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In the beginning…….. Diabetic patients were losing limbs, long stays in hospital, no hope of healing chronic ulcers inevitable amputation. No light at.

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Presentation on theme: "In the beginning…….. Diabetic patients were losing limbs, long stays in hospital, no hope of healing chronic ulcers inevitable amputation. No light at."— Presentation transcript:

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2 In the beginning…….. Diabetic patients were losing limbs, long stays in hospital, no hope of healing chronic ulcers inevitable amputation. No light at the end of the tunnel, only destruction, dismay and death. …But a new era was emerging….

3 Historical Events Launch of Sky TV Unleaded Petrol was at 38p per litre Inauguration of the 1 st President Bush Order of the garter opened to women Terry Waite was kidnapped in Beirut First ever Rugby World Cup kicks off

4 Reduce Amputations by 50% Where are we – where do we want to be, and how can we get there ?

5 Scotchcast Boot

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7 Patients Podiatrist District Nurses G.Ps Specialist Care Wards Practice Nurses The Greater Team

8 100 boots in Blackburn – 1988 Showed average healing rates of 8 weeks in neuropathic ulceration BUT How do we prevent the first ulcer? How do we keep them healed?

9 Historical Data 1988/1989 Precipitating Factors of Ulcers Kings (n=210) Blackburn (n=100) Shoes85%74% Accident9%14% Thermal2%3% Pressure4%9%

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12 LOW RISK Protective sensation intact (10g pressure) Optimise diabetes and blood pressure control (<139/80) Foot education/Low risk leaflet Podiatry only for problems

13 MODERATE RISK Loss of protective sensation No deformity No callus No previous ulcer Foot education/Moderate risk leaflet Consider Consultant opinion Optimise diabetes and blood pressure control (<139/80) Footwear advice and assessment Regular Podiatry (12 weekly)

14 HIGH RISK Loss of protective sensation Deformity and/or callus present No previous ulcer Optimise diabetes and blood pressure control (<139/80) Foot education/High risk leaflet Consultant opinion Specialist prescribed Footwear/Shoe review Regular Podiatry (4 – 12 weekly)

15 Very High Risk Ulcer present or Previous ulcer Loss of protective sensation (10 g pressure) Foot education leaflets/ very high risk leaflet Consultant opinion Specialist prescribed footwear / shoe review Optimise diabetes & blood pressure control (<130/80) Regular podiatry and review (1-4 weekly)

16 Arterial Disease Abnormal flow +/- History of claudication telephone: If you suspect acute vascular insufficiency Optimise diabetes & blood pressure control (>139/80) Prescribe aspirin/statin Stop smoking and keep walking Foot education/leaflet Consider consultant opinion Specialist prescribed footwear / shoe review Regular Podiatry especially nail care (1-12 weekly)

17 Referral Pathways For The Diabetic Foot Referral for Diabetic Footwear Referral for Non-urgent Problems Referral for Urgent Problems Urgent Patient Same Day Referral Ring :- Diabetes Hot Foot line Blackburn Burnley Condition becomes urgent refer via RED Pathway Continue treatment until Outpatient Appointment Non Urgent Patient Referral letter, or fax ( ) Dr G.R. Jones, Diabetes unit, RBH New patient Existing patient Letter of Referral to Dr G.R. Jones, Diabetes unit, RBH Prescribed footwear Orthotics RBH BGH Orthotics RBH BGH

18 N.I.C.E Guidelines recommend:- Annual inspection and examination Aggressive intervention to reduce morbidity Primary and secondary care should work together to identify a package of care for at risk feet

19 N.I.C.E. foot ulceration and lower limb amputation can be reduced if people who have sensory neuropathy affecting their feet are identified and offered regular podiatry and protective footwear if required

20 Do Shoes and Orthoses work? To look at the precipitating factors responsible for new DFU compared to previous studies. Are shoes still a major factor or have things changed? Change is inevitable – except from a vending machine! Robert C. Gallagher

21 Precipitating Factors of Referred Ulcers Kings 1988 (n=210) Blackburn 1988 (n=100) Blackburn 2004 (n=72) Shoes85%74%47.2% Accident9%14%12.5% Thermal2%3%4.2% Pressure4%9%15.3%

22 Outcomes Diabetic population and Ulcer Frequency

23 Aetiology of Foot Ulcers in Diabetic Foot Clinic

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26 100 boots in Blackburn – 1988 Showed average healing rates of 8 weeks in neuropathic ulceration BUT How do we prevent the first ulcer? How do we keep them healed?

