Transcript The diabetic foot CPG diabetes sub

Atlas of variation
R B Paisey, SW CCG advisory group 04/05/2014
•
•
•
•
•
Excuses or challenges!
Age
Ethnicity
Legacy effect
Rural population
Lack of detail
Evolution and the diabetic foot
Increasing numbers
Fashion victims
The problem in profile
R B Paisey, SW CCG advisory group 04/05/2014
Why speed is of the essence
R B Paisey, SW CCG advisory group 04/05/2014
Vascular disease and outcome
Reference Rate of Healing of Neuropathic Ulcers of the Foot in Diabetes
and Its Relationship to Ulcer Duration and Ulcer Area.
Ince, Game and Jeffcoate. Diabetes Care 2006
Profile Torbay total ulcer and
amputation rates 2005-2013
The diabetic foot
Other Audits
R B Paisey, SW CCG advisory group 14/07/2014
• 1. Williams MV, Drinkwater KJ. Radiotherapy in England in 2007:
modelled demand and audited activity. Clin. Oncol. R. Coll. Radiol.
G. B. 2009;21:575–90.
• 2. Cloud G, Hoffman A, Rudd A, Intercollegiate Stroke Working
Party. National sentinel stroke audit 1998-2011. Clin. Med. Lond.
Engl. 2013;13:444–8.
• 3. Birkhead JS, Walker L, Pearson M, Weston C, Cunningham AD,
Rickards AF, et al. Improving care for patients with acute coronary
syndromes: initial results from the National Audit of Myocardial
Infarction Project (MINAP). Heart Br. Card. Soc. 2004;90:1004–9.
• 4. Sweeney AB, Flora HS, Chaloner EJ, Buckland J, Morrice C, Barker
SGE. Integrated care pathways for vascular surgery: an analysis of
the first 18 months. Postgrad. Med. J. 2002;78:175–7.
• They all have admin, clerical and IT help
The first peer review visits (NHS Diabetes)
2011 to 2013
Team involved
Zoli Zambo
Shelina Jetha
Richard Paisey
Graham Bruce
Alex Harrington
Matthew Cichero
Rob McCarthy
Angie Abbott
Host team
Foot review patients
Multidisciplinary team in
action
Podiatry leads
Commissioners
Nursing support staff
Admin team
10 visits as NHS Diabetes
Amputation rates according to services available 2011
centre
Data base
MDT
Orthotics
In clinics
Pod lead for
foot service
Com pod >1/1000
Diabetic populn
1
+
+
+
+
+
2
+
+
+
+
+
3
-
+
+
-
+
4
+
+
+
+
-
5
-
+/-
-
-
+
6
-
+/-
-
-
+
7
-
-
-
+
+
8
-
-
-
-
+
9
-
-
-
-
+
10
-
-
+
-
-
Measuring within area variation
R B Paisey, SW CCG advisory group 04/05/2014
All amputations/1000 persons with diabetes
per 5 years per practice
Clustering within areas
R B Paisey, SW CCG advisory group 04/05/2014
Integrating with the patient and carers
Prompt treatment matters-the patient’s narrative
Major lower limb amputation
• Male age 61 T2DM 5 years
• Good family support
• Great toe ulcer
• Low dose antibiotics in
community 6 weeks
• Not healing, referral to MDT
• Osteomyelitis in tibia
• AKA
Resolution of ulcers
• Male age 84 T2DM 10 years
• Living alone
• Bilateral heel ulcers
• MDT in 5 days
• Offloading and intense
antibiotics
• Complete healing
• No surgery required
NHS England peer reviews
Thanks to
• Margaret Bamford, Michelle Roe NHS Diabetes
• Duncan Browne, SW regional diabetes lead
SW Region:
• podiatrists (Alex Harrington)
• vascular surgeons
• foot and ankle specialists
• diabetologists
• Orthotists
• DUK
• Persons living with diabetes
• Commissioners
Peer review team
•
•
•
•
•
NHS England lead for quality improvement
Two diabetes leads
Two podiatry leads
Vascular surgeon
Orthopaedic surgeon
What constitutes an effective MDT?
