1. health and fitness
2. disease
3. diabetes

Poster session 10: Education and prevention
P10.01
Pilot implementation of an e-learning course ”Diabetic Foot” for diabetes nurses in
primary care
Sabine Verstraete, Diabetes Liga, Ghent, Belgium
Frederik Muylle, Diabetes Liga, Ghent, Belgium
Hilde Beele, University Hospital Ghent, Ghent, Belgium
Els Broeckx, Wit-Gele Kruis Antwerpen, Antwerp, Belgium
Diégo Backaert, Primary Care Group Backaert, Aalst, Belgium
Frank Nobels, OLV Ziekenhuis Aalst, Aalst, Belgium
Kristien Van Acker, AZ Heilige Familie Rumst, Rumst, Belgium
Dimitri Beeckman, University Centre for Nursing and Midwifery, Ghent, Belgium
Aim: Diabetic foot ulcers are complex, chronic wounds which have a major long-term impact
on the morbidity, mortality and quality of patient’s lives. Without early and optimal
intervention, an ulcer will rapidly deteriorate, leading to amputation. However up to 50% of
the amputations can be avoided with an effective care plan.
In order to address these issues, an e-learning course focused on the diabetic foot was
developed and implemented. The aim of this course, is to allow the diabetes nurses in
primary care to improve their knowledge in a flexible, interactive and attractive way.
Methods: After elaborating the content by a task force of experts, the interactive course,
was implemented on an online learning platform. The e-learning course, including a pre- and
posttest, was then validated by a group of wound experts. Participants who took the posttest, were invited to complete an online survey.,
After a pilot implementation phase of 6 months, success was measured based upon the
outcomes of the survey, and the users’ improvement in knowledge.
Results: Until November 2014, 174 diabetes nurses signed up. Seventy-four percent (n=
129) of these participants logged into the online platform, but only 52% (N = 91) also took
the post-test. The survey (N=91) showed that 93% of the diabetes nurses are convinced that
e-learning is an easy way to train their knowledge. 71% declared that following the course
has made them feel more comfortable with the topic “diabetic foot” and 70% expect to pay
more attention to the prevention of diabetic foot problems.
For 78% (N = 50) of the diabetes nurses who completed the e-learning course, a score on
the pretest was also available. Mean scores were 57% for the pre-test and 69% for the posttest, an significant improvement in knowledge (p<0.005).
Conclusions: An e-learning course on the diabetic foot was successfully implemented in
Flanders, Belgium. 70% of the participating nurses expect to pay more attention to the
prevention of diabetic foot problems. Moreover following the e-learning course significantly
improved knowledge. Further implementation of this project is warranted as it holds the
promise to improve current practice and eventually lower amputation rates in diabetic
patients.
www.diabeticfoot.nl
Page 1 of 8
P10.02
D-Foot, an eHealth tool for foot assessment and risk stratification in patients with
diabetes
Ulla Hellstrand Tang, Sahlgrenska University Hospital, Institute of Clinical Sciences,
Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
Jacqueline Siegenthaler, Sahlgrenska University Hospital, Gothenburg, Sweden
Roy Tranberg, Institute of Clinical Sciences,, Sahlgrenska Academy,, University of
Gothenburg, Gothenburg, Sweden
Roland Zügner, Institute of Clinical Sciences,, Sahlgrenska Academy,, University of
Gothenburg, Gothenburg, Sweden
Kerstin Hagberg, Sahlgrenska University Hospital, Institute of Clinical Sciences,,
Sahlgrenska Academy,University of Gothenburg, Gothenburg, Sweden
Introduction: The orthotist prescribes insoles and footwear aimed to prevents ulcers and
amputation in patients with diabetes. A structured foot screening starts the process of
prevention. However, in Sweden, there is no structured tool available for the orthotist in the
foot assessment and risk stratification.
The aim: …was to construct D-Foot, an eHealth tool for foot assessment and risk
stratification in patients with diabetes.
Methods: The project started in 2011 as a project between four Departments of Prosthetics
& Orthotics (DPO) in the region Västra Götaland, Sweden. The expert group consisted of
orthotists, prosthetists, pedorthists and physiotherapists. Through systematic and ongoing
discussions and literature review consensus of risk factors was reached. The eHealth tool,
D-Foot, was continuously revised during the period of development., The local diabetes
association participated in the process. D-Foot is based on a 4-level risk classification
according to the Swedish National Diabetes Register. The D-Foot software is primary
intended to be used on a tablet.
