The NADC Collaborative Interdisciplinary Diabetes High Risk Foot Service Standards

Professor Stephen TwiggMBBS(Hons-I), PhD(Syd), FRACPHon. Chair of the NADC Foot Network;Medical Director Dept of Endocrinology and the Diabetes High Risk Foot Service,Royal Prince Alfred Hospital, Sydney;Kellion Professor of Endocrinology, Stan Clark Chair in Diabetes,Faculty of Medicine and Health, Sydney Medical School, Charles Perkins Centre,The University of Sydney NSW AUSTRALIA

nadcNational Association of Diabetes Centres

The Agenda

• The status of diabetes foot care outcomes in Australia

• Integrated foot care as a national health priority, including the importance of diabetes High-Risk Foot Services (HRFS)

• The NADC Foot Network and setting of collaborative interdisciplinary HRFS standards

nadcNational Association of Diabetes Centres

The Agenda

• The status of diabetes foot care outcomes in Australia

• Integrated foot care as a national health priority, including the importance of diabetes High-Risk Foot Services (HRFS)

• The NADC Foot Network and setting of collaborative interdisciplinary HRFS standards

nadcNational Association of Diabetes Centres

Some Diabetes-Related Complications

Significant Clinical Variation Occurs in Diabetes

https://www.safetyandquality.gov.au/wp-content/uploads/2017/06/Key-findings-and-recommendations.pdf

- Australia

Australian rate:23 per 100,000

Two fold the UK, ~half the USA

Australian Atlas of Healthcare Variation

https://www.safetyandquality.gov.au/atlas/

- Australian Capital Ci.es

Australian Atlas of Healthcare Variation

https://www.safetyandquality.gov.au/atlas/

States andTerritories

The Agenda

• The status of diabetes foot care outcomes in Australia

• Integrated foot care as a national health priority, including the importance of diabetes High-Risk Foot Services (HRFS)

• The NADC Foot Network and setting of collaborative interdisciplinary HRFS standards

nadcNational Association of Diabetes Centres

Ø The National Diabetes Strategy 2016-2020 was released November, 2015.

Ø A main goal in the strategy is to:

- ‘Reduce the occurrence of diabetes-related complications and improve quality of life among people with diabetes’.

Ø The NDSS are prioritising a diabetes foot care project:

- For people with diabetes- For foot care education and delivery systems

in diabetes

Ø The NDS outcome process has a diabetes complications focus.

http://www.health.gov.au/internet/main/publishing.nsf/content/

Ø 2017 Atlas: key recommendations for Diabetes –

Local Hospital Networks, Primary Health Networks and the Aboriginal

Community Controlled Health Service sector should promote appropriate

care for the management of people with diabetes using:

• The guidelines General Practice Management of Type 2 Diabetes 2016–18 as the routine model of care

• The Australian National Diabetes Strategy 2016–2020 to ensure the

provision of integrated models of care

• Performance management frameworks to assess compliance of care with

relevant diabetes treatment guidelines.

Ø Integration across all health care systems in chronic disease

https://www.safetyandquality.gov.au/wp-content/uploads/2017/06/Key-findings-and-recommendations.pdf

14/10/18

12

NHMRC of Australia

Clinical Care Guidelines

An access site :http://www.nhmrc.gov.au/guidelines/publications/cp102

https://www.bakeridi.edu.au/Assets/Files Foot_FullGuideline_23062011.pdf

Health Pathways: Where Should ParticularFoot Complications in Diabetes Ideally be Managed?

Community care

Inter-disciplinary

High-Risk Foot Service (HRFS)

Ambulatory

Inpatient care

Bergin SM et al., for the ADFNMed J Aust. 2012;197(4):226-9.

