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Gill Sykes & Gareth Hicks
What does the ‘future’ hold?
Insulin pumps BGL monitoring without taking bloodA diabetes vaccineArtificial pancreasVery low calorie diet
We’re at Foot HealthThe future of foot care in diabetes
Screening & Risk StratificationTreatment & adviceCorrect & Timely Referral
State of the nation3.2 million people diagnosed with diabetes61000 foot ulcers at any one time6500 amputations a yearIn 2010-11 NHS England spent £639-£662
million a year ( £74,000 an hour)Only 50% of patients with diabetes survive 2
years+80% of ulcers are preventable Ref: Footcare for people with Diabetes ( Kerr 2012) Putting Feet First , Diabetes UK 2009
Screening in private practice In NICE CG10 and SIGN 116 a foot
examination is indicated;
PulsesMonofilament & tuning fork testFoot deformityHistory ( ulcers and/or amputations)
The tools :10g Monofilament
128 MHz tuning forkNeurothesiometerRydel-Seiffer tuning
fork
Screening The purpose of screening is to award the
patient with a foot risk category.
Low risk 1:500 ulcer riskAt risk 1:20 ulcer riskHigh risk 1:2 ulcer risk
Leese et al 2006
Foot Risk Awareness & Management Education(FRAME) www.diabetesframe.org
Risk categoriesActive ulceration High risk – previous ulcer/amputation
At risk - neuropathy and or vascular impairment with foot deformity
Low risk – no neuropathy, no vascular problems or foot deformities
What do I do with this information?Note the risk factor in patients notes, with
date & reasonInform the patientInform GPScreen again in 12 -15 months – low riskScreen again in 3-6 months – at riskScreen again in 1-3 months –high risk (MDT)
Scottish modelThe Foot Attack is coined for patients
needing referral for immediate treatment.In line with this , CPR for feet has been
launchedC Check . Examination/assessmentP Protect Advice/footwear/insolesR Refer To Foot protection team
Referring a diabetic foot problemWho is patients’ GP ?
Who leads the hospital diabetic foot clinic?What is their phone number?How does the patient get there ? Self
ref/GP/directWhen you refer – record it !
Gill Sykes is a diabetes specialist podiatrist. With 27 years experience, she takes up the reins....
Clinical Lead Podiatrist Acute Diabetic Care
27 years NHS experience24 years communitySpecialising tissue viabilityWork as part of a multi- disciplinary teamIncluding vascular consultant surgeons,
diabetic consultant, tissue viability team, orthotist, specialist physiotherapist.
6 years private practice experience
CalderdaleIn Calderdale there were 13, 229 diabetics
diagnosed in 2013By 2030 there is predicted 19, 289 diagnosedThis is an increase from 8.0% of population to
9.8%(YHPHO, 2013)
HuddersfieldIn Huddersfield there were 27, 260 diabetics
diagnosed in 2013.By 2030 there is predicted 38, 262
diagnosed.This is an increase from 8.5% of population to
10.4%.(YHPHO, 2013)
There are two local diabetic foot screening tools within
Calderdale and Huddersfield.
Screening ToolsCalderdale utilise Podiatry Assistants with
competency based training by podiatrists
Huddersfield utilise Practice Nursing with competency based training by podiatrists
Benefits of podiatry assistants
Competency basedPro -podiatryMore thorough assessment i.e. more
knowledge of foot pathologiesQuicker referral to podiatryInspection/ adviceIn Calderdale 2013, 89% of all diabetics in
Calderdale were screened (not including DNA’s)
Screening Tool on Systm1 New/ Follow up screening – first
appt./ follow up option tick box. Peripheral sensory neuropathy
screening – left and right foot 10g monofilament/ normal abnormal.
Peripheral arterial screening – right foot left foot both pulses, present, absent. Signal – mono, bi, tri phasic.
Lesions/ foot deformity – free text. Diabetic risk category – low,
moderate, high , ulcerated. Annual screening plan – Podiatry
dept/ GP Practice Treatment plan – referral to podiatry,
continue with podiatry, self care/ private care
RECALL
NICE guidelines on foot risk The prevention and management of foot
problems advises that foot risk should be classified as:
at low current risk: normal sensation, palpable pulses
at increased risk: neuropathy or absent pulses
at high risk: neuropathy or absent pulses plus deformity or skin changes or previous ulcerated foot
SO…………..‘The postcode lottery of diabetes- related
amputations in England is getting worse, according to figures from Diabetes UK’ (Podiatry Now, 2014)
‘Too many people with diabetes not getting a good quality annual foot check or not being informed about their risk status at the end of their check’ (Podiatry Now, 2014)
The figures, based on NHS data, show that overall diabetes-related amputation rate has not improved, with 2.6 thousand lower limb amputations per year with diabetes. The gap between the worst and best performing areas has also got bigger’ (Podiatry Now, 2014).
What we don’t want is this……
Or this………
If in doubt, DO REFER
To pose some questions…..?What will happen to all the low/ medium risk
diabetics in the NHS?And staff shortages?And an increase in diabetics?And a growing elderly population?
WHAT NOW?
Food for thought..Some NHS Trusts already have done some of
the below….Discharge low/ medium risk to self
management.Training/ competencies for assistant
practitionersInvolvement of private clinicians, ?
partnership workingVoluntary sector
Thank You