Service Development Tool for the Assessment of Provision of Services for Patients with Diabetes Related Foot Problems

Transcription

1 Division of Medicine & Community Services Service Development Tool for the Assessment of Provision of Services for Patients with Diabetes Related Foot Problems Graham Holt Advanced Practitioner / Podiatrist Pennine Acute Hospitals Trust Division of Medicine and Community Services Version 2 July 2014

2 Introduction In 1999, the government s aim was to build a modern and dependable NHS which could provide a fast, responsive, high quality service where people s needs were dealt with as a whole without being passed from pillar to post. Clinical governance established the need to focus on the activities involved in delivering high-quality patient care and therefore required the creation of systematic mechanisms that would support staff and develop health organisations (DOH, 2000). This diabetes service assessment tool provides the opportunity to address two of the key principles of clinical governance which are to highlight areas in need of improvement and to identify areas of best practice so that these can be adopted by others. In addition, this assessment tool addresses the two principle objectives set out in Standards for Better Health (DOH, 2006). Firstly, to ensure that services are safe and of an acceptable quality and secondly, to provide a framework for continuous improvement. Integral to this standards based system are National Service Frameworks and NICE guidelines which have key roles in supporting local improvements in service quality. Furthermore, an organisation s performance is no longer assessed on national targets alone but increasingly whether they are delivering high quality standards in a number of areas including NSF s and NICE guidance (DOH, 2006). In 2013, these principles are more important than ever. There is no NHS Trust or organisation that hasn t been affected by the austerity measures and careful handling of resources is essential. The role of community services is vital in preventing unnecessary hospitalisation and having the pathways and skills in place to facilitate earlier discharge of patients to community, resulting in beds being freed sooner and more cost effective management of the patient. By using this tool, Trusts and services can highlight areas of improvement to ensure quality and parity of care for patients with diabetes related foot problems. In addition, this tool can be used in conjunction with the TRIE-Pod competency framework for integrated diabetic foot care (2012) ensuring that practitioners of all bands have the appropriate skills to deliver quality, cost effective care.

3 This updated diabetes service assessment tool has been developed using Guidelines for the Prevention and Management of Foot Problems for Patients with Diabetes published by the North West Podiatry Services Diabetes Clinical Effectiveness Group (NWCEG). These guidelines have been developed using International, National and local guidance as well as critically appraised published articles and includes reference to the new Putting Feet First (DUK,2012), Quality Outcome Framework (DOH, 2011) and TRIEPod-Uk (2012) competency documents. Where there is limited evidence a consensus of expert opinion has been used. This makes the NWCEG guidance a One-Stop-Shop for managing the diabetic foot.

4 How to use this audit tool Compare your service to each of the following standards as laid out in the guidance and rate each standard according to the following: Green Evidence can be provided that the service meets all aspects of the guidance Amber Evidence can be provided that the service meets some aspects of the guidance Red No evidence can be provided that the service meets the guidance Please note: A verbal agreement that these processes take place is not considered evidence. Evidence is shown through forms, pathways, advice leaflets, governance documents and policies and procedures that demonstrate the meeting of these guidelines. For full guidance visit

5 Risk Identification / Patient Assessment As part of an annual review, trained personnel should examine the patient s feet to detect risk factors for ulceration. Essential Standards The patient s perception of their problem is identified and their related perceived needs: Current beliefs, effects on life, barriers to acting on standard advice A full medical history is taken: such as Rheumatoid Arthritis, PVD, Renal disease, familial A full surgical history is taken: such as vascular, orthopaedic, amputation A medication assessment is undertaken: Complete list of medication should be obtained including prescribed, over the counter, herbal and recreational Diabetes Status is assessed: Latest HbA1C, current pre-meal blood sugars Social Factors are identified: Social Isolation, housebound, ability to self care, smoking, alcohol Activity levels are assessed: High (e.g. employed), moderate, low Peripheral Vascular Status is established: palpable foot pulses, intermittent claudication, rest pain, venous disease, oedema Peripheral Neuropathy status is established: 10g monofilament or 128 MHz tuning fork. Foot Type is established: excess pronation/hypermobility, excess supination/rigidity, toe/foot deformity, ankle equinus Footwear is assessed: Plantar Cushioning, toe box depth/width, flexible/rigid rocker sole Patient s quality of vision is established: Can the patient see the foot clearly? Reassessment of the foot should be performed on an annual basis where no previous complications have been found If a patient is admitted into hospital Immediate assessment of the foot (within 4 hours) is undertaken by a member of the admitting medical / nursing team. In Situ dressings are removed to establish severity of the wound. Feet / wounds are assessed for clinical signs of infection Patient s feet are checked for other inflammatory conditions such as Charcot Neuroarthropathy, fracture, dislocation, critical limb ischaemia

