1. Foot Care for People living with Diabetes Janine Malcolm MD, FRCP Diabetes Policy Summit November 4, 2014

2. Disclosures Co-Chair, Champlain Diabetes Foot Care Expert Committee Funding for The Ottawa Hospital Foot Screening project provided by the University of Ottawa Department of Medicine Quality and Safety Awards

3. “The one visual I have is someone cutting off my foot” Quote from a newly diagnosed patient with diabetes

4. “Major amputations present a mutilating admission of failure in the face of otherwise treatable disease” Dr. W. Jeffcoate

5. Foot Ulcers Foot ulcers are common, costly and burdensome 1, 2 –effecting ~ 20% of people with diabetes –preceding 85% of lower limb amputations –2/3 of lower limb amputations performed in Ontario are for people with diabetes –Lower limb amputations are associated with increased morbidity 3 –Diabetes foot ulcers costs ~ $2.5 billion annually 4 Foot ulcers are largely preventable through 2 : –risk assessment, early appropriate referral –patient-self-management education –providing care through inter-professional teams 1.Botros et al, 2010 2.Margolis et al, Med Clin N Am 2013 3.Capes S. et al, 2010 4.Canadian Association of Wound Care, 2014

6. Outline Improving Diabetes Foot Care –Experience within the Champlain LHIN and at The Ottawa Hospital Best Practices Gaps and Challenges Policy Solutions

7. Local Context Champlain LHIN, TOH Disproportionally high hospitalization rate for foot infection, ulcers, amputations –361/10,000 people living with diabetes 1 –2012-2013 339 patients admitted to TOH with ulcer or amputation High lower extremity amputation rate 1 –80/10,000 as compared to 74/10,000 Provincial average (ICES 2006-2011) –4 th highest in Ontario despite a lower than average diabetes prevalence –3X higher than rate of the best performing region (North Simcoe Muskoka) 1 Low foot examination rates –2011 Champlain LHIN survey: 37% of patients with diabetes reported not having a foot exam within the last year 2 –2012 TOH chart audit found only 45% of patients had documented foot exam 1.Booth et al, Regional Measures of Diabetes Burden in Ontario, ICES 2012 2. Living with Diabetes in the Champlain Region Champlain DRCC Report January 2012

8. Champlain Diabetes Foot Care Strategy Goals Every person living with Diabetes: Receives a standardized foot risk assessment at least annually to prevent foot ulcers Receives timely self-management education and referral for appropriate care when at high risk for foot ulcer Receives immediate care from a multidisciplinary team when an ulcer develops

9. Improving Foot Care for Patients within the Champlain LHIN Reducing Foot Ulcer Risk Foot Ulcer Management Phase 1Phase 2 – Development and implementation of Best Practices for Screening and Risk Stratification of Foot Ulcer Risk – Foot Screening Tool Box development and implementation – Map of Foot Care Services available in Champlain LHIN – Chiropody Services Funded by the Champlain LHIN – Health Care Practitioner Education – Development and Implementation of Best Practices for Management of the Acute Foot Ulcers – Rapid Referral Pathway for patients with active ulcer – Off Loading resources – Support for Multidisciplinary Clinics

10. Phase 1: Foot Ulcer Risk Reduction Foot care inventory completed & gaps identified Consumer consultation (clients & HCPs) Champlain Diabetes Foot Screening Toolbox created Webpage (www.champlaindrcc.ca) with regional resources and regional foot care services maps createdwww.champlaindrcc.ca Health Care Practitioner education and dissemination of Foot Screening Toolbox 10

11. Foot Care Toolbox Content Assessment: –Risk Assessment Algorithm –Foot Ulcer Risk Assessment –Diabetes Foot Care Teaching Record Education Resources for Clients/Patients: –Care Tips for Your Feet –Guide for Good Foot Wear –Your Foot Ulcer Profile Resources for Providers: –How to obtain and use monofilaments –How to locate and palpate pedal pulses –Examples of foot structural and biomechanical abnormalities –Guide to assessment of callus in the foot –Community foot care resource lists and maps

12. Implementation of Foot Screening Toolbox Since 2013 – 161 health care providers trained – 161 have accessed the online resources Ongoing workshops Online resources continue to be accessed regularly