Primary and Secondary

Preventive care

Tertiary Hospital

care

Tertiary Ambulatory

care

Diabetic High Risk Foot Service (HRFS)

Foot Education and Regular Community Podiatry

General InformationLow

High

Ulcer present

Stratification of Intensity of Care Required Based on Foot Ulcer Risk

Ulcer Risk

NHMRC Clinical Care Guidelines: Diabetes and Foot Disease 2011

Not Everyone with Diabetes Requires the Same Intensity of Foot Care: Risk Stratification

Risk Profile Risk Characteristics Recommendations Frequency

0 No risk factors No specific referralPodiatry care (private) for general foot problems.(+/- GP Management Plan(GPMP) /Team Care Arrangement (TCA))

Annual

1 Peripheral Neuropathy Podiatry care and High risk education(Public or Private care setting) GPMP/TCA

6 months

2 Peripheral Neuropathy and Deformity OR Peripheral Arterial Disease

Podiatry care and Education(Public or Private care setting) GPMP/TCA

3 months

3 Previous Ulcer or Amputation As above 1-3 months4 Active foot ulceration, infection or suspected

acute charcot�s arthropathy /neuropathic fracture.

Prompt High Risk Foot Service Referral (assess urgency)

Until issues resolved

Not Everyone with Diabetes Requires the Same Intensity of Foot Care: Risk Stratification

Risk Profile Risk Characteristics Recommendations Frequency

0 No risk factors No specific referralPodiatry care (private) for general foot problems.(+/- GP Management Plan(GPMP) /Team Care Arrangement (TCA))

Annual

1 Peripheral Neuropathy Podiatry care and High risk education(Public or Private care setting) GPMP/TCA

6 months

2 Peripheral Neuropathy and Deformity OR Peripheral Arterial Disease

Podiatry care and Education(Public or Private care setting) GPMP/TCA

3 months

3 Previous Ulcer or Amputation As above 1-3 months4 Active foot ulceration, infection or suspected

acute charcot�s arthropathy /neuropathic fracture.

Prompt High Risk Foot Service Referral (assess urgency)

Until issues resolved

Typical Interdisciplinary High Risk Foot Service (HRFS) Entrants

for People with Diabetes

Precipitants of Diabetic Foot Ulcers Tight fitting foot-wear

Burns Penetrating injury

Neuropathy and Arterial Assessments

Peripheral Neuropathy assessment

• Neuropathy Assessment: • Ankle reflexes• Vibration perception• 128 Hz tuning fork• Biothesiometer•10g S-W Monofilament

• Arterial Assessment:• Clinical• Ankle Brachial Pressure Index• Low threshold for arterial Doppler Ultrasonography

Andros, G etal.Diabetes Metab. Res. Rev. 2002; 20: S29-S33

Miranda-Palma B, etal.Diabetes Res. Clin. Pract. 2005; 70(1): 8-12

Treat Foot Ulcers in Diabetes

ØA multifaceted, patient targeted approachØAssessmentØTreatment

ØPressure offloading ØDebridémentØAntibioticsØRevascularisation This alone

Is not ideal!

Inter-disciplinary High-Risk Foot Service Delivery

TogetherEveryone Achieves More

Holistic patient care is required in an integrated manner,including shared decision making.

Many other team members

Diabetes High-Risk Foot ServiceInter-disciplinary Team Members

Differing Types of Diabetes Foot Ulcer

The Diabetes HRFS Has A Supportive Evidence Base

ØThe Diabetes HRFS can:

Ø Prevent hospital admissions

Ø Reduce length of hospital stay

Ø Reduce major amputations

Ø Be cost-effective

References:

Some Biomechanical Factors Associated with Hallux Ulcers, and Their Measurement

Vacuum Assisted Device (VAD) Healing as a Negative Pressure Wound Therapy (NPWT) in Complex Wounds

AmputationTime toUlcer Closure

162 pts, 16 weeks, 18 Centres,Partial foot amputation, wound av 20cm2

Armstrong DG et.al, Lancet 2005; 366: 1704-10

Pressure Off-loading: After Ulcer Healing –including Orthotics and Custom made Footwear

The Ideal Shoe

2015: A document for clinicians and administrators to improvequality, safety and consistency in the delivery of foot care forpatients with serious foot complications.