6 Patient s Lipid levels are checked Patient s Blood Pressure is checked BMI / waist measurement is checked Patient s renal function is recorded Vascular Assessment Regular (at least annual) visual inspection of a patient s feet and palpation of foot pulses by trained personnel is important for the detection of risk factors for ulceration. Pedal pulses (Dorsalis Pedis & Posterior Tibial) are palpated and the results recorded. If both pedal pulses in one foot are not palpable the patient is identified as increased risk. If pulses are not palpable, a Doppler assessment is performed to establish presence and quality of pulse. If the pulse is considered to be monophasic an Ankle Brachial Pressure Index test is performed Patient is assessed for symptoms of claudication using the Edinburgh claudication questionnaire The popliteal and femoral pulses are palpated and insonated with hand held Doppler Patient is assessed for other cardiovascular risk factors such as smoking, blood pressure, lipids, lack of exercise Neurological Assessment Testing of foot sensation should be carried out using a validated/calibrated 10g monofilament or by testing vibration perception with a 128 MHz tuning fork.

7 Neuropathy is identified using a 10g Monofilament and / or 128 MHz tuning fork Sites suggested for the monofilament are the plantar aspect of the hallux and 1 st & 5 th Metatarsal heads The monofilament should be applied 3 times at each site and include a sham application Protective sensation is absent at any site with two out of three incorrect answers The 128 MHz tuning fork is applied to a bony part on the dorsal aspect of the distal phalanx of the hallux The 128 MHz tuning fork should be applied 3 times and include a sham application in which the tuning fork is not vibrating Patient is assessed for symptoms of painful neuropathy A Neurothesiometer assessment is performed (>25v = reduced perception threshold) Neuropathy disability score is done Foot Deformity Assessment Patients with diabetes presenting with deformity such as prominence of the metatarsal heads, clawing of the toes, Charcot prominences or hallux valgus should be classified increased risk. Patient is assessed for plantar callus Patient is assessed for any nail pathologies Patient is assessed for any skin infections Any previous ulceration / amputation is established Any foot / toe structural abnormality is established Suitability of footwear is assessed Risk Category Patients are categorised as Low Risk, Increased / High Risk Emergency Foot i.e. ulceration / Charcot

8 Management of the Low Risk Foot The aim is to prevent patients from developing risk factors for ulceration / amputation and to improve knowledge and encourage self care to improve outcomes Management plan agreed with the patient which addresses their clinical needs. Group or individual patient education is arranged. Arrangements are made for annual re-assessment of risk factors for foot ulceration. Glycaemic control and modifiable cardiovascular risk factors are considered and patient referred as appropriate. Contact details for emergency access to Foot Protection Team are given. Patients are informed specifically on the key vascular risks associated with diabetes and lower limb arterial disease, namely heart attacks, strokes and amputations and a management plan negotiated. Health Education & Behavioural Change The provision of patient education is a central pillar to diabetes care. All patients with diabetes should have access to education which should include the following: Patients are given details of where and when to seek advice (including out of hours provision). Patients are told what services to expect regarding foot care. Patients are told the potential consequences of neglecting their feet. Patients are told how to manage symptoms (e.g. pain, odour). All patients with diabetes have access to foot health educational materials in a variety of formats. Podiatrists use a care planning approach to a consultation in an attempt to develop an agreed negotiated, goal focussed approach to management.

9 Management of the Increased / High Risk foot To help prevent patients with identified risk factors from developing ulceration or having amputation. Patients receive regular Podiatry treatment by a Foot Protection Team. Frequency of provision of skin and nail care is dictated according to need. Patients are given education regarding footwear and Footcare. Patient has emergency access to a Foot Protection Team including self-referral within one working day. Patients have assessment and review of footwear provision. Patients are referred for specialist footwear opinion if appropriate Patients receive assessments for orthotic provision Patients are referred for assessment of control of diabetes (if required) Patient are assessed and referred for other lifestyle changes including smoking, alcohol intake, exercise, weight loss as required Patients are referred for assessment and appropriate treatment of neuropathic pain including optimising glycaemic control and neuropathic analgesics. Podiatrists use a care planning approach to a consultation in an attempt to develop an agreed, negotiated, goal focussed approach to management. Ensure patient has had diabetes annual review Patients are informed specifically on the key vascular risks associated with diabetes and lower limb arterial disease, namely heart attacks, strokes and amputations and a management plan negotiated.

