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:
2In 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….
3Historical Events Launch of Sky TV Unleaded Petrol was at 38p per litreInauguration of the 1st President BushOrder of the garter opened to womenTerry Waite was kidnapped in BeirutFirst ever Rugby World Cup kicks off
4Reduce Amputations by 50% ‘ Where are we – where do we want to be, and how can we get there’?
12LOW RISK Optimise diabetes and blood pressure control (<139/80) Protective sensation intact(10g pressure)Optimise diabetes and blood pressure control (<139/80)Foot education/Low risk leafletPodiatry only for problems
13MODERATE RISK Loss of protective sensation No deformity No callus No previous ulcerFoot education/Moderate risk leafletConsider Consultant opinionOptimise diabetes and blood pressure control (<139/80)Footwear advice and assessmentRegular Podiatry (12 weekly)
14Regular Podiatry (4 – 12 weekly) HIGH RISKLoss of protective sensationDeformity and/or callus presentNo previous ulcerOptimise diabetes and blood pressure control (<139/80)Foot education/High risk leafletConsultant opinionSpecialist prescribed Footwear/Shoe reviewRegular Podiatry (4 – 12 weekly)
15Regular podiatry and review Very High RiskUlcer present orPrevious ulcerLoss of protective sensation (10 g pressure)Foot education leaflets/ very high risk leafletConsultant opinionSpecialist prescribed footwear / shoe reviewOptimise diabetes & blood pressure control (<130/80)Regular podiatry and review(1-4 weekly)
16Regular Podiatry especially nail care (1-12 weekly) Arterial DiseaseAbnormal flow+/- History of claudicationtelephone:If you suspect acute vascular insufficiencyOptimise diabetes & blood pressure control (>139/80)Prescribe aspirin/statin‘Stop smoking and keep walking’Foot education/leafletConsider consultant opinionSpecialist prescribed footwear / shoe reviewRegular Podiatry especially nail care (1-12 weekly)
17Referral Pathways For The Diabetic Foot Referral for Urgent ProblemsReferral for Non-urgent ProblemsReferral for Diabetic FootwearUrgent PatientNon Urgent PatientNew patientExisting patientReferral letter, or fax ( )Dr G.R. Jones, Diabetes unit, RBHPrescribed footwearSame Day ReferralLetter of Referral toDr G.R. Jones, Diabetes unit, RBHContinue treatment until Outpatient AppointmentRing :-Diabetes Hot Foot lineBlackburnBurnleyOrthoticsRBHBGHOrthoticsRBHBGHCondition becomes urgent refer via RED Pathway
18N.I.C.E Guidelines recommend:- Annual inspection and examinationAggressive intervention to reduce morbidityPrimary and secondary care should work together to identify a package of care for at risk feet
19N.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’
20Do 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
21Precipitating Factors of Referred Ulcers Kings1988(n=210)Blackburn 1988(n=100)Blackburn2004(n=72)Shoes85%74%47.2%Accident9%14%12.5%Thermal2%3%4.2%Pressure4%15.3%
22Diabetic population and Ulcer Frequency OutcomesDiabetic population and Ulcer Frequency
23Aetiology of Foot Ulcers in Diabetic Foot Clinic
26100 boots in Blackburn – 1988Showed average healing rates of 8 weeks in neuropathic ulcerationBUTHow do we prevent the first ulcer?How do we keep them healed?26
27Stock footwearBespoke footwearDiabetic specificationCustom made insolesModular footwear
28(Orthotic & Podiatric) Continuous follow-up(Orthotic & Podiatric)2-3 servicable pairs of shoesLong term care (>2yrs)Weaning processLong term healing“A neuropathic patient is a footwear patient for life” (Ulbrect J 15/05/08)
29Footwear Follow-up Study 100 consecutive patients recalled after 2 yearsThen followed up for a further 7 years
30Results 2 Years 5years 10Years Intact 70% 24% Cracked skin/callus 30% 23%14%Ulceration3%22%Amputation1 Major3 Minor7 Major5 Minor
31Conclusion 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
33G H Nuttall P/O BSc(hons) MBAPO 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.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.
34Am I of value in treating feet ? (or am I just an expensive accessory?) Effective?Efficient?Contribution?Cost effective?
