In the beginning……..

Diabetic patients were losing limbs, long stays in hospital, no hope of healing chronic ulcers inevitable amputation.

No light at the end of the tunnel, only destruction, dismay and death.

…But a new era was emerging….

Historical Events

• Launch of Sky TV • Unleaded Petrol was at 38p per litre • Inauguration of the 1

st President Bush

• Order of the garter opened to women • Terry Waite was kidnapped in Beirut • First ever Rugby World Cup kicks off

Reduce Amputations by 50%

‘ Where are we – where do we want to be, and how can we get there ’?

Scotchcast Boot

The Greater Team

Podiatrist Specialist Care Patients Wards District Nurses Practice Nurses G.P’s

100 boots in Blackburn – 1988

Showed average healing rates of 8 weeks in neuropathic ulceration BUT How do we prevent the first ulcer?

How do we keep them healed?

Historical Data 1988/1989

Precipitating Factors of Ulcers Shoes Accident Thermal Pressure Kings (n=210) 85% 9% 2% 4% Blackburn (n=100) 74% 14% 3% 9%

LOW RISK Protective sensation intact

(10g pressure)

Optimise diabetes and blood pressure control (<139/80) Foot education/Low risk leaflet Podiatry only for problems

• • • •

MODERATE RISK Loss of protective sensation No deformity No callus No previous ulcer

•

Foot education/Moderate risk leaflet

• Consider Consultant opinion • Optimise diabetes and blood pressure control

(<139/80)

• Footwear advice and assessment

Regular Podiatry (12 weekly)

HIGH RISK

• Loss of protective sensation • Deformity and/or callus present • No previous ulcer •

Optimise diabetes and blood pressure control (<139/80)

• Foot education/High risk leaflet • Consultant opinion • Specialist prescribed Footwear/Shoe review

Regular Podiatry (4 – 12 weekly)

Very High Risk

•

Ulcer present or

• Previous ulcer • Loss of protective sensation (10 g pressure) •

Foot education leaflets/ very high risk leaflet

• Consultant opinion • Specialist prescribed footwear / shoe review • Optimise diabetes & blood pressure control

(<130/80) Regular podiatry and review (1-4 weekly)

Arterial Disease •

Abnormal flow

• +/- History of claudication

telephone: 07793 119344

• If you suspect acute vascular insufficiency •

Optimise diabetes & blood pressure control (>139/80)

• Prescribe aspirin/statin • ‘Stop smoking and keep walking’ • Foot education/leaflet • Consider consultant opinion • Specialist prescribed footwear / shoe review

Regular Podiatry especially nail care (1-12 weekly)

Referral Pathways For The Diabetic Foot

Referral for Urgent Problems Referral for Non-urgent Problems Referral for Diabetic Footwear

Urgent Patient Same Day Referral Non Urgent Patient Referral letter, or fax (01254 736311) Dr G.R. Jones, Diabetes unit, RBH Ring : Diabetes Hot Foot line Blackburn 07866684362 Burnley 07875011972 Continue treatment until Outpatient Appointment Condition becomes urgent refer via RED Pathway New patient Existing patient Prescribed footwear Letter of Referral to Dr G.R. Jones, Diabetes unit, RBH

Orthotics RBH

Orthotics

01282 804602

N.I.C.E Guidelines recommend:-

  

Annual inspection and examination Aggressive intervention to reduce morbidity Primary and secondary care should work together to identify a package of care for at risk feet

N.I.C.E.

‘foot ulceration and lower limb amputation can be reduced if people who have sensory neuropathy affecting their feet are identified and offered regular podiatry and protective footwear if required ’

Do Shoes and Orthoses work?

To look at the precipitating factors responsible for new DFU compared to previous studies.

Are shoes still a major factor or have things changed?

“Change is inevitable – except from a vending machine!” Robert C. Gallagher

Precipitating Factors of Referred Ulcers

Shoes Accident Thermal Pressure Kings 1988 (n=210) 85% 9% 2% 4% Blackburn 1988 (n=100) Blackburn 2004 (n=72) 74% 14% 3% 47.2% 12.5% 4.2% 9% 15.3%

Outcomes

Diabetic population and Ulcer Frequency 14000 12000 10000 8000 6000 4000 2000 0

1988

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 1000 900 800 700 600 500 400 300 200 100 0 Diabetic Population Ulcer Frequency

Aetiology of Foot Ulcers in Diabetic Foot Clinic 30 20 10 0 90 80 70 60 50 40 55 1988/89 33.3

12 1994/95 neuropathic 1996/97 36.1

2003/04

100 boots in Blackburn – 1988

Showed average healing rates of 8 weeks in neuropathic ulceration BUT How do we prevent the first ulcer?