10 Additional standards for patients identified with Ischaemia Patients are referred for a full, non invasive vascular assessment of the lower limb whether symptomatic or asymptomatic. On diagnosis of PAD, patients are referred for consideration of optimal medical management of cardiovascular risk factors i.e. hypertension, anti-platelet therapy and lipid lowering drugs Patients are made aware of smoking cessation strategies Patients are given education regarding lifestyle changes including exercise, alcohol intake, weight loss Patients receive advanced vascular investigation by a podiatrist with specialist skills Patients have rapid access to a vascular specialist team especially for patients with CLI Exercise regimes are advised as they are beneficial for improving patients cardiovascular outcomes generally People with Intermittent Claudication are educated about and referred to supervised exercise programmes where available.

11 Management of the ULCERATED FOOT A new foot emergency including ulceration should be referred and treated by the multidisciplinary foot care team within 24 hours. New foot emergency has been described as: New ulceration (wound) New swelling New discolouration (redder, bluer, paler, blacker over al or part of the foot). The multidisciplinary Footcare team should comprise of highly trained specialist podiatrists, orthotists, nurses with training of diabetic foot wounds and diabetologists with expertise in lower limb complications. They should have unhindered access to suites for managing major wounds, urgent in-patient facilities, antibiotics administration, community nursing, microbiology diagnostic and advisory services, orthopaedic / podiatry surgery, vascular surgery, investigational radiology and orthotics. New foot emergencies are referred to a MDT within one working day. If not already in pace, the service is working towards having access for referral and treatment by the MDT within 24 hours. The podiatrist should identify whether the level of skill required to manage the wound is within their competence and/or whether they have access to the necessary support e.g. diagnostics. If not, there should be a pathway in place for referral to an appropriate practitioner e.g. specialist podiatrist. All people with a diabetes related foot ulcer should be referred to a multidisciplinary diabetes foot care team within 24 working hours if such a team exists within the Trust. Pathways for rapid referral of people with deteriorating or static diabetes related foot ulceration are established. All people with critical limb ischaemia are assessed by a vascular multidisciplinary team before treatment decisions are made. Major amputation is not offered to people with critical limb ischaemia unless all options for revascularisation have been considered by a vascular MDT. Podiatrists have access to an opinion from Microbiology in the case of diabetes related foot infection

12 Assessment of the ULCERATED FOOT In addition to the previous assessment components in the risk factor identification chapter, appropriate consideration should also be given to the following: Ulcer type is identified e.g. Neuropathic, Ischaemic, Neuroischaemic Ulcer cause is identified e.g. trauma, footwear, excess activity Ulcer status is identified: Depth, area, slough, necrosis, callus, colonisation/infection, pain Wounds are classified using a standard system such as Texas or SINBAD. Patients receives full clinical assessment for PAD with appropriate use of Doppler analysis, ABPI s and access to a vascular team for further investigation Patient is assessed for Neuropathy using vibration perception threshold Patient is assessed for Foot Type including gait analysis, foot pressure measurement and footwear Patient s ulcer status is assessed including x-ray, MRI scan, swab & culture and bone biopsy Treatment of the ULCERATED FOOT When choosing wound dressings, the Health Care Professional in the MDT should take into account the wound, patient preference and the clinical circumstances and use wound dressings with the lowest acquisition cost. Wounds should be closely monitored and dressings changed regularly. Debridement should only be done by professionals from the MDT using the technique which best matches their expertise, clinical experience, patient preference and site of the ulcer

