Oral session 9: Organization of care
O9.1
An audit of diabetic foot ulcer in a specialized centre Eastern Sudan
Sami Eldirdiri Elgaaili Salah, Gadarif University, Gadarif, Sudan
Yasir O. M. Awadelseed, Gadarif University, Gadarif, Sudan
Saadeldin A. Idris Idris, Alzaeim Alazhari University, Khartoum, Sudan
Background: Foot ulcerations are among the most serious and frequent complications in
diabetic patients. It puts enormous burden on the patient and the health care services in low
income countries.
Objective: To evaluate the outcome of diabetic foot ulcers.
Design and methods: Data was collected prospectively from patients presented to a
specialized multidisciplinary foot care center in a district hospital. Between January 2009 and
December 2014 and analyzed statistically. Gadarif State (1.300.000 population), is 420
kilometers, eastern to the capital, with limited health care facilities. An ulcer for each patient
was classified at presentation according to the Edmond and Foster simple staging system
(SSS). Patients were followed up until healing or for 12 months. Ulcer outcome such as
healing, ipsilateral amputation or death were determined compared with patient related
outcomes such as survival, amputation, or being free from any ulcer at 12 months.
Results: A total of 6.951 diabetic patients were registered during the study period with a
prevalence of 0.53%. DFU was found in 751 patients. Mean age was 54.3 years (Range 26 93). Male to female ratio was 0.47:1. The incidence and prevalence were 10.8% and 0.058%
respectively. In 78.2 % DFU was located in forefoot. Eleven patients (1.5%) were lost from
follow up and 15 (1.9%) were referred to diabetic foot center in Khartoum (The capital).
Outcome was variable in form of healing, amputation, and death in 91.6%, 3.9%, and 1.1%
respectively. The rate of healed ulcer was 98.1%, 98.3%, 56.8%, and 16.7% in stage 1, 2, 5
and 6 respectively, (p=0.03). No amputation or death was observed in the patients of stage 1
and 2. The rate of amputation was 0.36%, 9.8%, 27.3%, and 44.4% in stage 3, 4, 5, and 6
respectively, (p=0.01). The rate of mortality was 0.7%, 1.2%, 4.5%, and 16.7% in stage 3, 4,
5, and 6 respectively, (p=0.008).
Conclusion: Care for DFU should be provided by a multidisciplinary team by ensuring
glycemic control, local wound care and regular debridement, off-loading of the foot, control of
infection by dressing and antibiotics and management of comorbidities. Amputations are
usually the treatment of last resort but occasionally can be considered early to allow faster
mobilization and rehabilitation.
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O9.2
Low cost system for data management in foot care clinics
Line Kleinebreil, UNFM, Sarcelles, France
Thomas Baratier, UNFM, Paris, France
Kristien van Acker, IDF CS, CHIMAY, Belgium
Stephan Morbach, IDF CS, SOEST, Germany
Simone McConnie, Comfeet Poodiatry Foundation, Barbados, Barbados
Nalini Campillo, Foundation, Santo Domingos, Trinidad and Tobago
Hermelinda Cordeiro Pedrosa, hospital regional Taguatinga, Brazilia, Brazil
Evariste Bouenizabila, IDF Africa, Brazzaville, Congo
Aim : provide to the foot clinics a simple, cheap, user friendly, management system, adapted
to developping countries to improve patients follow-up and clinic management.
Methods : Amputations are a major problem in developping countries. A number of centers
have been trained to deal with foot lesions but the implementation of good practices remains
difficult. The challenges are : 1) frequent turn-over of healtcare professionals 2) non
structured paper based medical records 3) no recall system for at risk patients not attending
the consultation 4) no clinic dashboard to set-up local priorities and, report to health
authorities 4) no budget for a standard electronic medical record 5) irregular internet access
6) high risk of computer dammage and loss of data. An international team, with footcare
specialists, information technology specialists and representatives from foot clinics in
developping countries set together to developp and test the DIAFI-DATA system (DIAbetes
Foot Information-DATA collection).
Results:, DIAFI-DATA is a USB flashdrive. The complete system is running on the key.
Nothing has to be installed on the computer. The sytem contains : 1- free access to medical
documentation and training on footcare to support continuous medical education 2- free
access to a medical record test for training with the system 3- restricted access (login
/password) to the patients files and management dashboard. In practice the flashdrive is
personalized for the center, under the responsibility of the medical director. He is the one
who owns the key, decides who is going to use it, and also is responsible to store the key in
a safe place to respect data protection and privacy. An encrypted copy of the database is
stored for back-up. Benefits of the system are : 1) low cost to enter data (less than 10 $) 2)
can be used at the clinic or in any place (cybercafe, university, ..) to enter data 3) defines
clear responsibilities 4) provides simple recall system 5) provides automatically an overview
of individual patient profile, as well as population profile 6) allows the clinic to benchmark
indicators, at regional, national or international level.The DIAFI-DATA is tested in the Saca
Region with technical support from UNFM, DESG, IWGDF and is planned to extend to
Africa.
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O9.3
Color Coded Etiological Keys; a simple survey tool towards amputation free limb
survival in diabetic foot lesions, 5 years experience
Mohamed Sharkawy, Cairo University, Cairo, Egypt
Ayman Samadoni, Cairo University, Cairo, Egypt
Background: Majority of non-traumatic limb amputations occur in diabetics and often
preceded by active foot conditions. In the lack of dedicated foot clinics, management often
follow specialty oriented rather than problem oriented strategy which often leads to missing
an integral etiological factor that would increase the potentiality for limb loss., Based on an
earlier survey at Cairo University Hospitals, certain modifiable etiological factors were found
significant regarding the limb salvage/loss potential.
