Root cause analysis of major lower limb amputations in diabetes 2013/14 at County Durham and Darlington Foundation Trust (CDDFT). By Dr Sara Haq GP Registrar, Durham and Tees Valley Deanery Diabetes Audit Day 22/04/15 Audit supervisor : Dr Tarigopula, Consultant
6,000 people with diabetes have leg, foot or toe amputations each year in England. Amputation is 23 times more than people without diabetes. 61,000 people have foot ulcers at any given time. 20% ( 600m) of the 3bn the NHS spends on diabetes each year goes on treating diabetic foot problems, and at least 252m of this is spent on amputation.
Todays talk Background What did we do Audit Conclusions/Recommendations
Cumulative survival rates in foot ulcers of various etiologies. Moulik P K et al. Dia Care 2003;26:491-494 Copyright 2011 American Diabetes Association, Inc. 56% of patients with diabetes who have had ulcers survive for 5 years
Rate of major amputations for every 1,000 people in the local population with diabetes for CCGs in the North East between April 2009 and March 2012 Incidence per 1,000 2.5 2.0 1.5 00C 00J 00D 00C Darlington 2.04 00D Durham Dales, Easington and Sedgefield 1.75 00J North Durham 1.67 00H Newcastle West 1.18 00K Hartlepool and Stockton-On-Tees 1.11 00N South Tyneside 1.07 00M South Tees 1.07 00G Newcastle North and East 1.03 00F Gateshead 0.97 00P Sunderland 0.84 00L Northumberland 0.79 99C North Tyneside 0.64 1.0 00G 00H 00N 00F 00K 00M 99C 00P 00L 0.5 0.0 0 10000 20000 30000 40000 Population with Diabetes Significance Limits England All CCGs North East CCGs Source: The information on these slides is taken from Hospital Episode Statistics (HES) and Information Centre for Health and Social Care
What did we do? Establish Multidisciplinary foot clinics October 2012. Fully functional from early 2013 Inpatient diabetes service October 2012 Mandatory diabetes foot documentation for all diabetes inpatients. Close links with vascular and orthopaedic surgeons Involvement of microbiologists-trust diabetes foot guidelines Regional foot network
MDFT Roles and responsibilities Doc-2013 Contacts details of various MDFT Outpatient and inpatient pathways. Antibiotics Guidelines Active diabetes foot disease must be seen within 24 hours agreed tailored management plan. June 2012 : 1 clinic a month Current status today is : 11 clinics a month across the trust
CDDFT OUTPATIENT DIABETES ACTIVE FOOT DISEASE REFERRAL PATHWAY > Active Ulceration > Spreading Infection > Critical Ischaemia > Gangrene > Unexplained hot, red, swollen foot > Acute Charcot ACTIVE FOOT DISEASE IDENTIFIED Monday Friday Working Hours Out of Hours Weekends & Holidays RAPID REFERRAL WITHIN 24 HOURS TO THE MULTIDISCIPLINARY FOOT TEAM (MDfT) Fax number: 01207 594406 (Internal 64406) Telephone numbers: 01207 594609 (Internal 64409) 01207 594407 (Internal 64407) 01207 594407 The term active foot disease refers to anyone with diabetes who has: An ulcer, blister or break in the skin on any part of the foot, or any sign of infection Unexplained pain in the foot Fracture or dislocation in the foot with no preceding history of significant trauma Gangrene of all or part of the foot (Diabetes UK, 2009) ASSESS CLINICALLY: 1. Superficial Ulceration. Clinical signs of infection Oral Flucloxacillin 1g qds or Doxycycline 100mg bd. Advise rest (offloading) and fax referral to Multidisciplinary Foot Team to be seen in the next Foot Clinic 2. If Charcot Foot suspected. Advise non-weight bearing and fax referral to Multidisciplinary Foot Team to be seen in the next Foot Clinic 3. If ulcer infected (spreading) / cellulitus / gangrene or Charcot foot suspected. Admit to MAU / RAMAC. On call Doctor to assess foot and liaise with a member of the MDfT. 4. IF IN DOUBT ADMIT
CDDFT inpatient Diabetes foot referral pathway All diabetes patients foot care documented in the admission clerking sheets. Check HbA1c if not done within 3 months. Ensure BM between 6-10 mmol/l Any foot ulcer /infection/gangrene/charcots/unexplained painful foot. YES No Contact Multidisciplinary FOOT TEAM within 24 hours DMH EXT 43530. Fax 01325 743373 UHND EXT XXXX FAX Involve the diabetic team/podiatry Every diabetic patient admitted must have a diabetic foot exam. 4% of patients develop ulcers as an inpatient. Link in with the diabetes team who will involve the Podiatrist and Orthotist No action needed
Aims To look at the number of major foot amputations over a one year period(2013-2014) at CDDFT Referral time in days between patient reported symptom onset and first contact with the multidisciplinary foot team (MDFT). To assess whether the foot care pathway has been followed and to evaluate its impact on the incidence of major lower limb amputations. To determine whether these amputations were preventable
Objective To collate data using a regional data tool/excel spread sheet inclusive of complications. The data tool comprises of 58 key parameters per patient. Two additional parameters of HBA1c and sex were added. Measurement: A number of key variables Comparison/Gold standard: Diabetes UK /centre for health and Social care Evaluation: Reflection on the outcome of the audit.
