1. 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

2. 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 /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

3. Core team focus in diabetic foot disease: Results in 2009

4. 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

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

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

7. 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

8. 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

9. 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

10. Off-loading and protecting: The art of Casting

11. Emergency Admission To The MDT at Ysbyty Gwynedd

12. Following Surgical Debridement

13. Skin Grafting (Split skin graft)

14. Following Skin Graft and Casting by Podiatry

15. Vascular outreach service

16. 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?

17. 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?

18. 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

19. 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 ed 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

20. 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

21. 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

22. 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

23. Major amputation rates
(Accepted for publication in Diabetes Res and Clin. Practice)
Adjusted major amputation rates for population with diabetes per 100,000 for years
Year
England: major amputations:
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
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

24. 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

25. Diolch yn Fawr