Implementing the updated NICE Guidance on the Diabetic Foot Rachel Berrington Senior Diabetes Specialist Nurse Foot Lead University Hospitals of Leicester NHS Trust
Key Priorities for Implementation NG19 Care within 24 hours of a person being admitted to hospital Care across all care settings Assessing the risk of developing a diabetic foot problem Diabetic foot referrals Diabetic foot infection Charcot arthropathy
Care Across all Settings Training and competency Special arrangements for people with disabilities Integrated pathways Screening Foot Protection Service (FPS) Multidisciplinary Diabetic Foot Service (MDFS) Orthoses and Footwear
Children under 12 Basic foot care advice Young people 12-17 Annual assessment Adults On diagnosis Annually Admission to hospital or change in status Assessing the Risk Neuropathy Limb Ischaemia Ulceration Callus Infection/Inflammation Deformity Gangrene Charcot
Diabetic Foot Infection Use soft tissue or bone samples from the base of a debrided wound Locally developed antibiotic guidelines implementation across primary and secondary care Consider osteomyelitis duration of treatment
Why Classify Wounds NG19 Use a standardised system to document the severity of the foot ulcer, such as the SINBAD or the University of Texas classification system
Orthotics NICE health economist looked at the cost effectiveness of providing custom orthotic footwear Footwear is cost-effective in the prevention of primary ulceration and re-ulceration in the diabetic foot Between 82 and 671 is cost effective when provided to moderate and high risk people Cost is 671-859, footwear is only cost effective for high risk patients Financial investment needed to provide this footwear would have a huge impact on the NHS - given the current budget constraints unlikely to occur
Charcot Arthropathy Raise awareness to people with diabetes & health care professional High amputation rates when deformity occurs Effect on the individuals life Refer the person within 1 working day to the MDFT for triage within 1 further working day Offer non-weight-bearing treatment until definitive treatment started by the MDFT
Risk Assessment Low risk (0 risk factors except callous alone) Annual foot assessment and education Moderate risk (1 risk factor deformity, neuropathy or non-critical limb ischaemia) Referred to FPS, for New Patient assessment in 6-8 weeks Follow up 3-6 months
Risk Assessment High risk (2+ risk factors) Previous ulceration Previous amputation Renal replacement therapy Neuropathy and non-critical limb ischaemia Neuropathy in combination with callus and/or deformity Non-critical limb ischaemia in combination with callus and/or deformity - Refer to FPS for New Patient assessment within 2-4 weeks - Follow up 1-2 months no immediate concern - 1-2 weeks immediate concern
Active Diabetic Foot Problems Ulceration, spreading infection, critical limb ischaemia, gangrene or suspicion of acute Charcot Refer people with active diabetic foot problems within 1 working day to the FPS or MDFS according to local protocols and pathways Triaged within 1 further working day
Limb and Life Threatening Immediate referral to acute services for limb or life threatening diabetic foot problems
Structure of footcare services Response to National Diabetes Foot Care Audit (NDFA)- Structures Audit questionnaire received from only 60 per cent of commissioners (CCGs in England and LHBs in Wales) Only 62% of those responding were able to give a definitive answer to all three questions Foot care service Yes No Don't know Conflicting response Not recorded Training for routine diabetic foot examinations 57% 19% 20% 4% 0% Foot protection service 77% 10% 6% 4% 3% Pathway for assessment within 24 hrs 54% 25% 9% 2% 11%
Reason for Diabetes Related Admission Reason for admission 2010 2011 2012 2013 2015 Foot Disease Hypoglycaemia Hyperglycaemia DKA HHS 44.3% 47.1% 45.2% 47.2% 50.6% 20.4% 16.1% 16.4% 17.7% 14.7% 17.3% 18.0% 18.3% 15.8% 15.8% 12.7% 13.2% 13.7% 14.7% 15.3% 5.3% 5.5% 6.3% 4.7% 4.6%
Care of Inpatients All patients admitted should have their feet examined on admission and if any change in status Documentation of foot examination within 24 hours Documentation of foot examination after 24 hours Documentation of foot examination at any time 2010 2011 2012 2013 2015 23.2% 21.3% 28.8% 36.3% 28% 5.0% 4.4% 5.3% 6.1% 5% 28.2% 25.8% 34.1% 42.4% 33%
Care outcomes for inpatients admitted with/for active foot disease 2015 Refer the person to the multidisciplinary foot care service within 24 hours of the initial examination of the person's feet.
Multi-disciplinary foot care teams NICE recommends that a MDFT should manage the care pathway of patients with diabetic foot problems who require inpatient care MDFT should include Diabetologist, Surgeon, DSN, Podiatrist & TVN Almost one third of hospital sites do not have a multidisciplinary foot care team
Hospital Acquired Ulceration All moderate and high risk patients are given pressure redistribution devices Patients who developed a foot lesion during their admission 2010 2011 2012 2013 2015 2.2% (257) N/A 1.6% (210) 1.4% (196) 1.1% (168)
ThinkGlucose - Leicester 2009/2010 bid for innovation fund - Post NaDIA data Tagged Putting feet first Band 7 DSN year secondment - implement education & paperwork Rolled out across 3 sites Audited staff knowledge prior to training and post Referral pathway once admitted Increased referral Watered down version Pressure avoidance
Touch the toes test
Diabetes UK Putting Feet First
Amputation Is it possible to eliminate avoidable amputations? Patient choice/quality of life Digital/ minor amputation Major amputation Preventable? Reducible?
Eliminate Amputations
Challenges of NICE (NG19) Implementation Resources Capacity or availability of FPS & MDFS Waiting times Integration Effective and timely communication Agreeing local pathways and policies Centralisation of Vascular Services Training & Competency Staff turnover, recruitment Backfill for training