35Cost Savings by Orthotics of £102,000Cost savingof £147,000Cost savingof £282,000Cost savingof £392,00030396688
36Allied 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
40Ulceration/Hot FootREFER patients to a multidisciplinary foot care team within24 hours if any of the following occur:new ulceration (wound)new swellingnew 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
41Treatment of Ulceration Pressure relief (preferably non removable)Medical management (CVS, oedema, diabetes, infection)Debridement and dressingsAnd…….. a team
45Innovations from Diabetic foot Service Scotchcast BootBespoke castingScreening ProgrammeEffective and efficient orthotic serviceHot foot lineHouse shoeCharcot data and register
46HOME? NOT SO SWEET HOME Lomax G McLaughlin C Jones G R Kenwright C Blackburn Royal Infirmary
47HOME? NOT SO SWEET HOME “THE GREATEST NUMBER OF STEPS PER DAY ARE TAKEN INTHE PATIENTSOWN HOME.”David Armstrong et al.(American Podiatric Medicine 2001)
48HOME? NOT SO SWEET HOMEPRESCRIBED INSOLES AND FOOTWEAR CAN PREVENT FOOT PATHOLOGY(TOVEY F.I. 1987)
49HOME? NOT SO SWEET HOMEFootwear 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.
50HOME? NOT SO SWEET HOME AIM OF STUDY To assess what proportion of patients who had been prescribed Diabetic footwear were wearing at home.
51How could we do this study? HOME? NOT SO SWEET HOMEHow 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”
52HOME? NOT SO SWEET HOME RESULTS QuestionNo shoesOwn shoesOwn slippersPrescribedshoes1. What is patient wearing on entry to house?19%8%52%21%2. What does patient apply after treatment?15%56%
53HOME? 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.
56Care 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.”
57Definition ? No definitive “test” Xrays & scans – open to interpretationDiagnosis is primarily clinical & subjective
58Identification of Charcot Arthropathy Unified district wide diabetic foot serviceCentralised referral pointValidated district diabetes register
59Charcot Data (1996-2006) Incidence and Prevalence Patient CharacteristicsDiagnostic PresentationTreatment and Outcomes(including the effect of an audit and community education event in 2001)
60Presenting Site Of Charcot Arthropathy 1st.2nd.3rd.Midfoot 32(71%)Ankle 9(20%)Forefoot 4(9%)
61Presentation Charcot 10 (35%) delayed diagnosis on presentation 7 (24%) developed C.N.A on ipsilateral limb3 (10%) developed C.N.A on contralateral limb.9 (31%) diagnosed correctly
62Local Charcot “Programme” (2001) Why Delays in diagnosis/Late PresentationsHow Education event in community for all HCPsWhat Road show – staff meetings,lunch hours, training events
64Treatment of Charcot Arthropathy Mean time in casts2001, weeks (8 - 56) , weeks (range )(p<0.001)Mean time from active to quiescence2001, weeks (8 -70) , weeks (range 8 – 40)39 (87%)4 (9%)2 (4%)
65exostectomies and minor amputations Outcomes n=45No. ofC.N.ASurgery -exostectomies and minor amputationsBelow KneeAmputationDeathsHealed/StableFeet317Feet with Ulcers145+442
66Mortality/Morbidity Charcot v Matched Controls (p>0.05)
67Summary Charcot Arthropathy IS uncommon (1:500 people with diabetes) Diagnosis is often initially delayed, but community education and awareness significantly reduces thisPoor diabetic control appears to be a prerequisite for CNA
68Outcome for both limb and life is NOT adversely affected. ConclusionEarlier 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 onlyOutcome 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
69Grant from DUK The Charcot register National data baseLead and managed from ELHT
70The Charcot Register Scotland 6 North East 4 North West 10 Yorkshire & HumbersideWest Midlands3East MidlandsNorthern Ireland1Republic of Ireland2WalesEast Anglia5South WestSouth East16We’ve had centres registering patients from as far north as Aberdeen and as far south as Plymouth. The majority of centres have been in the south and north west.We’ve also had interest in the project from America, Argentina, Malta and Australia.
73Finally Latest Benchmarking Data from the SHA Lowest non-elective admission ratesShortest length of stayEffective and efficient service
74Then & now Diabetic Foot Service 1988 People working in isolated pocketsFoot clinic inauguratedMDT formedInadequate referral pathwaysHigh amputation ratesLong in patient staysHuge NHS costsNOWFoot clinic 23 years oldEffective implemented pathwaysWell established clinicsGood interagency and interprofessional relationshipsLow amputation ratesReduced in patient stayCost efficient