Transcript Ipswich Diabetic Foot Unit

Integrated care for the diabetic
foot: impact on outcomes
Gerry Rayman
Ipswich Hospital
Suffolk
The Ipswich Diabetic Foot
Clinic
Healing
Untreated
Infection
Replace
Lose
footwear
footwear
OffOff-loading
and
loading of
treatment
infection
Amputation
Wound
Referred to Foot Clinic
Screening to characterise risk
Pathways
Health care professional
Patients and carers
Coordination of Interventional procedures
Ipswich Diabetic Foot Unit
Main Treatment Room
Primary Care
GPs Practice nurses Community nurses Podiatrists
Community
nurse
‘Hot Line’
Patient held record
DSN
Community
Podiatrist
Senior
Podiatrist
Secondary Care
Diabetologist Podiatrist Orthotist Vascular & Orthopaedic surgeons Radiologist
Integrated care
Community Nurses
Foot Protection
Team
Multidisciplinary
foot care team
GP practices
In-patient service
Fast tracking
Possible admission routes for the
acute diabetic foot
Discharged
home
Acute foot
lesion
Vascular
surgeon
General
surgeon
Orthopaedic
surgeon
On call gen
physician
Care of
elderly
Diabetes
team
There needs to be a clear pathway for the acute diabetic foot
Amputation rates per 100,000 gen. population
Amputation rates 1995-2009 per 100,000
gen population
2.82
UK Evidence for effectiveness of Multi-disciplinary foot teams and provision
of inpatient foot care service
Organisation
Population
size
Year
Change in major
amputation rates
Estimated savings
based on bed days
alone(£200/d)
Ipswich Hospital
NHS Trust
335,000
1997- 2009
Reduced by 75%
£386,000/yr
Southampton
540,000
2003-2007
Reduced by 60%
£754,000/yr
Middlesbrough
273,987
1995-2000
Reduced by 75%
N/A
Northampton NHS
Trust
350,000
1999-2002
Reduced by 53%
N/A
Kings College
Hospital
Inner city
hospitalpopulation not
clearly defined
1990-2002
Estimated reduction
>70% (difficult to
assess as population not
clearly defined)
N/A
Larsson J, Eneroth M, Apelqvist J, Stenstrom A. Acta Orthop 2008
The trend of Total amputations
in diabetes in Finland
Number of 1st Amputations per 10,000diabetics in Finland 1988-2002
Lepantalo 2006
Total Amputations (major and minor) per 10,000 diabetics
Trends in LEA in people with diabetes in
England 1996-2005 (HES data)
• Type 1
Minor
Major
decreased 11.4%
decreased 41.0%
• Type 2
Minor
Major
increased 95.0%
increased 83.5%
Vamos EP; EASD 2009
Why is care patchy
across the UK?
Not rocket science
Not on the agenda
Not all plain sailing
•
•
•
•
Loss of in patient foot nurse
Foot protection team not supported in primary care
Community podiatry not full integrated
Education of community staff relies on good will- no funding
Southampton 2003 -2007 (520
admissions)
60
50
40
LOS
Major
Minor
30
20
10
0
2003
2004
2004
2005
2005
2006
2006
LOS from 50 days to 18.5 days
Major amputations reduced by 60%
2007
Bed days –Invest to Save
1997-1998 2005-2006
Amputation
1680
477
Other foot
1307
579
Total
2987
1056
Reduction
65%
Saving ~£400,000
“I marvel that society would pay a
surgeon a large sum to remove a
patient’s leg but nothing to save it”.
George Bernard Shaw
“I marvel that the health service
should continue wasting large sums
on the disasters arising from poor
diabetic foot care but little or none to
develop integrate services to prevent
them in the first place”
Gerry Rayman