Aim of the work: We devised a simple implementable Color Coded Etiological Key Survey
based on those six significant categories where all diabetic foot’s patients enrolled, were
screened and managed accordingly. The results will be analyzed to verify the impact of this
survey
Patients & Methods: During the period from May 2007 to May 2012 we received 4102
diabetic foot patients of which 739 patients were suggested for major amputation by other
medical facilities due to the severity of their foot lesions. It is that later group that was
subjected to further analysis to study the value and the impact of the survey on amputation
free limb survival.
Results: Majority of patients were males with average age 52±6.3 years and blood quality’s
abnormalities were the most prevalent (66%) seconded by peripheral occlusive diseases
(42%) while tissue loss was the least (8%).
Following completion of assessment, the management was implemented according to
defined protocol based on lesion’s characteristics. Primary end point of major amputation
free limb survival was achieved in 72.5% with hospital stay of average 13.3 days.
Statistical analysis of the etiological keys against the primary outcome using Fischer Exact
and Student-t Test showed significant impact of tissue loss and previous foot surgery as bad
predictor for limb loss
Conclusion: Implementation of the Color Coded Etiological Key Survey can provide efficient
and effective service to the diabetic foot victims with comparable outcome to dedicated
diabetic foot clinics. Being economic and posing no additional financial burden to hospitals,
we recommend its implementation in those hospitals which lacks specialized diabetic foot
programs.
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O9.4
Can we capture the intensity of foot care delivery by diabetes foot teams? presenting
the, diabetes foot appointment complexity score
Prash Vas, Kings College Hospital, London, United Kingdom
Ana Manas, Kings College Hospital, London, United Kingdom
Chris Manu, Kings College Hospital, London, United Kingdom
Maureen Bates, Kings College Hospital, London, United Kingdom
Michael Edmonds, Kings College Hospital, London, United Kingdom
Aim: The burden of diabetes foot disease is increasing and foot units are seeing a significant
rise in patient referral numbers. Many such units work within a multidisciplinary (MDT)
framework whereby podiatrists, doctors, nurses and allied care givers work together.
However, there is paucity of data on what procedures/interventions are delivered to a patient
attending for one such visit. Our aim was to develop a diabetic foot scoring system to
capture the complexity of procedures, interventions and services (PIS) delivered per patient
per appointment.
Methods: We prospectively reviewed all patients attending our foot centre over a two-week
period. The complexity of PIS was graded between 1 and 6 incorporating either
time/expertise required. The extremes were 1 points for routine care (e.g. skin debridement)
and 6 points for toe amputation. All other activities were scored according to their relative
complexity (e.g. 1 for cannulation and bloods test, 2 for deep tissue debridement, 3 for
intravenous antibiotic infusion, 4 for application of removable total contact cast. A Foot
Appointment Complexity Score (FACS) reflecting the composite of all interventions, and thus
intensity of care per appointment was then calculated.
Results: There were 305 patients. The main presentations included infected ulcers
with/without osteomyelitis (60%) and acute/chronic Charcot’s foot (15%), painful
neuropathy (3%) and others (22%). The distribution of the FACS was 1 in 25%, 2 in 25%, 3
in 13%, 4 in 11%, 5 in 8% and ≥6 in 18%. There was a significant correlation between the
FACS score and the duration of time spent in the clinic for each appointment (r=0.96,
p<0.0001). Additionally, there was also a significant correlation between the number of
comorbidities present and FACS (r=0.28, p<0.0001).
Conclusion: Using FACS, we are able to capture the overall intensity of the service
delivered to the patient. The score can at one glance, highlight interventions from specific
members of MDT. This novel approach can help facilitate resource deployment to the foot
service and allow comparison of care delivered by other foot teams.
Funding Source: None
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O9.5
Transfer of knowledge and organization between Sweden and the Baltic Region
regarding foot complications in patients with diabetes mellitus.
Kurt Gerok-Andersson, Karolinska University Hospital, Stockholm, Sweden
Börje Åkerlund, Karolinska University Hospital, Infectious Diseases, Stockholm, Sweden
Paul Lundgren, Södertälje hospital, Orthopaedics, Södertälje, Sweden
Jonas Malmstedt, South hospital, Vascular Surgery, Stockholm, Sweden
Valdis Pirags, Pauls Stradins Clinical University Hospital, Riga, Latvia
Andre Trudnikov, East Tallinn Central Hospital, Tallinn, Estonia
Rasa Verkauskiene, Medical Academy, Institute of Endocrinology, Kaunas, Lithuania
Aim: Transfer of organization and best clinical practice of patients with diabetes mellitus and
foot complications.
Methods: An inventory, based on an inventory list and an inventory session, of the current
structural capital and requirements for a successful implementation was accomplished by
the project partners. The need of organizational improvement of diabetological, vascular
surgical, orthopedic surgical and in infectious disease aspects as well as the orthopedic
engineering and podiatry/chiropodist resources in the three countries was estimated., With
the use of a representative diabetic foot case the different roles of the Swedish
multidisciplinary team specialists was exemplified and further discussed with the local
audience. The audience consisted of each country’s chosen local specialists in a future
Centre of Excellence. The inventory also includes analysis of possible quality control
markers as well as health economical benefits with local authorities.
Results: In summary, we find sufficient technical facilities and adequate competence but
suboptimal organizational structure. The lack of a quality control marker to evaluate the
development of the management and organization change was observed.
Conclusions: We find that an inventory is essential for a future implementation of
organization and best clinical practice management of patient with diabetes mellitus and foot
complication. The further overall aim is first the establishment of a Center of excellence in
each country, second to assist in spreading the management to local hospitals and finally to
the primary care and to the patient. The implementation includes also establishment of a
quality register and initiation of a health economical analysis. This model could be useful for
any, organisationsal transfer from a well developed to a less well developed country.
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