Aims to improve:ü Patient experiencesü Health outcomesü Effective use of resources

The Agenda

• The status of diabetes foot care outcomes in Australia

• Integrated foot care as a national health priority, including the importance of diabetes High-Risk Foot Services (HRFS)

• The NADC Foot Network and setting of collaborative interdisciplinary HRFS standards

nadcNational Association of Diabetes Centres

National Association of Diabetes Centres -Foot Network (NADC-FN)

MISSIONØTo establish and maintain reduced morbidity and mortality from

diabetes-related foot disease

AIMØTo realise a coordinated national process of prioritising high quality and

accessible foot assessment and management across the spectrum of foot disease in diabetes.

Promoting excellence in diabetes care

National Association of Diabetes Centres -Foot Network (NADC-FN)

Ø NADC FN Working Party (WP) Membership (stakeholders):• National Association of Diabetes Centres• Australian Diabetes Society• Wounds Australia • Advanced Practicing Podiatrists - High Risk Foot Group• Australian Podiatry Council (APodC)• Diabetic Foot Australia (DFA)• Pedorthic Association of Australia (PAA)• Agency for Clinical Innovation (ACI)• Australian Diabetes Educators Association (ADEA)• Australian Primary Care Nurses Association (APNA)• Diabetes, Obesity and Metabolic Translational Research Unit (DOMTRU)

National Association of Diabetes Centres -Foot Network (NADC-FN) Interdisciplinary HRFS

Working Party Initiative • Using a HRFS standards setting document 2015, derived from the NSW State Dept of

Health Agency for Clinical Innovation

• WP consensus review process face to face held on June 23rd, 2017, onwards

• The standards were set with accompanying indicators• Standards and indictors directly translated into a HRFS accreditation program

• Indicators include participating in annual foot audits and collecting a minimal data set

• Two levels of standards established: ‘Core’ and ‘Centre of Excellence’ Standards

• The business case for integrated foot care supporting HRFS can then be further put to local, state and national Health Departments

• A FN Reference Group supports the FN WP as required.

Promoting excellence in diabetes care

The NADC Collaborative Interdisciplinary Diabetes High Risk Foot Service Standards - Finalised

• Consolidated standards:1. Interdisciplinary approach2. Coordination and administration3. Evidence-based clinical management4. Access and defined intake criteria5. Continuity of care and communication6. Equipment7. Wound care 8. Quality improvement

• Core Indicators• Centre of Excellence Indicators

Staff

Equipment

patient outcomes

Processoutcomes

nadcNational Association of Diabetes Centres

…and key additional Collaborators!

The NADC Collaborative Interdisciplinary Diabetes High Risk Foot Service Standards – Finalised and Released!

1. Multi-disciplinary approach - staff skills sets, % presence, interdisciplinary communication

2. Coordination and administration- champion, co-ordinator, administrative support

3. Evidence-based clinical management- local guidelines, patient protocols, regular guidelines/protocols reviews

4. Access and defined intake criteria- documented intake criteria, timing of access documented, area provision

5. Continuity of care and communication- ward consultations, direct admissions, handover, inpatient processes

6. Equipment- offloading equipment, orthotics lab and devices, NPWT, TCC onsite

7. Wound care products- access to and rational use of products

8. Quality improvement- parameters to support internal audits, benchmarking- research and education

•Medical Data

The HRFS Team

Telemedicine in Interdisciplinary HRFS: The ‘hub and spoke’ Concept Realised

DubboLismoreNowraOrange

GraftonPort Macquarie

GriffithForbesQuirindi

Mullumbimby E-mail

NSW Rural and Regional •Standardised wound images

Standard 8 – Data Collection

• Relates to quality improvement for HRFS • Collecting valuable data to assist service development • Quality improvement plans are undertaken and supported by

collecting clinically significant data relevant to the HRFS

nadcNational Association of Diabetes Centres

Service Development

Quality Improvement

Data InterpretationData AnalysisData Collection

Standard 8 - The Challenges

• Data collection is time consuming, onerous • Collaborative input to data fields • Needs to be useful – center dependent • Centre based – not easy to externally benchmark• The future - NADC looking at developing an online data tool to assist

centers to achieve this standard and thrive

nadcNational Association of Diabetes Centres

Standard 8 – Core Service Indicators

• Annual clinical audit• HRFS collects minimum data and develops KPIs – center relevant • Key data are reported, shared with the NADC annually• Quality improvement cycle that addresses any serious adverse event(s)• Routine and ongoing education and professional development in high

risk foot care is provided for all HRFS staff

nadcNational Association of Diabetes Centres

RPA

Less Delay In Presentation of Patients to the Service (Days Between Ulcer Development Historically and HRFS Presentation)