Results: The D-Foot, 2014 version, has been reduced to 22 risk assessments together with
an illustrative manual. Assessments include: foot deformities; gait abnormalities; neuropathy;
skin pathologies; range of motion in the lower extremities; earlier ulcers or amputation;
present ulcers and/or acute Charcot foot. Inspection of footwear is included and a short
survey. The eHealth tool generates a pdf-report.Together, the 22 assessments and the four
survey questions, generate a 1-4 risk classification for each patient. Content validity is
confirmed through the development process used.
Conclusion: D-Foot, an eHealth tool for risk stratification of the foot in patients with
diabetes, will be implemented in daily practise during 2015. An updated eHealth version will
be released based on the results from an ongoing study of reliability. The intension is to
include measure of peripheral angiopathy in next version.
Acknowledgement:
Fundings: Stiftelsen Promobilia, Skobranschens utvecklingsfond, Gunnar Holmgrens Minne,
Regional R&D, stiftelsen Felix Neubergh, stiftelsen, IngaBritt &Arne Lundbergs
Forskningsstiftelse and Adlerbertska forskningsstiftelsen.
www.diabeticfoot.nl
Page 2 of 8
P10.03
Measuring disability and health status in diabetic patients with ischemic lowerextremity ulcers
Katrien Santema, Academic Medical Centre, Amsterdam, Netherlands
Marcel Dijkgraaf, Academic Medical Centre, Amsterdam, Netherlands
Mark Koelemay, Academic Medical Centre, Amsterdam, Netherlands
Dirk Ubbink, Academic Medical Centre, Amsterdam, Netherlands
Aim: Diabetic foot ulceration may affect the patients’ functional status and quality of life.
Hence, these parameters are important outcomes in clinical studies. The AMC Linear
Disability Score (ALDS) is a generic instrument to measure disability, comprising of a 77
item-bank with daily life activities. The ALDS allows selecting a subset of items to tailor the
questionnaire to the target population. The ALDS comprises a range between 0 and 100 with
lower values representing easy activities (e.g. get out of bed, 30) and difficult activities (e.g.
walk > 15 minutes, 74).The EQ-5D is a widely used instrument to measure health status.
The ALDS and EQ-5D were used in this study to measure disability and health status in
diabetic patients with ischemic lower-extremity ulcers.
Methods: A convenience sample of patients with ischemic diabetic foot ulceration (i.e. ankle
systolic blood pressure <70 mmHg, a toe pressure <50 mmHg or a forefoot transcutaneous
oxygen tension <40 mmHg) participating in the DAMOCLES-trial was included.
Patients completed the ALDS (27 items) and EQ-5D questionnaires at trial inclusion. Utilities
corresponding with the observed EQ-5D scores were determined by applying a Dutch tradeoff based scoring algorithm with possible outcome values between -0.33 and 1. The
correlation between, ALDS and EQ-5D utilities was expressed as a Spearman correlation
coefficient.
Results: Fifty-seven patients were included (84.3% males, mean age 71±10 years). The
median ALDS was 69 but scores ranged widely (Interquartile range (IQR) 46 to 87). EQ-5D
also ranged extensively (median 0.65; IQR 0.30 to 0.78). ALDS and EQ-5D utilities
correlated significantly (r = 0.69; P<0.001). In patients with a prior below-ankle amputation
ALDS was lower (median 61; IQR 24-82) than in non-amputated patients (median 77; IQR
60-88) (P=0.023, Mann-Whitney). In contrast, prior amputation did not influence EQ-5D
utilities (P=0.111).
Conclusions: Disability and health status as measured with the ALDS and EQ-5D varied
widely in diabetic patients with ischemic ulcers. Construct validity of the ALDS was
confirmed by the strong correlation with EQ-5D utilities. Future research should address at
whether the ALDS can help to select patients who may or may not benefit from
revascularisation.