27 Custom made insoles Stock footwear Modular footwear Diabetic specification Bespoke footwear

28 Continuous follow-up 2-3 servicable pairs of shoes Long term care (>2yrs) Weaning process Long term healing A neuropathic patient is a footwear patient for life (Ulbrect J 15/05/08) (Orthotic & Podiatric)

29 Footwear Follow-up Study 100 consecutive patients recalled after 2 years Then followed up for a further 7 years

30 Intact70%70%24% Cracked skin/callus 30%23%14% Ulceration03%22% Amputation0 1 Major 3 Minor 7 Major 5 Minor 2 Years 5years 10YearsResults

31 Conclusion from footwear follow-up study Prescribed footwear is effective when worn, inspection is a vital part of follow up although this is written into guide lines it is not usually adhered to. The importance of footwear review needs more emphasis at all levels of care

32 Thats ok but is it cost effective? £

33 I am asked (told) to provide footwear for diabetic patients. I am asked (told) to provide footwear for diabetic patients. 20% of my working week is dedicated to working within the East Lancashire Diabetic Foot Team.20% of my working week is dedicated to working within the East Lancashire Diabetic Foot Team. I am expected to provide orthosis that will prevent high risk feet from ulcerating & healed ulcerated feet from re-ulcerating.I am expected to provide orthosis that will prevent high risk feet from ulcerating & healed ulcerated feet from re-ulcerating. Ensure patients have TWO serviceable pairs of footwear.Ensure patients have TWO serviceable pairs of footwear. G H Nuttall P/O BSc(hons) MBAPO

34 Am I of value in treating feet ? (or am I just an expensive accessory?) Effective? Effective? Efficient? Efficient? Contribution? Contribution? Cost effective? Cost effective?

35 Cost saving of £392,000 Cost saving of £282,000 Cost saving of £147,000 Cost saving of £102,000 Cost Savings by Orthotics

36 Allied Health Professions input to the Diabetes pathway The cost on the NHS to heal one ulcer is £3k to £7.5k. Should this progress to amputation the cost is estimated to escalate to £65k. This is much more than the cost of preventative orthoses. For every £1 spent in orthotics the NHS saves £4. Hutton and Hurry 2009, Orthotic Service in the NHS: Improving Service Provision. York Health Economics

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40 Ulceration/Hot Foot REFER patients to a multidisciplinary foot care team within 24 hours if any of the following occur: new ulceration (wound) new swelling new discolouration (redder, bluer, paler, blacker, over part or all of foot). ( NICE Guideline – Type 2 diabetes: prevention and management of foot problems ) REFER non-healing wounds from 0 – 4 weeks duration

41 Treatment of Ulceration Pressure relief (preferably non removable) Medical management (CVS, oedema, diabetes, infection) Debridement and dressings And…….. a team

42 Pressure Relieving Devices DARCO walker DH shoe Half shoe Aircast Walker Padding & strapping Podo-med

43 Nothing works like casting

44 Modified TCC Bi-valved cast Cast Variations Focused Rigidity Cast Heel ulceration

45 Innovations from Diabetic foot Service Scotchcast Boot Bespoke casting Screening Programme Effective and efficient orthotic service Hot foot line House shoe Charcot data and register

46 HOME? NOT SO SWEET HOME Lomax G McLaughlin C Jones G R Kenwright C Blackburn Royal Infirmary

47 HOME? NOT SO SWEET HOME THE GREATEST NUMBER OF STEPS PER DAY ARE TAKEN IN THE PATIENTS OWN HOME. David Armstrong et al. (American Podiatric Medicine 2001)

48 HOME? NOT SO SWEET HOME PRESCRIBED INSOLES AND FOOTWEAR CAN PREVENT FOOT PATHOLOGY (TOVEY F.I. 1987)

49 HOME? NOT SO SWEET HOME Footwear is most effective when worn for a minimum of 60% of the day. (Chanteleau, E. Haage, P.) Most effective when worn for 100% of the ambulatory time.