How do we keep them healed?

Stock footwear Bespoke footwear Custom made insoles Diabetic specification Modular footwear

Continuous follow-up

(Orthotic & Podiatric)

   

2-3 servicable pairs of shoes Long term care (>2yrs) Weaning process Long term healing

“A neuropathic patient is a footwear patient for life” (Ulbrect J 15/05/08)

Footwear Follow-up Study

100 consecutive patients recalled after 2 years Then followed up for a further 7 years

Results

2 Years 5years 10Years 70% 70% 24% Intact Cracked skin/callus Ulceration Amputation 30% 0 0 23% 3% 14% 22% 1 Major 3 Minor 7 Major 5 Minor

Conclusion from footwear follow-up study

Prescribed footwear is effective when worn, inspection is a vital part of follow up although this is written into guide lines it is not usually adhered to.

The importance of footwear review needs more emphasis at all levels of care

That’s ok but is it cost effective?

£

G H Nuttall P/O BSc(hons) MBAPO

•

I am asked (told) to provide footwear for diabetic patients.

•

20% of my working week is dedicated to working within the East Lancashire Diabetic Foot Team.

•

I am expected to provide orthosis that will prevent high risk feet from ulcerating & healed ulcerated feet from re-ulcerating.

•

Ensure patients have TWO serviceable pairs of footwear.

Am I of value in treating feet ?

(or am I just an expensive accessory?)

•

Effective?

• Efficient? • Contribution? • Cost effective?

600 500 400 300 200 Cost Savings by Orthotics

Cost saving of £102,000 Cost saving of £147,000

30 39

Cost saving of £282,000

66

Cost saving of £392,000

88 100 0 0 10 20 30 40 50 60 70 Number of ulcers prevented 80 90 100 Healed ulcer £5,000 Total orthotic cost £48,142

Allied Health Professions input to the Diabetes pathway

• The cost on the NHS to heal one ulcer is

£3k to £7.5k. Should this progress to amputation the cost is estimated to escalate to £65k. This is much more than the cost of preventative orthoses.

• For every £1 spent in orthotics the NHS

saves £4. Hutton and Hurry 2009, Orthotic Service in the NHS: Improving Service Provision. York Health Economics

Ulceration/Hot Foot

REFER patients to a multidisciplinary foot care team within 24 hours if any of the following occur:

• new ulceration (wound) • new swelling • new discolouration (redder, bluer, paler,

blacker, over part or all of foot).

( NICE Guideline – Type 2 diabetes: prevention and management of foot problems ) REFER non-healing wounds from 0 – 4 weeks duration

Treatment of Ulceration

Pressure relief (preferably non removable) Medical management (CVS, oedema, diabetes, infection) Debridement and dressings And…….. a team

Pressure Relieving Devices

DARCO walker DH shoe Aircast Walker Padding & strapping Half shoe Podo-med

Nothing works like casting

Cast Variations

Modified TCC Focused Rigidity Cast Bi-valved cast Heel ulceration

Innovations from Diabetic foot Service

• Scotchcast Boot • Bespoke casting • Screening Programme • Effective and efficient orthotic service • Hot foot line • House shoe • Charcot data and register

HOME? NOT SO SWEET HOME

Lomax G McLaughlin C Jones G R Kenwright C Blackburn Royal Infirmary

HOME? NOT SO SWEET HOME “THE GREATEST NUMBER OF STEPS PER DAY ARE TAKEN IN THE PATIENTS OWN HOME.” David Armstrong et al. (American Podiatric Medicine 2001)

HOME? NOT SO SWEET HOME PRESCRIBED INSOLES AND FOOTWEAR CAN PREVENT FOOT PATHOLOGY (TOVEY F.I. 1987)

HOME? NOT SO SWEET HOME Footwear is most effective when worn for a minimum of 60% of the day. (Chanteleau, E. Haage, P.) Most effective when worn for 100% of the ambulatory time.

HOME? NOT SO SWEET HOME

AIM OF STUDY

To assess what proportion of patients who had been prescribed Diabetic footwear were wearing at home.

HOME? NOT SO SWEET HOME

How could we do this study?

• Ask patients at clinics?

• A telephone survey?

• Send patient questionnaires?

• Knock on patient doors and ask and look?

