Poster session 24: Organization of footcare
P24.01
CPR for Diabetic Feet
Duncan Stang, NHS Scotland, Glasgow, United Kingdom
Aim: To prevent patients with diabetes developing a foot ulcer during their stay in hospital
The need for this new national initiative in Scotland was discovered following an inpatient
audit of 1 048 patients with diabetes in November 2013 which revealed that;
2.4% of patients had developed a new foot ulcer during their stay in hospital
57% had not had their feet checked during their stay
60% of those discovered to be at risk did not have any protection in place
Method: A new inpatient initiative has been developed by the Scottish Diabetes Foot Action
Group to ensure;
All patients on admission to hospital have their feet Checked
All patients who are discovered to be 'at risk' of developing a foot ulcer during their stay in
hospital have their feet Protected
All patients who are discovered to have an existing foot ulcer are Referred to a member of
the diabetes foot team
An on line training package has been developed for all ward based staff to raise awareness
of this issue, to teach staff how to Check feet visually for any existing problems and for
neuropathy, to teach staff how to supply and fit appropriate pressure relief to Protect patients
and how to Refer to a member of the diabetes foot team when an existing problem is
discovered.
This initiative has been formulated by the Scottish Diabetes Foot Action Group (SDFAG)
with the support of the Scottish Diabetes Group (SDG) and the Scottish Government.
Results: Up until now the roll out of this initiative has helped raise awareness of the issue
surrounding acquired foot ulceration for patients while in hospital.
Laminated CPR posters have been distributed to all hospital wards within NHS Scotland,
with ward based training and education being carried out in each health board to ensure
implementation of the CPR initiative. New pressure relief has been introduced and
cleaning/disinfecting instructions have been developed and distributed for staff and patients
Conclusions: Hospital acquired foot ulceration is unnecessary and easily avoidable with this
simple campaign
In November 2015 a re-audit will be undertaken to gauge the success of this national
campaign and the results will be published.
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P24.02
Do people with and without diabetes receive recommended foot care prior to
hospitalisation?
Peter Lazzarini, Queensland University of Technology, Brisbane, Australia
Vanessa Ng, Queensland Health, Brisbane, Australia
Suzanne Kuys, Griffith University, Gold Coast, Australia
Maarten Kamp, Queensland University of Technology, Brisbane, Australia
Michael d'Emden, Queensland Health, Brisbane, Australia
Courtney Thomas, Queensland Health, Mount Isa, Australia
Jude Wills, Queensland Health, Rockhampton, Australia
Ewan Kinnear, Queensland Health, Brisbane, Australia
Scott Jen, Queensland Health, Ipswich, Australia
Sheree Hurn, Queensland University of Technology, Brisbane, Australia
Lloyd Reed, Queensland University of Technology, Brisbane, Australia
Aim: Guidelines recommend annual foot screens for people with diabetes and more frequent
care for those with foot complications. Few studies have investigated if people are receiving
recommended foot care. The aims of this paper was to determine the prevalence and
correlates of attendance at health professionals for foot care in the year prior to
hospitalisation in general inpatient populations, plus, analyse differences in diabetes and
non-diabetes sub-groups.
Methods: Eligible participants were adults admitted overnight for any reason into five
diverse hospitals on one day; excluding maternity, mental health and cognitively impaired.
Participants underwent a foot examination to clinically diagnose foot complications; including
wounds, infections, deformity, peripheral arterial disease (PAD) and peripheral neuropathy
(PN). They were also surveyed on demographic, social determinant, medical history, foot
disease history, self-care, footwear and health professional attendance for foot care in the
year prior to hospitalisation.
Results: Overall, of 733 participants (mean(±SD) age 62(±19) years, 408 (55.8%) male, 172
(23.5% (20.5-26.7)) had diabetes) 34.9% (95% CI) (31.6-38.4), had attended a health
professional for foot care in the year prior. Diabetes populations reported significantly higher
proportions of past foot care than non-diabetes populations (58.7% vs 27.6%; p< 0.001). In
backwards stepwise multivariate analyses attending a health professional for foot care in the
past year was independently associated (OR (95% CI)) with previous foot ulcers (5.4 (2.99.9)), diabetes (3.0 (2.1-4.5)), mobility impairment (2.0 (1.4-2.9)), arthritis (1.8 (1.3-2.6)) and
increasing age years (1.02 (1.01-1.03); yet PAD, PN and current foot ulcers were not.