13. Improving Access to Chiropody Services in the Champlain LHIN Four full time chiropodists funded through the Champlain LHIN Chiropodist program provides outreach to 16 sites in the Champlain region 13

14. Improved Access to Chiropody Services MOHLTC funded Chiropodist program provides outreach to 16 sites in the Champlain region

15. Progress to date Chiropody Program In Q2: 177 new clients for individual appointments, 148 for group education – 98% of clients have diabetes, 2% pre-diabetes – 976 individual chiropody appointments – 33% included treatment of ulcer – 5.9% included pre-ulcer treatment – 26.5% included callous reduction – 34.6% include other types of treatment – 22 group sessions

16. Implementation of Best Practices for Foot Screening and Risk Stratification A quality improvement project at the Ottawa Hospital

17. Intervention 1.Developed and disseminated evidence based tools and practice protocols based on the CDA and RNAO best practice guidelines 2.Provided information and training sessions to all team members 3.Implemented new practice –at 15 weekly clinics, attended by 11 Endocrinologists, rotating residents, 11 nurses and tracked uptake over 8 months 4.Provided audit and feedback at group and individual levels –poster board, individual meetings, team meetings 5.Used Iterative cycles to revise forms and processes

18. Results Practice changed All 362 newly referred patient charts were audited and reviewed by an expert Standardized foot ulcer risk assessment increased from a baseline of 48% to a sustained rate of 89% Higher risk patients were identified and supported 36% of patients classified as “higher risk” for foot ulcer 10% of patients presented with an ulcer 88% of higher risk patients were provided with self management information, support or specialist referral

19. Weekly Uptake of Process

20. Clinicians were satisfied 17 staff members were surveyed (8 physicians, 6 RN, 1 RPN, 1 RD, 1 clerk) 88% (15/17) rated the foot assessment form/process as helpful 88% (15/17) recommended continued use of the form/process Now a quality indicator for the TOH Diabetes Clinic with audits occurring quarterly

21. BEST PRACTICES

23. Best Practices Recommendations CDA 2013 Guidelines, RNAO Guidelines 2013, Canadian Association for Wound Care 2010 Prevention: Regular foot examination and evaluation for foot ulcer risk Patient self-management education Access to professionally fitted shoes

24. Best Practices Recommendations from Guidelines Ulcer Management Early detection and treatment of ulcers Access to multidisciplinary care (including endocrinologist/diabetologist, vascular surgery, plastic surgery, dermatologists, chiropodists, infectious diseases, family physicians, nurses, OT, PT, dietitians) Access to offloading devices Ongoing measures for evaluation and benchmarking

25. Amputation Reduction - What Works Integrated multidisciplinary approach to prevention 1,2,3 Foot risk assessment and appropriate referral 4 Patient education 5 Access to foot care professionals and prescription footwear 6, 7 Ulcer Management by a multidisciplinary team 1 1.Bakker et al, 2012 2.Dargis et al, 1999 3.Aydin et al, 2010 4.Crawford et al, 2007 5.Valk et al, 2002 6.McCabe et al, 1998 7.Uccioli, 2006

26. Key Challenges Prevention: –Lack of foot care education for health care professionals –Access to and funding for skilled practitioners chiropody Services orthotics and prescription footwear –Access to vascular assessment –Poverty and lack of social supports –Access to care in rural areas

27. Key Challenges Ulcer Management: –Integration/coordination of care across specialties Limited access and availability of multidisciplinary wound management clinics –Communication across specialties especially during transitions of care –Access and Funding for offloading devices (eg: total contact casting) –Access to outcome data for evaluation and benchmarking –Poverty and lack of social supports –Access to care in rural areas

28. Possible Solutions Promotion of Integration of Multidisciplinary Specialized Care –Communication among care providers –Referral and management pathways –Multidisciplinary specialized clinics Funding solutions for improving access to –Chiropody services –Prescription footwear –Offloading devices

29. Possible Solutions Knowledge translation and implementation of Best Practice Guidelines –Health care professional education –Organizational support (delivery system design/ decision support) Support for patient education, engagement and empowerment Emphasizing patient centered approach –Access to appropriate, timely care within their community

30. Possible Solutions Promotion of data collection within organizations of foot care outcomes for ongoing evaluation and benchmarking

31. Thank-you