• Data collection by Community Podiatrists visiting patients homes on Domiciliary visits. “The sneak approach”

HOME? NOT SO SWEET HOME

RESULTS

Question 1. What is patient wearing on entry to house?

2. What does patient apply after treatment?

No shoes Own shoes 19% 15% 8% 8% Own slippers 52% 56% Prescribed shoes 21% 21%

HOME? NOT SO SWEET HOME

CONCLUSION

• 75% of patients visited do not wear prescribed shoes at home.

• All health care professionals need to be aware of this.

“ HOME SAFE HOME”

Charcot Foot

Care of People with Charcot Osteoarthropathy (NICE 01/04)

“People with suspected or diagnosed Charcot osteoarthropathy should be referred immediately to a specialist multidisciplinary foot care team for immobilisation of the affected joint(s) and for long-term management of offloading to prevent ulceration.”

Definition ?



No definitive “test”



Xrays & scans – open to interpretation



Diagnosis is primarily clinical & subjective

Identification of Charcot Arthropathy



Unified district wide diabetic foot service



Centralised referral point



Validated district diabetes register

Charcot Data (1996-2006)



Incidence and Prevalence



Patient Characteristics



Diagnostic Presentation



Treatment and Outcomes (including the effect of an audit and community education event in 2001)

Presenting Site Of Charcot

1 st .

Arthropathy

2 nd .

3 rd .

Midfoot 32(71%) Ankle 9(20%) Forefoot 4(9%)

Presentation Charcot



10 (35%) delayed diagnosis on presentation



7 (24%) developed C.N.A on ipsilateral limb



3 (10%) developed C.N.A on contralateral limb.



9 (31%) diagnosed correctly

Local Charcot “Programme” (2001)



Why Delays in diagnosis/ Late Presentations



How Education event in community for all HCPs



What Road show – staff meetings, lunch hours, training events

15 10 5 0 30 25 20 12, 41% 13, 45%

Presentation

25, 56% 16, 35% 4, 14% 4, 9% 2001 Acute (<2 weeks) (p<0.05) Sub-acute(<3 months (p>0.05) Chronic(>3 months) 2006

Treatment of Charcot Arthropathy

39 (87%) 4 (9%) 2 (4%) Mean time in casts 2001, 33.6 weeks (8 - 56) 2006, 20.5 weeks (range 8 - 30) (p<0.001) Mean time from active to quiescence 2001, 42 weeks (8 -70) 2006, 26.3 weeks (range 8 – 40) (p<0.001)

Outcomes

n=45

Healed/ Stable Feet Feet with Ulcers No. of C.N.A

Surgery exostectomies and minor amputations Below Knee Amputation Deaths 31 14 0 5+4 0 4 7 2

Mortality/Morbidity Charcot v Matched Controls

20 15 10 5 0 40 35 30 25 4, 11% 9, 26% 7, 20% 12, 34% Patients with C.N.A

(p>0.05) Control Group Total (n=35) Amputations Deaths

Summary



Charcot Arthropathy IS uncommon (1:500 people with diabetes)



Diagnosis is often initially delayed, but community education and awareness significantly reduces this



Poor diabetic control appears to be a prerequisite for CNA

Conclusion



Earlier recognition and treatment of C.N.A. translates into significantly faster healing & 3/12`s less time in casts! (Charcot “Road shows” work!)



Our local surgical practice is conservative & reserved for feet with recurrent or non healing ulcers only



Outcome for both limb and life is NOT adversely affected.



Larger patient numbers are needed to be studied to ratify these findings and this will demand collaborative working e.g. CDUK

Grant from DUK The Charcot register

• National data base •

Lead and managed from ELHT

The Charcot Register

Scotland North East North West Yorkshire & Humberside West Midlands East Midlands Northern Ireland Republic of Ireland Wales East Anglia South West South East 6 4 10 4 5 10 16 3 6 1 2 4

2.5

2 1.5

1 0.5

0

Major lower limb Amputations

PCT

Series1

4 3.5

3 1 0.5

0 2.5

2 1.5

Minor Lower Limb Amputation

PCT

Series1

Finally

Latest Benchmarking Data from the SHA • Lowest non-elective admission rates • Shortest length of stay • Effective and efficient service

Then & now

Diabetic Foot Service 1988 NOW

• People working in isolated pockets • Foot clinic inaugurated • MDT formed • Inadequate referral pathways • High amputation rates • Long in patient stays • Huge NHS costs • Foot clinic 23 years old • Effective implemented pathways • Well established clinics • Good interagency and interprofessional relationships • Low amputation rates • Reduced in patient stay • Cost efficient

Thank you