Diabetes Foot Care: Saving Limbs, Saving Lives James Elliott National Indigenous Diabetes Prevention Conference Thunder Bay September 27 th 2016
About Me Researcher / advocate Trustee for T1Internati Consultant for WoundPedia Person living with type 1 diabetes No financial conflicts of interest with this talk
Today 1. Prevention 2. Treatment 3. Advocacy
Prevention
Diabetic Foot Ulcer is Deadly Diabetic foot ulcer / amputation 5-year mortality worse than prostate cancer, breast cancer and Hodgkin s disease Source: Armstrong DG, Wrobel J, Robbins JM. Guest Editorial: are diabetes-related wounds and amputations worse than cancer? Int Wound J. 2007 Dec;4(4):286-7
5 S s of Diabetic Foot Ulcer Prevention Screening Stop Smoking Shoes Systemic BG/BP Control Sibbald & Ayello 2012 Skin Temperature
1. Screening Screening Sibbald & Ayello 2012
How can we improve the screening rate for diabetic foot ulcer? Only ~52% of people with diabetes in Canada receive an annual foot exam
Focus on Prevention: 60 Second Screening Available at www.diabeticfootscreen.com www.woundpedia.com History Inspection abnormalities Palpate pulse Deformity Monofilament testing (4 out 10 negative) After Inlow 60 sec exam Adv. Skin Wound Care 2012 Oct;25(10):465-76; Screening for the high-risk diabetic foot: a 60- second tool (2012). Sibbald RG, Ayello EA, Alavi A, Ostrow B, Lowe J, Botros M, Goodman L, Woo K, Smart H. Screening for the high risk diabetic foot: A 60-Second Tool (2012) Sibbald Name: ID#: Phone #: Facility: DOB (dd/mm/yy): / / Gender: M F Years with diabetes: Ethnicity: Black Asian Caucasian Mixed Other Date of Exam (dd/mm/yy): / / CHECK BOTH FEET (Circle correct response) YES on either foot = HIGH RISK LEFT RIGHT HISTORY 1. Previous ulcer NO YES NO YES 2. Previous amputation NO YES NO YES PHYSICAL EXAM 3. Deformity NO YES NO YES 4. Absent pedal pulses (Dorsalis Pedis and/ or Posterior Tibial) NO YES NO YES FOOT LESIONS Remember to check 4 th and 5 th web spaces/nails for fungal infection and check for inappropriate footwear. NEUROPATHY MORE THAN 4/10 SITES LACKING FEELING = YES 5. Active ulcer NO YES NO YES 6. Ingrown toenail NO YES NO YES 7. Calluses (thick plantar skin) NO YES NO YES 8. Blisters NO YES NO YES 9. Fissure (linear crack) NO YES NO YES 10. Monofilament exam (record negative reaction): a) Right /10 negatives ( 4 negatives = Yes) b) Left /10 negatives ( 4 negatives = Yes) NO YES NO YES Total # of YES: Total # of YES: PLAN a) POSITIVE SCREEN- Results when there are one or more Yes responses. Refer to a foot specialist or team for prevention, treatment and follow up. (Bony deformity, current ulcer, absent pulse are most urgent). These individuals are at increased risk of a foot ulcer and/or infection. Patients should be educated on what changes to observe and report, while waiting for the specialist appointment. Referral to: Appointment time: b) NEGATIVE SCREEN- Results when there are all No responses. No referral required. Educate patient to report any new changes to their healthcare provider and re-examine in 1 year. One Year Date for Re-Examination (dd/mm/yy): / / Completed By: Date: Additional Note: See reverse side for recommendations from the International Diabetes Federation, & International Working Group on the Diabetic Foot. Local referral patterns may vary depending on expertise and available resources.
Validation of the Simplified 60 Second Tool Tool for Rapid & Easy Identification of High Risk Diabetic Foot: Validation & Clinical Pilot of the Simplified 60 Second Diabetic Foot Screening Tool M. Gail Woodbury, R. Gary Sibbald,* Brian Ostrow, Reneeka Persaud, and Julia M. Lowe PLOS One June 29, 2015 Simplified 60-second screen Canadians & Canadians Guyanese items Guyanese Previous Ulcer.966.975.942 Previous Amputation.969.920.948 Deformity.874.833.665 Absent Pulses.868.828.669 Fixed Ankle.909.909.759 Fixed Toe.798.600.696 Active Ulcer.971.923.961 Ingrown Nail.723.481.636 Callus.874.882.690 Blisters.768.704.587 Fissures.553.245.415 Monofilament Test R foot.983.966.971 Monofilament Test L foot.978.966.955
2. Stop Smoking Screening Stop Smoking Sibbald & Ayello 2012
Tips on Smoking Cessation Convey the reasons simply; Cigarettes harm blood flow and healing and your risk for foot problems increases Be culturally appropriate; - see Wabano s Sacred Smoke program - messaging, Limit non-traditional tobacco use
Reading about Smoking Cessation Google: Lessons Learned in Ontario Aboriginal Tobacco Cessation
3. Shoes / Offloading Screening Stop Smoking Shoes Sibbald & Ayello 2012
Shoes / Offloading - Preventative shoes, socks, and plantar pressure redistribution (offloading) core elements of diabetes foot ulcer care - Public coverage is lacking in Ontario and much of Canada, forcing people to pay out of pocket (or not get care at all) - Google: Working for Change The CAWC s Advocacy Campaign
Diabetic Foot Open Letter Campaign Google: Diabetic Foot Open Letter
4. Systematic Blood Glucose / BP Screening Control Stop Smoking Shoes Systemic BG/BP Control Sibbald & Ayello 2012
If controlling blood sugar was easy, everyone would do it!