www.diabeticfoot.nl
Page 3 of 8
P10.04
Diabetic Foot workshop: Improving technical and educational skills for nurses
Maryam Aalaa, Tehran University of Medical Sciences, Tehran, Iran
Mahnaz Sanjari,Tehran University of Medical Sciences, Tehran, Iran
Samimeh Shabazi, Tehran University of Medical Sciences, Tehran, Iran
Zahra Shayeganmehr, Tehran University of Medical Sciences, Tehran, Iran
Maryam Abooeirad, Tehran University of Medical Sciences, Tehran, Iran
Mohammad Reza Amini, Tehran University of Medical Sciences, Tehran, Iran
Hossien Adibi, Tehran University of Medical Sciences, Tehran, Iran
Neda Mehrdad, Tehran University of Medical Sciences, Tehran, Iran
Background: Diabetes mellitus, as one of the most common metabolic disorders has some
complications which one of the main complications is a Diabetic Foot (DF). The, appropriate
care and education prevents 85% of diabetic foot amputations. Ideal management for
prevention and treatment of diabetic foot needs close collaboration among all health team
members and diabetic patient. Obviously, improving nurses' knowledge about DF care and
progress in the quality of care which performed by a nurse as a one member of diabetes
care team member could be improved diabetic foot prevention and treatment.
Methods: According to the important role of nurses in the DF care team, EMRI was planning
to establish, Diabertic Foot workshops for nurses. Two workshops were held in in the fall of
2014 led by EMRI focused on topics related to diabetic foot for nurses. In holding that
workshop, 14 coordinating sessions hold during 3 months in which all coaches participated.
Three first sessions were about brainstorming. Eleven sessions were related to the
workshop contents and lectures. And last 3 sessions was about the pilot of the workshop.
Actually, each lecture related to the diabetic foot prevention, management, rehabilitation
followed by a team work activity.
Conclusion: Diabetic Foot Workshop for nurses national cause DF nurse specialist will be
trained. Combination of theory and practice in this workshop not only increase nurses'
knowledge, but also improve their skills in the field of the Diabetic Foot. Providing education
and care by DF nurse specialist instead of general nurse, could be an important output of
this workshop which cause, DF prevention and amputation decrease in the long term.
www.diabeticfoot.nl
Page 4 of 8
P10.05
Prevention of new foot ulcers in patients with diabetes and previous healed ulcer on
the foot below the ankle
Magdalena Annersten Gershater, Malmö University, MALMÖ, Sverige, Sweden
Jan Apelqvist, Skane University Hospital, MALMÖ, Sverige, Sweden
Carin Alm-Roijer, Malmö University, MALMÖ, Sverige, Sweden
Aim: To explore whether participant driven group education had an impact on ulceration
during 24 months in a group of patients with diabetes and a previously healed ulcer.
Method: A randomized controlled study was designed in accordance with CONSORT
criteria. Number needed to treat: 174. Inclusion criteria were: age 35–79 years old, diabetes
mellitus, sensory neuropathy, and healed foot ulcer below the ankle. Inclusion process was
difficult due to the patients’ general health condition. A total of 134 patients (35 women) were
included in the study. The patients were followed up every 6 months when feet were
inspected and photograph taken to prove foot status. Any new ulcer was referred to the
multidisciplinary diabetes foot clinic.
Result: After 24 months follow up, 43 patients (32%) had not developed a new foot ulcer.
There was no statistical difference between the two intervention groups. After 24 months 10
patients had died, and 10 had declined further participation or were lost to follow up. The
main reasons for ulcer development were external trauma and plantar stress ulcer.
Conclusion: Patients with diabetes and a healed foot ulcer develop new foot ulcers in spite
of participant-driven group education. This high risk patient group has external risk factors
that are beyond this form of education. Educational methods should be evaluated in patients
with lower risk of ulceration.
www.diabeticfoot.nl
Page 5 of 8
P10.06
High prevalence of heel pressure ulcers in a teaching hospital and inefficacy of a inservice education program in reducing their occurrence
Laura Ambrosini Nobili, University of Pisa, Pisa, Italy
Pradal Marilena, Azienda ospedaliero-Universitaria Pisana, pisa, Italy
Andrea Casano, University of Pisa, Pisa, Italy
Francesco Uccelli, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
Iacopi Elisabetta, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
Monica Scateni, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
Alberto Piaggesi, University of Pisa, Pisa, Italy
Aim:, Heel represents a frequent location of pressure ulcers (PU), and the first among
diabetic patients. We designed this study in order to assess the frequency of both primary
(P) and jatrogenic (J) heel PU (HPU) in our 400-bed teaching hospital, and to evaluate the
efficacy of a dedicated in-service educational intervention focused on prevention and
treatment of HPU.
Methods: We prospectively screened all the admssion in our hospital during two
consecutive months (March - April, 2014) for HPU in the departments of our hospital. We
then intensively trained two nurses for each ward, on the early detection of HPU and on
their adequate management during the months of May and June 2014. The same data on
the frequency of HPU were collected during September and October 2014 to detect any
change from baseline.
