Keeping the diabetic foot healed How effective is the Newcastle Foot Protection Team? Linda Robertshaw Advanced Podiatrist Nicola Coates Principal Podiatrist (Diabetes)
Background Risk factors for diabetic foot ulceration Peripheral arterial disease Peripheral neuropathy Foot deformity Previous history of foot ulceration Newcastle Podiatry Department Diabetes caseload by category 0 risk factors = Low risk (DBL) 1 risk factor = Increased risk (DBI) 2 risk factors = High risk (DBH) History of previous foot ulcer Current foot ulceration = High risk (DBH) = Ulcerated (DBU)
Newcastle Podiatry Clinical Guideline Diabetic Foot Risk Classification Revised July 2014 (Review July 2016) DBL LOW DBI INCREASED DBH HIGH DBU ULCERATED Priority 5 Priority 4 Priority 2 Priority 1 8/8 monofilament score OR < 25v neurothesiometer score AND < 8/8 monofilament score OR >25v neurothesiometer score (or unreliable test result) OR <8/8 monofilament score or >25 neurothesiometer score (or unreliable test result) AND /OR v4 Current diabetic foot ulcer (after 1 month of ulcer healing then change back to DBH). At least one pulse on each foot palpable OR At least one Pulse on each foot triphasic or biphasic with Doppler No signs of ischaemia or rest pain or symptoms of intermittent claudication AND No foot deformity or lesions or History of foot ulcer Both pulses on at least one foot absent to palpation, OR Both pulses on at least one foot monophasic with Doppler, OR Previous lower limb angioplasty or bypass surgery OR Rest pain or symptoms of intermittent claudication OR Foot deformity with resulting pressure area /lesion including nail pathologies, corns, callous Eye sight problems Immunosuppressant therapy or conditions including pancreas transplant patients Renal Dialysis Both pulses on at least one foot absent to palpation, OR Both pulses on at least one foot monophasic with Doppler, OR Previous lower limb angioplasty or bypass surgery OR Rest pain or symptoms of intermittent claudication AND/OR Foot deformity with resulting pressure area/lesion including nail pathologies, corns, callous Eye sight problems History of foot ulcer or amputation Immunosuppressant therapy or conditions including pancreas transplant patients Renal dialysis No risk factors 1 risk factor 2 or more risk factors Diabetes leaflet 1,2 as appropriate Diabetes leaflet 1,2,3,4 as appropriate Diabetes leaflet 1,2,3,4,5,6 as appropriate Diabetes leaflet 2,3,4,5,6 as appropriate Annual Review minimum 6 monthly minimum 3 monthly minimum As requested by Podiatrist. (NICE CG010 recommendation) (NICE CG010 recommendation) (NICE CG010 recommendation) (NICE CG010 recommendation) If no treatment required Discharge Basic package with Podiatry Assistant Basic package with Podiatry Assistant or CC for treatment and assessment for annual assessment only to GP or cc package for preventative cc package for preventative treatment with podiatrist Practice or Newcastle Diabetes treatment with Podiatrist. with Podiatrist. Centre (wherever patient has annual review) First diabetic assessment with podiatrist then Annual Podiatry assistant Screening (as per pathway for diabetic foot assessment) Basic Appointment as available if clinically required Annual Diabetic assessment with Podiatrist or annual PAS if basic care only required. Annual Diabetic Assessment with Podiatrist Refer to NDC up to 6 weeks of duration and not healing. If unable to refer to NDC then discuss with Diabetes team lead as per Newcastle Diabetes Footcare Pathway Not more than 8 weeks overdue Must not be overdue Appointment booked by Podiatrist, or to be offered on time
All patients with Diabetes and a Newcastle GP As per NICE CG010 24,000 contacts for patients with Diabetes in 2012/13 Stage 1 Annual foot assess only GP practice, or consultant (Training delivered by podiatry) LOW RISK PTS Stage 2 Community podiatry Annual assess and treatment Podiatrist or pod assistant Risk Categorised 6,600 patients Stage 3 Diabetes Centre Podiatry assess & treatment of Complex foot 300 pts. Stage 4 Medical foot clinic Diabetes Centre Multi- Disciplinary management of complex & Acute Diabetic foot 60 pts. Patient with Diabetes admitted to a Newcastle hospital ( as per NICE CG119-2011)
Audit protocol Aim To establish the percentage of patients with a previously healed diabetic foot ulcer who remain ulcer-free at 24 months and, for those who did re-ulcerate, the time they remained ulcer-free. Standard 58% of patients with a previously healed foot ulcer remained ulcer-free at 6 months follow up. (Pound et al. Diab Med. 2005)
Sample People with diabetes classified as DBH with a history of a previously healed diabetic foot ulcer and who attended one of the Newcastle Community Podiatry Clinics during the period of January 2011 to December 2012. Data collection Length of time, in months, between the one diabetic foot ulcer healing and another diabetic foot ulcer occurring (in a follow up period of 24 months). Age Sex Type of diabetes
Results Results Total number of patients with a healed diabetic foot ulcer who attended a Community Podiatry clinic between January 2011 and December 2012 = 83 Number of patients remaining in the audit = 72 Number of these patients who died during the 24 month period (remaining healed up to that point) =11 (13%) Number who re-ulcerated during the 24 month period = 27 Number of patients remaining ulcer-free for at least 24 months = 45 (62%) This is comparable to the 58% from the previous audit by Pound et al.
Median of 4.2 months in audit by Pound et al Median of 10.5 months in this Newcastle audit.
11 patients remained healed up to their deaths: 13% (same % as audit by Pound et al) 7 males 4 females All Type 2 DM Mean age 80 (range 64 92) 72 remaining patients: 39 males 33 females 2 Type 1 DM 70 Type 2 DM Mean age 71 (range 35 95)
Characteristics of the group who re-ulcerated: 18 males 9 females 2 Type 1 DM 25 Type 2 DM Mean age 73 (age range 43 87) Characteristics of the group who remained healed: 21 males 24 females All Type 2 DM Mean age 71 (age range 35 95)
Conclusion This sample is transferable to all of Newcastle because services are delivered equally to all clinics and waiting lists are managed across the city; not per site. So, in conclusion, we can say that the Newcastle Foot Protection Team 62% of the HIGHEST RISK patients ulcer-free for at least 2 years.
Follow-up audit The 45 patients remaining ulcer-free at 24 months will be re-audited next year to monitor how many have remained ulcer-free for 36 months.