Conclusions: Findings suggest one in three inpatients, and three in five with diabetes, had
attended a health professional for foot care in the year prior to hospitalisation. People with
diabetes and previous foot ulcers were much more likely to have attended health
professionals for foot care; however, those with other foot complications were not. It appears
much more concerted efforts are required to ensure people with foot complications are
receiving recommended foot care to prevent hospitalisation.
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P24.03
Patient education and foot care clinic, can achieve prevention of foot ulcer and lower
extremity amputation, in diabetic patients
Mohamed Ahmed, University of Khartoum & Jabir Abu Eliz Diabetic Centre, Khartoum,
Sudan
Seif Ibrahim Mahadi, University of Khartoum & Jabir Abu Eliz Diabetic Centre, Khartoum,
Sudan
Aims: This presentation aims to outlines methods than minimize the incidence of both foot
ulceration and lower extremity amputation..
Methods: Diabetic without symptomatic foot ulceration attending the diabetic clinic should
be subjected to full programme of foot care,
Results: A total of, 624 diabetic patients were contacted. More than half the patients
(59.3%) had 4 or more, foot care sessions.
Seventy two per cent of patients (n=449) had one or more of the chronic complications, the
major ones being neuropathy in 56% (n=351), ischemic symptoms in 24% (n=149). The
incidence of foot ulceration was 9.6% (n=60). The rate of, toes amputation was 3.5%,
(n=22), and major lower extremity, amputation, 2.9% (n=18). The higher the level of patient
primary education was the most significant factor associated with early reporting, (p<0.02).
Conclusion:, Patient education and regular foot care for diabetic was effective in reducing
both minor and major lower extremity amputation.
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P24.04
Impact of mandatory foot exam in the pre-clinic of university diabetic center setting
Mohammed Derwish, University Diabetes Center, Riyadh, Saudi Arabia
Introduction: The prevalence of diabetes among Saudi population is almost 24%, and
mainly type 2 due to life style changes and some genetic background. It is generally
assumed that regular foot exam may reduce the burden of diabetic foot ulceration. So,
appropriate patient foot exam in the pre-clinic setting will enhance lower limb salvage. King
Saud University diabetes center is a referral center dealing with more than 15 000 diabetic
patients yearly.
Aim: We sought to implement a mandatory foot exam policy referral, in our pre-clinic setting
for foot screening and follow up.
Methods: In the pre-clinic diabetic setting policy assessment:, vital signs, body mass index
(BMI), hip/waist ratio, mid-stream urine (MSU), gluco-markers, complete blood culture, lipid
and hormonal profile, and foot exam are implemented. 42 641 diabetic patients visits in the
pre-clinic rooms were examined during 3 years, among them 34 169 patients were referred,
to the foot unit between 2011 and 2013 for further evaluation. In the foot unit patients were
screened for, neuropathy, vasculopathy, dermatology, musculoskeletal assessment and
pedorthic evaluation.
Results: In 2011, 2012, and 2013: 9596 patients with 84 ulcers, 11 616 patients with 83
ulcers, and, , , 12 984 patients with 36 ulcers were found respectively. The number of
screened patient for pedal ulceration decreased significantly (see Table) after the mandatory
foot exam referral implementation while the number of examined cases increased. Most of
them were pick it up earlier and manage in timely manner except 4 cases were sent for
further vascular consultation.
Conclusion: The mandatory referral showed an increase number of examined patients with
less foot ulceration since 3 years witch underline the role and urgent need of mandatory foot
exam referral in our community diabetes center settings.