13 Treatment of the ULCERATED FOOT All diabetes related foot ulcers with an undetermined depth are probed with a blunt sterile probe to establish its full extent. In the absence of significant arterial disease the ulcer should be sharp debrided of all callus/necrotic/sloughy tissue. The wound bed is managed with appropriate debridement and dressing choice. If available refer to local trust guidelines / formulary for appropriate wound care products. Where extensive tissue death of digits has occurred (local gangrene) dressings must be used which dry the necrosis out to encourage auto amputation and discourage spread of infection via moist necrosis Wounds requiring extensive debridement (bones, tendons, necrotic tissue) are undertaken with support and consultation with the multi-disciplinary team X-ray and subsequent tests (CT/MRI) are undertaken when the following occurs: A positive probe to bone test Suspected Osteomyelitis Suspected Charcot Neuroarthropathy Patients with non-healing ulcers (i.e. minimum duration of 6 weeks) Sausage shaped toes Where exudate is expected to be synovial in origin Infection Management Broad spectrum antibiotics should be sought initially for ulcers with associated cellulitis/pus, increasing pain or penetrating to bone. Subsequently decisions must be made subject to microbiological findings and clinical response (SIGN 2001). Start antibiotic therapy based on infection severity (Lipsky 2012) using the antibiotic with the lowest acquisition cost appropriate for the clinical situation. Take into account local antibiotic guidelines as well as the microbiology results. Do not delay starting therapy for suspected OM pending MRI results. For mild infections offer oral Antibiotics with activity against gram + organisms for moderate and severe infections offer antibiotics with activity against gram+ and gram- organisms and anaerobic bacteria. For moderate use oral or I/V for severe start with I/V and then reassess.

14 Where clinical infection is suspected appropriate antibiotics are commenced as soon as possible. Antibiotic prescription follows local antibiotic protocol. Severity of infection should follow the Lipsky Severity Table. Topical antimicrobials are considered for locally infected or colonised ulcers. e.g. iodine and silver Where there is deep or systemic infection and ulcerations with vascular compromise a two-pronged attack is used consisting of systemic antibiotics and topical antimicrobials Swabbing of ulcers and management of antibiotic resistant bacteria follows local trust guidelines Offloading the ULCERATED FOOT Patients with a plantar ulcer are initially supplied with a minimum standard of 7-10mm poron full length insole in a Darco / Derby sandal Podiatrist working with diabetic foot ulcers can make, provide or have access to total contact casts / removable cast walkers / other off loading devices Behaviour Change / Structured Patient Centred Education At the point of presentation all patients with foot ulcerations are provided with written contact details for accessing the clinic All patients with a foot ulcer receive education which encourages partnership in decision making and supports them in achieving the best clinical outcome for their presenting foot ulceration All patient advice is documented in the patient s notes and followed up at subsequent appointments An agreed plan of management between the patient and the podiatrist is negotiated that is mutually acceptable to both patient and clinician to achieve adequate levels of care. Patient education adopts behaviour change strategies which encourage patient interaction both during consultations and when away from the clinic.

15 Wound documentation All assessment, treatment advice and action details are recorded in line with local Trust Documentation Policy / information governance policy. Informed consent is obtained using NHS consent form 3 for radical debridement of wounds or other interventions e.g. using larval therapy Management of CHARCOT NEUROARTHROPATHY Diagnosis should be made by clinical examination, patient history including onset supported by the use of thermography. Diagnosis / Investigations Differential diagnosis between Charcot Neuroarthropathy and infection Patient is checked for good blood supply to lower limb with evidence of neuropathy. Patient s foot is assessed for obvious signs of tissue trauma, cellulitis or systemic toxicity to rule out infection. Patient is assessed for history of trauma. Patient is assessed for heat differentiation between the limbs using thermography. Patient receives Biochemical profiling as indicated e.g. HbA1c, ESR and C-Reactive protein. Patient receives X-Ray for baseline and to exclude diabetic neuropathic fracture. If Charcot foot suspected consider MRI, bone scan.

16 Management Patient receives urgent immobilisation until heat differentiation disappears and bone activity reduces. Patients are given education on the causes and management of Charcot foot and advice on the prevention of complications. All suspected cases of Charcot foot are reviewed by a consultant physician to review treatment options. Consideration is given to referral to an Orthopaedic surgeon for assessment and discussion of appropriate surgical procedures. Long term management Patient is provided with long-term pressure relief with footwear and orthoses as appropriate. Refer to orthotist or specialist Podiatrist. Patient is classified as High Risk and reviewed regularly for signs of long-term complications.

17 References Department of Health (2000). The NHS plan: a plan for investment, a plan for reform. Department of Health (2004 updated 2006). Standards for Better Health Diabetes UK (2012). Putting Feet First. National Institute for Health and Clinical Excellence (2011). Diabetes in adults: Quality Standards. London. TRIEPodD-UK (2012). Podiatry competency framework for integrated diabetic foot care a user s guide. TRIEpodD-UK. London.