•
•
•
•
•
•
•
Enough space for parallel working
Two podiatrists with rotation in from community
Orthotist contract
Diabetologist
job plan
Vascular surgeon job plan
Orthopaedic/podiatric surgeon job plan
Access to microbiology/tissue viability/diabetes
nursing
• Access point for referral
The foot protection team
R B Paisey, SW CCG advisory group 04/05/2014
• Practice nurse annual review and education for
low risk patients
• 7.2 podiatrists/100,000 populace (all podiatry)
• Skill mix-band 5 for high risk patients
band 6 for ulcer treatment
• Liaison with district nurse, care homes, practice
• Link and rotation in to MDT with clear point of
contact
Ref Health Committee Written evidence from the Society of Chiropodists and
Podiatrists (PEX 21) 2013
Heterogeneity of diabetic foot care
services
Social
enterprise
General
Practice
Nursing
and
residential
homes
Patient
CCG
and carer
NHS Trust
Hospital
Advanced information
R B Paisey, SW CCG advisory group 04/05/2014
• To be obtained by CAG review
team
• a) Population served by CCG
• b) Percentage with diabetes
• c) Five year minor and major
amputation rates/1000 diabetic
persons in each practice
• d) What is the compliance in
practices with the 9 care
processes for diabetes annual
review?
• Supplied by CCG,MDT,Community Pod
• a) Location, frequency and regular
attendees at MDT
• b) Locations, skill mix and frequency of
community diabetes podiatry clinics
• c) Rotation scheme between community
and MDT podiatry
• d) Access to diabetic foot care pathways
• e) Root cause analysis of amputations
• f) Services commissioned and delivered
for low, medium and high foot risk
diabetic persons
• g) Are there regular training programmes
for primary and secondary care staff in
diabetes foot care?
Peer review timetable
Time
Venue
Purpose
Participants from locality
10.0010.15
Meeting room
Introductions
10.1510.30
Meeting room
Aims and structure of review
10.3012.00
MDT area
(clinic in
progress if
necessary)
Assessment of clinic space,
frequency, staffing and
integration with community and
wards
10.3012.00
Interview room
Interviews with patients
CCG, Trust Board, review
team, diabetes foot care
leads in podiatry and
diabetes
CCG, Trust Board, review
team, diabetes foot care
leads in podiatry and
diabetes
Podiatrist, diabetes lead,
vascular surgeon,
orthopaedic surgeon,
orthotist, clerical support
staff
4 patients two healed two
amputees
10.3012.00
12.0012.30
12.301.00
Quiet room
Review of 4 of 10 sets of patient notes
Admin staff member for clinic
Meeting room
Coffee break
none
Meeting room
Discussion of access to diabetes foot
care general practice-community
podiatry –MDT and back
GP, CCG, community
podiatry, diabetes, vascular
surgery leads for diabetes
foot care and orthotist
All
None
All
GP, CCG, community
podiatry, diabetes, vascular
surgery leads for diabetes
foot care and orthotist
All
1.00-1.30
1.30-2.00
Meeting room
Lunch
Outline of recommendations
2.00-3.00
Meeting room
Feedback to local team
Review team
member
All
Documentation
All
Written notes
Diabetes specialist,
podiatrist and
surgeon
Use data collection
form
NHS England lead
and second
podiatrist
Second
diabetologist
All
Use national audit
form
Written notes
Use national audit
form
Highlight list of
important issues
Use data collection
form
Written notes
Thanks for listening
Best practice
•
•
•
•
•
•
Patient centred continuity of care
Integration with general practice
Podiatry based
With audit of all ulcers
Clarity in commissioning
Research HEELS and future studies
18
The Time of Intervention in Days after first presentation of ulcer and
their outcomes
16
14
Number of Patients
12
10
Number of Ulcers Healed
Number of Major Amputations
8
Number of Minor Amputations
Number of Deaths
6
4
2
0
0-20
21-40
41-60
61-80 81-100 101-120 121-140 141-160 161-180 181-200 201-220 221-240 241-260 261-280 281-300
Time of Intervention (Days)
Delivery of Care
Prevention of foot disease
Hospital acquired heel ulceration