• 1995 - 1999• 55 days [17-140]

• 2000 - 2003• 49 days [22-122]

• 2004 - 2007• 33 days [17-90]

• 2008 - 2012• 30 days [14-66]; since 2012 median has reduced to 18 days.

Ttrend = 3.7, p =0.0002; Bolton T, et al WDC 2014

A Clinical Audit Process Example:RPA Hospital Interdisciplinary High Risk Foot Service: Longer Term Data

RPA

Time to Access Interdisciplinary HRFS Care Relates to Ulcer Severity

00.10.20.30.40.50.60.7

Months

0 1 2 3

Grade

Bolton T et al., ADA Abs 2013; IDF Abs 2014 n=1486 Foot ulcers

Standards Facilitate Accreditation

42

‘One Vision’ – Australian Diabetes HRFS Standards Accredited Sites

Belgium

Morbach S. et al

In some initial investigations, the NADC located 120 services that either identify themselves as HRFS or offer services to individuals at high risk.

‘Core Centres’, and ‘Centres of Excellence’

One ‘vision’

Health Care Professional Educational Projects:ADS NDSS - Promoting Optimal Diabetes Foot Care

https://diabetessociety.com.au/diabetesfoot/

• The Foot Examination

• Preventive foot care

• Managing basic diabetes foot complications

• State-based and national programs for interdisciplinary HRFS• Incl. Best Practice in Diabetes Centres Workshops

Audiovisual resources:

Supportive Regional and International Approaches

IDF-Western Pacific Region- Train the Foot Trainer Foot Care Education International Working Group on the Diabetic Foot

Major Challenges in Diabetes Foot Care in Australia Can be Realised

Ø The geography and fewer people living in rural areas

ØRoutine stratifying foot complications risk in people with diabetes

Ø Preventive foot care specifically for those at increased risk

Ø Providing timely access to accredited diabetes interdisciplinary high risk foot services

Ø Achieving sustained outcomes in diabetes HRFS

Ø Providing efficient hospital inpatient foot care in diabetes and integrated care across systems

Ø Adequate funding models and incentives at all levels

ØContinuing education to clinicians and patients Adapted: Bergin SM et al. Med J Aust. 2012;197(4):226-9; Lazzarini P et al MJA 2018

The Agenda - Realised

• The status of diabetes foot care outcomes in Australia addressed

• Described integrated foot care as a national health priority, including the importance of diabetes High-Risk Foot Services (HRFS)

• The NADC Foot Network and setting of collaborative interdisciplinary HRFS standards

nadcNational Association of Diabetes Centres

AcknowledgementsØNational bodies:

• The National Association of Diabetes Centres and the Australian Diabetes Society§ Ms Natalie Wischer, Ms Leanne Mullan, Michaela Watts§ Prof. Sophia Zoungas, Prof. Sof Andrikopoulos, Prof. Jonathan Shaw

• NADC FN Working Party and Reference Group members• Kellion Diabetes Foundation • Diabetes Australia Ltd: A/Prof. Greg Johnson• National Diabetes Services and Supply scheme• Federal Dept of Health and Ageing• NHMRC of Australia

ØState Bodies:• ACI Network NSW Dept of Health• NSW Diabetes Task Force

ØLocal bodies:• Ms Vanessa Nube, Head of Podiatry, SLHD and NSW DoH ACI FN Co-chair• Diabetes Centre, Dept of Endocrinology, Royal Prince Alfred Hospital, Sydney• Maari Ma Aboriginal Health Service, Broken Hill, NSW