Diabetes Self-Management Education Diet Education Exercise Medications
Source: Type 1 Diabetes Memes - Tumblr
Patient Interaction Tips Source: Type 1 Diabetes Memes - Tumblr Non-judgmental, non-confrontational, nonadversarial approach more effective Patients who feel judged less likely to act
23 PEP Talk: Diabetes, Healthy Feet & You A self-management educational workshop program designed for lay Peer Leaders to empower people living with diabetes, to adopt self-management behaviors that can help them prevent diabetic foot ulcers and amputations Peer-led workshop Supported through portal http://www.diabeticfootcommunity.ca Connected to diabetes community Monthly e-blasts Webinar Partner
5. Skin Temperature Screening Stop Smoking Shoes Systemic BG/BP Control Sibbald & Ayello 2012 Skin Temperature
Skin Temperature Temp difference over 4 F (2.2 C) between feet diagnostic feature Infrared dermal thermometry useful tool to foot through acute phase Temperature is a quantitative measure and can be recorded in a matter of seconds Home patient monitoring possible Sources: Armstrong, D. G., and L. A. Lavery. "Monitoring healing of acute Charcot's arthropathy with infrared dermal thermometry." Journal of rehabilitation research and development 34.3 (1997): 317-321. & Lavery, Lawrence A., et al. "Home monitoring of foot skin temperatures to prevent ulceration." Diabetes care 27.11 (2004): 2642-2647. 25
Skin Temperature Patient Self-Monitoring Prevents Reoccurrence! Infrared Thermometry CE-Sibbald, Mufti, Armstrong Advances Skin + Wound Care Jan. 2015
One Last Simple and Cost Effective Prevention Strategy: Look at the feet!
Treatment
VIPS of Treat the Cause Vascular Insufficiency Inflammation and / or Infection Pressure downloading Sharp Surgical debridement Callus= pressure Blister=friction or shear
Wound Bed Preparation 2015 Prevent or Manage a chronic Wound Identify & Treat the cause Patient/Family Centered Concerns Determine Healability for patient outcomes & local wound care Debridement Sibbald, Ayello, Smart 2014 Inflammation/ Infection Edge Effect Moisture Balance Sibbald et.al Advances in Skin & Wound Care Oct 2015
International Interprofessional Wound Care Course IIWCC IIWCC-CAN IIWCC - IR IIWCC-NYU IIWCC- ZA IIWCC - UAE IIWCC -SA
HUB and Spoke Interprofessional Capacity Building Model Toronto Regional Wound Healing Clinic in Mississauga = Hub Spokes based throughout Ontario, focus on primary care Weekly sessions based on International Interprofessional Wound Care Course (IIWCC)
Guyana Diabetes Project - Collaboration between Canadian group and Guyanese Ministry of Health - Training of local health staff, encouraged team work - Very low cost effective interventions 60 second screening tools to risk stratify $20 offloading shoe 78% Fewer Amputations
Free to Read: Google Guyana Diabetic Foot
Advocacy
Advocacy: How Change Gets Made Elliott J. Advocating for the Diabetic Foot. Diabetic Foot Canada Volume 3 No 1 2015
Diabetes Amputations: The North vs Toronto Central Number and rate (per 100,000) of hospitalizations for amputation among Ontarians with diabetes, by LHIN, 2011/12 400 350 368 300 250 X 3 Higher 200 150 100 118 50 0 North West LHIN Toronto Central LHIN Source: Key Performance Measures for the Ontario Diabetes Strategy Final Report 2013
Advocacy Tips What Exactly Do You Want? Be consistent, ambitious and realistic Know the Facts How many people are affected? What are the costs? What are options? What do other places do different? Think of Arguments For/ Against What You Want Be ready for that s too expensive right now and Be ready for we ve spent X million dollars already Who Is/Can Be on Your Team? Passionate individuals, local leaders, big organizations
Resources www.diabeticfootcanadajournal.ca www.diabetes.ca/charter
Life with diabetes is complicated. Access to vital insulin, diabetes supplies and medical care should not be.
Cape Town Diabetes Declarations Read: http://woundpedia.com/cape-town-declaration/ Read: https://www.t1international.com/cape-town-declarations/
Take Home Points 1. Remember the 5 S s of Prevention 2. Recall VIPS for treatment + Wound Bed Prep 3. Never assume any prior diabetes education 4. Look into ECHO and IIWCC Courses 5. Check out T1International, CDA Diabetes Charter and CAWC/RNAO advocacy efforts
Miigwech! Merci! Thank You! james.elliott51@gmail.com Twitter @jandelliott P.S. Talk to me about ECHO