K., et al. (2003). Amputation and mortality in new-onset diabetic foot ulcers stratified by etiology 2. APHO Diabetes Prevalence Model. Updated 28/09/ Rajani K et al 2007, Re-amputation occurrence in the diabetic population in South Wales, UK. International wound Journal, volume 4, issue 4, p