50 HOME? NOT SO SWEET HOME AIM OF STUDY To assess what proportion of patients who had been prescribed Diabetic footwear were wearing at home.

51 HOME? NOT SO SWEET HOME How could we do this study? Ask patients at clinics? A telephone survey? Send patient questionnaires? Knock on patient doors and ask and look? Data collection by Community Podiatrists visiting patients homes on Domiciliary visits. The sneak approach

52 HOME? NOT SO SWEET HOME RESULTS QuestionNo shoesOwn shoesOwn slippers Prescribed shoes 1. What is patient wearing on entry to house? 19%8%52%21% 2. What does patient apply after treatment? 15%8%56%21%

53 HOME? NOT SO SWEET HOME CONCLUSION 75% of patients visited do not wear prescribed shoes at home. All health care professionals need to be aware of this.

54 HOME SAFE HOME

55 Charcot Foot

56 Care of People with Charcot Osteoarthropathy (NICE 01/04) People with suspected or diagnosed Charcot osteoarthropathy should be referred immediately to a specialist multidisciplinary foot care team for immobilisation of the affected joint(s) and for long-term management of offloading to prevent ulceration.

57 Definition ? No definitive test Xrays & scans – open to interpretation Diagnosis is primarily clinical & subjective

58 Identification of Charcot Arthropathy Unified district wide diabetic foot service Centralised referral point Validated district diabetes register

59 Charcot Data ( ) Incidence and Prevalence Patient Characteristics Diagnostic Presentation Treatment and Outcomes (including the effect of an audit and community education event in 2001)

60 Presenting Site Of Charcot Arthropathy Forefoot 4(9%) Ankle 9(20%) Midfoot 32(71%) 1 st. 2 nd. 3 rd.

61 Presentation Charcot 10 (35%) delayed diagnosis on presentation 7 (24%) developed C.N.A on ipsilateral limb 3 (10%) developed C.N.A on contralateral limb. 9 (31%) diagnosed correctly

62 Local Charcot Programme (2001) Why Delays in diagnosis/ Late Presentations How Education event in community for all HCPs What Road show – staff meetings, lunch hours, training events

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64 Treatment of Charcot Arthropathy Mean time in casts 2001, 33.6 weeks (8 - 56) 2006, 20.5 weeks (range ) (p<0.001) Mean time from active to quiescence 2001, 42 weeks (8 -70) 2006, 26.3 weeks (range 8 – 40) (p<0.001) 39 (87%)4 (9%) 2 (4%)

65 Outcomes n=45 No. of C.N.A Surgery - exostectomies and minor amputations Below Knee Amputation Deaths Healed/ Stable Feet Feet with Ulcers

66 Mortality/Morbidity Charcot v Matched Controls (p>0.05)

67 Summary Charcot Arthropathy IS uncommon (1:500 people with diabetes) Diagnosis is often initially delayed, but community education and awareness significantly reduces this Poor diabetic control appears to be a prerequisite for CNA

68 Conclusion Earlier recognition and treatment of C.N.A. translates into significantly faster healing & 3/12`s less time in casts! (Charcot Road shows work!) Our local surgical practice is conservative & reserved for feet with recurrent or non healing ulcers only Outcome for both limb and life is NOT adversely affected. Larger patient numbers are needed to be studied to ratify these findings and this will demand collaborative working e.g. CDUK

69 Grant from DUK The Charcot register National data base Lead and managed from ELHT

70 The Charcot Register Scotland6 North East4 North West10 Yorkshire & Humberside4 West Midlands3 East Midlands6 Northern Ireland1 Republic of Ireland2 Wales4 East Anglia5 South West10 South East16

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73 Finally Latest Benchmarking Data from the SHA Lowest non-elective admission rates Shortest length of stay Effective and efficient service

74 Diabetic Foot Service Then & now 1988 People working in isolated pockets Foot clinic inaugurated MDT formed Inadequate referral pathways High amputation rates Long in patient stays Huge NHS costs NOW Foot clinic 23 years old Effective implemented pathways Well established clinics Good interagency and interprofessional relationships Low amputation rates Reduced in patient stay Cost efficient

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76 Thank you


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