Departments of Vascular Surgery and Wound Healing A specialist lower limb ulcer service in a rural setting Setting the standards Dean Williams Carys Park Jamie O’Malley Departments of Vascular Surgery and Wound Healing & Podiatry Ysbyty Gwynedd, Bangor

Emergency diabetic foot services in a department of vascular surgery In 2005: Population of 220,000 North West Wales No focus for diabetic foot patients No clear clinical pathways Major amputation rates approx. 20-30/10,000 population with diabetes Aim To create an urgent/emergency diabetic foot service that augmented the existing community provision for ulcers of all aetiologies-ischaemic and neuropathic

Core team focus in diabetic foot disease: Results in 2009

The Core Team September 14, 2018 Our model of a vascular-led diabetic foot service has been used in the latest NICE guidelines, suggesting an MDT with a core team led by a vascular surgeon. It also recommends our use of rapid access referral pathway to the vascular team, parallel vascular, podiatry and orthotic clinics, and admitting patients with diabetic foot disease to the vascular ward. Copyright UPM-Kymmene Group

Podiatry Diabetic Foot Ulcer Team Ysbyty Gwynedd Jaime O'Malley Iola Roberts Sioned Jones

Podiatry North Wales OVERVIEW 11 Podiatrists 14 Clinic Sites 1 Diabetic Foot Ulcer / MDT Clinic 2 Satellite Diabetic Foot Ulcer Clinics

Diabetic Foot Service at YG Diabetic patients with foot ulcers are referred to the Diabetic Foot Ulcer Clinic (DFU) at Ysbyty Gwynedd. From Community Podiatrists, GP's, Practice and District Nurses, Paediatric Diabetic Nurses or in-patient referrals Practice Nurses in all GP surgeries have had training in Foot Screening Neuropathy Vascular/Doppler Foot Pathologies Practice Nurses carry out Foot Screening yearly and anything above low risk is referred to the Podiatry Department

Service improvements Referrals and follow-up Parallel Podiatry and vascular clinics Referrals are triaged and then added to a waiting list Patients are assessed and treatment plans are set Patients may require admission for intravenous antibiotics, surgical intervention and/or debridement of the wound Upon discharge patient will normally be followed up by: District Nurses Vascular Outreach Nurses DFU Podiatrists Off-loading via casting and Orthotist referral

Satellite Clinics and training Staff rotation at DFU Alltwen, Tremadog and Ysbyty Penrhos Stanley depending on home address. Therapy Manager Notes made Cameras / pictures taken Following healing, patients are discharged from the DFU to Post Diabetic Ulcer Clinic (PDU) in the community for regular podiatry intervention to prevent re-ulceration

Off-loading and protecting: The art of Casting

Emergency Admission To The MDT at Ysbyty Gwynedd

Following Surgical Debridement

Skin Grafting (Split skin graft)

Following Skin Graft and Casting by Podiatry

Vascular outreach service

When? Where? Who? Vascular outreach team began in 2013 First vascular outreach team within the U.K. at Ysbyty Gwynedd, Bangor. Two nurses with experience of caring for patients with vascular disease and complex diabetic foot wounds. Work in partnership with all multi-disciplinary team members. When? Where? Who?

Why? Service established to: Reduce length of hospital stay. Increase number of available surgical beds. Prevent re-admission to hospital. Safely expedite early discharge. Ensure continuity of specialist vascular care Act as a link between secondary and primary care Why?

Pre service Pre-service introduction: Increased length of hospital stay. Lack of clear wound management plan on discharge. Lack in continuity of care. Lengthy wait for post discharge Consultant review. Many patients missed or were too unwell to attend outpatient appointments. Increased potential for re-admission to hospital. Medically unwell patients transferred for surgical intervention. Pre service

Current service Benefits of current day service: Daily clinics enable review within one to three weeks post discharge Enables earlier hospital discharge – Psychological, social and economic benefits. Link between secondary and primary care- improved communication and comprehensive plans. Patients can be reviewed at their place of residence if required. Photographs of problematic or deteriorating wounds can be e-mailed by community staff members- advice is then given or review of the patient is expedited. Ability to arrange urgent reviews- reduces need for emergency admission. Early reporting and detecting of problems reduces need for hospital admission. Medically unwell patients can remain on admitting ward.   Current service

Communication Enhanced communication: Effective communication essential. Ensures early detection of problems. Helps prevent deterioration of potential problems. Acute problems can be escalated – have immediate access to Vascular consultant. Immediate access to treatment. Post review progress updates provided. Clear comprehensive photo care plans- enable continuity of care between the acute and community settings. Includes the rationale for each dressing choice. Staff education. Communication

Integrated vascular and wound care service September 14, 2018 Community care Secondary care Community podiatry Inpatient referrals Senior diabetic podiatrist Vascular nurse specialist Community/ practice nurse Consultant vascular surgeon Vascular outreach nurses This is a diagrammatic representation of the set up of our vascular service for non-diabetics. Apart from the input from the senior diabetic posidatrist, it is the same as that for diabetic patients. The key development is the vascular outreach nurses who, like the senior diabetic podiatrist, traverses the divide between primary and secondary care facilitating rapid referral and follow-up. As the non-diabetic patients receive similar service we looked at whether they had had simliar benefits in terms of limb salvage. General practitioner On-call surgical team Emergency department Direct urgent/emergency referral to core team consultant Referral to other core team staff Indirect referral to consultant via other core team staff = Core team Copyright UPM-Kymmene Group

Enhanced diabetic foot services: an overlap More recent anecdotal observations that amputation rates were falling for all patients Aspects of diabetic foot service potentially benefiting all patients: Consultants with particular (generally undeterred) interest in lower limb disease/wound healing Dedicated wound nurses in ward/clinics ‘Hospital at home’ service provided by outreach nurses Minor surgery performed in ward/clinics Enhanced established communication/clinical pathways between core team and primary and secondary care

Major amputation rates (Accepted for publication in Diabetes Res and Clin. Practice) https://doi.org/10.1016/j.diabres.2017.10.015 Adjusted major amputation rates for population with diabetes per 100,000 for years 2004-2015 Year England: major amputations: 2007-2010 22–220 per 100,000 with diabetes Currently ~80 per 100,000 Adjusted major amputation rates for population without diabetes per 100,000 for years 2004-2015 1–16 per 100,000 without diabetes 2011: Global major amputation ranges from 5.6 to 600 per 10(5) in the population with diabetes and from 3.6 to 68.4 per 10(5) in the total population. (Unadjusted data) Year

Summary A service development aimed initially at improving the care for patients with diabetic foot disease has changed the provision for patients without diabetes Parallel improvements in limb salvage observed for patients with and without diabetes presenting with lower limb tissue loss/ulceration Reductions in lower limb major amputations associated with core team provision have been sustained A small, dedicated team of individuals working together in a rural setting have been recognized as providing a world class service for a global healthcare challenge

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