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P24.05
The 3-second foot exam for the emergency department:, how to create a “hot foot”
hotline to prevent amputations
John Miller, Des Moines University, Johnston, IA, United States
Eric J. Lew, Univerisity of Arizona, SALSA, Tucson, AZ, United States
Nicholas A. Giovinco, University of Arizona, SALSA, Tucson, AZ, United States
David G. Armstrong, University of Arizona, SALSA, Tucson, AZ, United States
Joseph L. Mills, University of Arizona, SALSA, Tucson, AZ, United States
Overall, 1.0 million cases of diabetic foot complications presented to emergency
departments (ED) in the US from 2006-2010. These constituted 1.9% of the 54.2 million total
diabetes cases. The severity of these wounds, and thus their ability to heal, is primarily
based on three vital components: 1) tissue loss, 2) ischemia, and 3) infection. However,
comprehensive investigation into their severity may be superfluous to the interests of the
emergency room physician. This project outlines the basic principles needed to create and
activate a 'hot' footline through a single point of contact. This rapid response team may
engage multiple health providers within an established limb salvage team as described in
Figure 1, and consult external specialties based on profound characteristics distilled from the
Society of Vascular Surgeons’, Wound Ischemia & Foot Infection (WIfI) threatened limb
classification . It is our hope that this unified service will expedite lower extremity triage in the
emergency room setting by relying on simple, definitive guidelines for specialty referral.
The authors express no external sources of funding for this project.
A general guideline for the workflow of a diabetic foot ulcer (DFU) to the emergency
department (ED). Swift activation of a ‘one call’ rapid response limb preservation team
which, following activation, the members evaluate the “dominance” of ischemia or infection
and determine a short and long-term course of care.
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P24.06
Identification of the at-risk diabetic foot in general hospital care
Jarmila Jirkovska, Charles University and Military University Hospital, Prague, Czech
Republic
Johana Venerova, Charles University and Military University Hospital, Prague, Czech
Republic
Libuse Fialova, Charles University and Military University Hospital, Prague, Czech Republic
Svatopluk Solar, Charles University and Military University Hospital, Prague, Czech Republic
Miroslav Zavoral, Charles University and Military University Hospital, Prague, Czech
Republic
Aim: Foot problems belong to serious and expensive complications in diabetic patients. The
purpose was to determine a strategy to identify the at-risk diabetic foot patients in general
hospital care as a target group for education and prevention.
Methods: To integrate diabetic foot screening throughout our general hospital, methodical
guidelines were created. Yes/no questionnaire with 7 groups of risk factors was included: 1.
skin colour/temperature changes, foot oedema; 2. nail changes; 3. foot ulcer, previous
ulcer/amputation; 4. mycosis; 5. callus; 6. inappropriate footwear; 7. foot deformities (e.g.
claw toes). The electronic questionnaire is fulfilled by general nurse in hospitalised patients
during admission. In case of at least one positive answer the specialised podiatric nurses are
contacted.
Results: At present each diabetic patient admitted to any hospital ward undergoes the
questionnaire. If one ore more risk factors are present, there is a duty to inform podiatric
nurse. The system includes 3 specialised nurses who provide basal foot examination and
education on diabetic foot in patients without ulcers. In case of present ulcers, chief podiatric
nurse in cooperation with diabetologist provides foot care.
Conclusions: Implementation of diabetic foot screening in general hospital care enables to
search for at-risk patients early. Diabetics receive complex information on foot care and
prevention. Educated patients are then able to prevent possible feet problems more
consistently.
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P24.07
Multidisciplinary team approach and its effect to save the “pedal peninsula”
Rumneek Sodhi, Medanta-The medicity, Haryana, India
The prevalence of individuals with diabetes continues to rise in the developing world. The
disease affects more than 62 million Indians, which is more than 7.1% of India's Adult
Population. Consequently, the demand for diabetic foot care continues to increase and this
is exemplified by the one-year incidence of newly occurring ulcerations in patients with
diabetes ranging from 1 to 2.6 percent.
Diabetic foot ulcers occurs in 15% of all patients with diabetes and precedes 84% of all lower
leg amputations.
It is the multifactorial nature of diabetes that results in limb loss, generally as a consequence
of chronic wounds and poor vascular status. Clinical management of diabetic foot disease
has significantly improved over the last two decades. Prevention by identifying individuals at
high risk and setting up multidisciplinary foot clinics has been the most effective way to
reduce the socio-economic burden of the disease.