Results:, 75 HPU were registered in March and April on 2730 admission (0.027 HPU/adm);
36% of them were JHPU. According to EPUAP staging tey were 32% stage I; 33.3% stage
II; 25.3% stage III; and 9.4% stage IV. After the training, in September and October 75 HPU
on 2920 admission (0.026 HPU/adm); 24% of them were JHPU (χ2, = 0.267; p = 0.7305
post- vs pre-); EPUAP staging: 40% stage I; 37.3% stage II; 21.3% stage III; and 1.4% stage
IV (χ2, = 5.595; p = 0.133 post- vs pre-).
Conclusions: Our data confirm the high prevalence of HPU and the necessity of a
prolonged, repeated, and articulated intervention to significantly reduce their number among
inpatients.
www.diabeticfoot.nl
Page 6 of 8
P10.07
Is the use of the Ipswich Touch Test valid and Reliable in Routine Clinical Practice?
Pauline Wilson, St James' Hospital, Dublin, Ireland
Corey Gillen, St James' Hospital, Dublin, Ireland
Christine Kiernan, AMNCH Tallaght, Dublin, Ireland
Aims: The aim of this study is to consider the inter rater reliability of the Ipswich Touch test
(IpTT). This test is a subjective test for identifying neuropathy in patients with diabetes. Interrater reliability, inter-rater agreement, or concordance is the degree of agreement among
raters., As the Ipswich Touch test is a subjective test we, investigated the reliability of this
test in routine clinical practice.
Methods: Participants were opportunistically recruited from the Diabetes centres of 2
hospitals. Two researchers completed the test on the same occasion in the same way for
each participant. These results were then collated.
Results: 90 patients were recruited from the Diabetes clinics in the 2 hospitals. 44 from site
(a) and 46 from site (b)., Site (a) showed a 95% concordance between testers and site (b)
showed a 74% concordance. This gave an overall concordance rate of 84% across both
sites. Of the 16% of participants where concordance was not reached, 10% of the results led
to a different in risk status. Overall this gives a 96% concordance rate in the analysis of risk
status across the 2 sites.
Conclusions: The researchers feel that given a total concordance rate of 96% the Ipswich
touch test is a valid and reliable tool in the completion of base line diabetic neuropathy
screening for assigning risk categories of patients with diabetes. Further investigation is
warranted, to consider concordance in the Iptt when compared to other methods of
neurological testing.
www.diabeticfoot.nl
Page 7 of 8
P10.10
Team care for people with diabetes and complications: The role of a psychologist
Rajna Ogrin, Royal District Nursing Service (RDNS), St Kilda, Australia
Michelle Duwyn, Private Practice, London, Ontario, Canada
Background: People with diabetes who have foot ulcers have significantly lower quality of
life and higher rates of depression compared to the general population and to people with
diabetes who do not have foot complications. Addressing psychosocial factors in the
individual with diabetes related foot ulceration is becoming increasingly important, as is the
utility of a team approach which would include psychologists, to optimise self-care behaviour
in adults with diabetes. Although there is increasing recognition of the role of psychologists
in the general management of diabetes and chronic disease, there is a dearth of literature
outlining the role that a psychologist might play on an interprofessional diabetes foot ulcer
team. This presentation will outline the development of a psychologist’s role within a newly
developed interprofessional diabetes foot ulcer team.
Methods and Results: A literature review on psychologist role in diabetes foot ulcer teams
was undertaken, then expanded to include the roles and responsibilities of a psychologist in
any chronic disease management team, due to lack of articles., Review outcomes were
discussed with the team in a facilitated focus group, and based on this, draft roles and
responsibilities for a psychologist in the team were developed. These were then piloted in a
practice setting over 12 months.A Participatory Action Research approach was used through
monthly team meetings, and the roles and responsibilities of the psychologist were adapted
over time., The final draft model included not only addressing patient issues, but also
facilitating communication of team members, and encouraging a positive team environment.,
Conclusion: The next step is to implement and evaluate this model in clinical practice, and
evaluate outcomes related to inclusion of psychology using this model within clinical teams.
Acknowledgements
This project was funded by HealthForce Ontario, Canada.
RDNS received funding from the Commonwealth and Victorian Governments under the
HACC program.
www.diabeticfoot.nl
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