Methodology Retrospective audit over a one year period. Looking at major amputations identified by clinical coding. Data was analysed using Systm 1 One and ECDM. Regional audit data tool used to collate data.
Results N=35. n=4 wrongly coded. Hence n=31 identified 2 pts in Prison 1 demented Patient 3 females 28 male Mean age 68
numbers 16 Chart to show age range in total sample T=31 14 12 10 8 6 4 2 0 30-40 40-50 50-60 60-70 70-80 80-90 age in years
3 females 28 male Number of males and females in major amputation sample T=31 female 3 male 28
numbers No of patients with diabetes complications as per audit data tool 30 25 20 15 10 5 0 PVD Renal failure visual impairement neuropathy complications prev minor amputation poor complaince unknown
Percentage patients (T=31) seen by a member of the MDfT within the foot referral pathway seen within 24hrs seen within 7 days unknown 20% 50% 30%
Numbers HBA1C range in sample T=31 10 9 8 7 6 5 4 3 2 1 0 <40 40-50 51-60 61-80 81-100 >100 HBA1c
Numbers numbers 60 Total amputations and amputation rate 2011/12 52 60 Total amputations and amputation rate 2012/13 51 50 50 40 40 30 30 20 20 10 10 0 Total amputations 1.5 Amputation rate 0 Total amputions 1.50 Amputation rate
numbers 35 30 Total amputations 2013/2014 31 25 20 15 10 5 0 Total amputations 0.88 Amputation rate
Major amputation trends 60 55 50 45 40 35 30 25 20 15 10 5 0 52 51 31 31 Major amputations 1.5 1.5 0.9 0.9 Maj amputation rate 2011-12 2012-13 2013-14 2014-15
Minor amputation trends 60 50 Minor amputations 53 47 40 30 20 10 34 20 Minor amputations 0 2011-2012 2012-2013 2013-2014 2014-2015
Limitations N= 4, Incomplete data or limited data Data tool did not incorporate sex and HbA1C - Self added Certain pieces of information difficult to find such as ABPI/Debridement/SINBAD score First onset of symptoms not easy to find. Work load
Conclusions Reduction in major amputation rate. 50% of patients are seen within 24 hours as per NICE Up to 75% were seen within 1 week. Suboptimal diabetes control noted in these patients. Lack of awareness leading to delay in reporting and also referring.
Conclusion Impact of footcare pathway: For the majority of our patients the foot care pathway was followed. As there was no foot care pathway prior to Oct 2012, the foot care pathway for those patients prior to this will not have been followed. Our Trust major amputation rate has significantly reduced.
Recommendations Patient Education-Imp good glycaemic control implications of poor control, raising awareness of diabetes foot problems. Primary care physicians and other health care professionals- Education of the pathway and need to refer immediately. Inpatient education in the hospitals. Linking with regional networks Re auditing.
References Diabetes uk Table 4 also available on the Yorkshire & Humber Public Health Observatory and is available on: http://yhpho.york.ac.uk/diabetesprofiles/foot/defaul t.aspx County Durham and Darlington NHS Foundation Trust - Multi Disciplinary foot Team and Foot Protection Team. Developments, Roles and Responsibilities