The pathology at presentation predicates the component of the limb salvage team to be
activated. The core of the team typically starts with clinicians caring for the structural and
surgical aspects of the foot (Foot Care Specialist-the TOE team) at the diabetic foot care
centre, along with clinicians caring for the vascular integrity of the lower extremity (vascular
surgeons-the FLOW team). For a more comprehensive care model, other specialties of the
team will include internal medicine, diabetology, infectious disease, orthopedic surgeons,
physical therapy, reconstructive surgeons, emergency medicine and prosthetics.
This literature states that the multidisciplinary team approach to wound care is: extremely
beneficial for the patients by achieving optimal diabetic foot management; effective in
prevention and treatment of the diabetic foot; and can help achieve significant increase in
the chances of successful healing and prevention of wound recurrence, thereby assisting in
reducing the costs of treatment and rehabilitation.
Conclusion: The early recognition and diagnosis of the “foot at risk”, along with the
combination of aggressive management of diabetic foot ulcers with the implementation of a
team approach espically the "Toe & flow" team has resulted in a 50% decrease on the
amputation rate in our centre in the last five years.
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P24.08
Lowering HbA1c of patients with diabetes and foot complications by a patient centred
multidisciplinary organization in the foot clinic
Karen Rytter, Steno Diabetes Center, Gentofte, Denmark
Anne Rasmussen, Steno Diabetes Center, Gentofte, Denmark
Ulla Bjerre-Christensen, Steno Diabetes Center, Gentofte, Denmark
Sine Hangaard, Steno Diabetes Center, Gentofte, Denmark
Volkert Siersma, University of Copenhagen, Copenhagen, Denmark
Mette Glindorf, Steno Diabetes Center, Gentofte, Denmark
Aim: The aim of this study was to develop quality and organization of the multidisciplinary
team in the foot clinic targeting poorly controlled patients and their needfor improved
HbA1cand psychosocial wellbeing
Methods: A controlled, prospective, descriptive study with follow-up after 1 year. A Diabetes
Specialist Nurse (DSN) was integrated in the team and discussed metabolic regulation when
the patientswere present in the foot clinic referred to orthopaedic surgeon. Inclusion criteria:
type 1 or 2 diabetes, foot complication and HbA1c > 75 mmol/mol. During nine months
consultations were providedby DSN in the foot clinic (typically 6-9 times). Topics covered
during consultations were monitored and included self-monitoring guidance, medication and
individual psychosocial support. Psychosocial aspects were monitored with two validated
psychometric scales: PAID and WHO-5. HbA1c was measured before and after the
intervention with follow-up after one year. The study included two HbA1c control groups
Results: Forty-nine patients were included, aged 56 ± 22 years, male 69.3%, HbA1c 88 (75125) mmol/mol, type 1 diabetes 55%, disease duration 25.1 (2-67) years, multiple
complication 85.4%. HbA1c 77.9 (40-135) mmol/mol after intervention, HbA1c 79.7 (53-114)
mmol/mol one year after which is a significant change. Forty-three patients answered
baseline PAID and WHO-5. 37.2% had a PAID sum-score > 33 indicating serious diabetes
related problems. 34.8% had a WHO-5 score < 50 indicating poor well-being and 18.6% <
20 indicating depression.High PAID score correlated with low WHO-5 score. At the end of
intervention and one year after there was significant change in PAID but not in WHO-5
scores. DSN supported areas were especially on medication and dialogue about life with
diabetes and foot complication
Conclusion: This study shows that individual DSN support offered to patients as a part of
multidisciplinary treatment, when they are present in the foot clinic, makes it possible to
improve and sustain HbA1c in this vulnerable group as much as in a control group without
foot complication. There is a significant improvement in diabetes related problems although
wellbeing in general was not improved. The patient centred approach seems to improve
results in relation to treatment
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P24.09
Diabetic foot ulcer management in the remote Australian Kimberley
Amy Freeman, Boab Health Services, Broome, WA, Australia
Jennifer Kitchen, Boab Health Services, Broome, WA, Australia
Bethany Zubovic, Boab Health Services, Broome, WA, Australia
Between 2002 and 2012 there was an average of 15 lower limb amputations related to
diabetes each year for residents of the remote Kimberley Health Region in Western
Australia. This rate is 2-3 times the Australian average. Geographically the Kimberley is 421
451 square kilometers with a population of 37 500 (1). Aboriginal Australians are known to
be at particularly high risk of diabetic foot complications (2) and make up 45% of the
population in the Kimberley (1).
Aim: To investigate the current management of diabetic foot ulcers in the Kimberley region
against evidence based best practice.
Methods: A tool audited foot ulcer management including podiatry contact, sharp wound
debridement, pressure offloading, footwear and referral to multidisciplinary foot team
Prospective data was collected at each podiatry treatment to a diabetic foot ulcer over 47
weeks in 2014.
Results: Overall there were 241 podiatry contacts for diabetic foot ulcers. 217 (90%)
contacts were to Aboriginal patients. The average age was 51 years.
73 (30%) contacts were to patients who had not seen a podiatrist for at least three months.
201 (83%) contacts had sharps debridement performed.
86 (36%) contacts had nil offloading as part of foot ulcer treatment. There were 0 pressure
offloading casts and only 2 irremovable boots used. Pressure offloading was most frequently
in the form of felt padding (n=49, 20%), or post-op shoe (n=49, 20%). 93 (39%) contacts
presented with no shoes, thongs or footwear deemed inappropriate.
55 (23%) contacts were recorded as referred to a multidisciplinary team or remote specialist.
Conclusion: Evidence based best practice management strategies including regular
podiatry review, pressure offloading and referral to specialist multidisciplinary diabetic foot
teams are under utilised as treatment for diabetic foot ulcers in the Kimberley. The results of
this study indicate the need for improving the approach to diabetic foot disease in this
remote area of Australia.
References:
(1) Wood, N; Newton, B; Bineham, N & Lockwood, T. Kimberley Health Profile 2012.
(2) Department of Health, Western Australia. High Risk Foot Model of Care. Perth: Health
Networks Branch, Department of Health, Western Australia; 2010
www.diabeticfoot.nl
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P24.10
Evaluating the implementation of evidence-based diabetes foot screening in a
community home care organisation
Rajna Ogrin, Royal District Nursing Service (RDNS), St Kilda, Australia
Tracy Aylen, Royal District Nursing Service (RDNS), St Kilda, Australia
Aim: To assess the uptake of diabetes foot screening across a community based nursing
organisation after clinical practice guideline (CPG) implementation.
Methods:
Dissemination of evidence-based foot assessment CPG’s was undertaken across a
community based home care organisation using standard multi-modal methods of
implementation:
1. Education of all staff about foot screening in people with diabetes (PWD) based on
evidence-based CPGs.
2. Basic electronic assessment decision support developed and implemented.
3. CPG posted on the organisations internal webpage.
4. Dissemination of reminder memo’s outlining CPG organisation wide.
Data collection:
• Number of foot assessments undertaken in PWD seen by nurses for diabetes
management, pre and post CPG implementation.
• Classification of risk for amputation post CPG implementation.
Results:
In 2012, 50% of the 1807 PWD seen by nurses for diabetes management underwent a foot
assessment.
In 2013, after CPG implementation, 48% of the 1879 PWD seen by nurses for diabetes
management underwent foot assessments; the foot assessment categories outcomes are
shown in Table 1.
Discussion and conclusions: A home care organisation implemented evidence-based
CPGs to screen and identify risk of amputation for all PWD seen by the organisations’
nurses for diabetes management. There was no difference in the number of foot
assessments undertaken post CPG implementation. Over 40% of PWD who underwent the
full foot assessment were at high or very high risk of amputation, and as half of the PWD
were not assessed and 20% of those assessed had incomplete information, many PWD who
may have been at risk of amputation were unrecognised. These results indicate the need for
an improvement in methods to implement CPGs in practice settings.
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