Transcript NDA Foot Exam Why important – risk classification

National Diabetes Audit - Foot Examination
Keith Hilston – Podiatry Diabetes Lead, May 2013
Content32pt
Main
Main heading
heading
32pt
• Why foot examination is important
• National / Local picture
• Foot screening (examination)
• Outcomes
NDA Foot Exam
Main
Main heading
heading32pt
32pt
Why important – risk classification
Total adult population with diabetes
1-4%
4-8%
20%
LOW
70%
Level of risk
Patients with active foot
disease
Patients with a history of
diabetic foot disease: risk of
reulceration 40 – 50% per
year. HIGH RISK
Patients with established risk
factors for diabetic foot
disease: risk of ulceration 3 –
7 % per year. MODERATE
RISK
Patients at LOW RISK of
diabetic foot disease: risk of
ulceration 99.6% ulcer free
after 2 years
Berkshire
Population
170 – 680
(358)
680 – 1360
(849)
3400
(1097)
11900
NDA Foot Exam
Main
Main heading
heading32pt
32pt
Why important – Quality of Life
NDA Foot Exam
Main
Main heading
heading32pt
32pt
Why important – Mortality
NDA Foot Exam
Main
Main heading
heading32pt
32pt
Why important – Cost
NDA Foot Exam
Main
Main heading
heading32pt
32pt
National Update
• Halving amputation rates in 5 years
• Develop Quality Improvement
Framework
• Audit and publish local outcome data
annually
Main
Main heading
heading32pt
32pt
NDA Foot Exam
Main
Main heading
heading32pt
32pt
Locality Update
Indicator NM12 DM10
The percentage of patients with diabetes with a record of
testing of foot sensation using a 10g monofilament or
vibration (using biothesiometer or calibrated tuning fork),
within the preceding 15 months
Indicator NM13 DM9 now DM29
The percentage of patients with diabetes with a record of
a foot examination and risk classification: 1) low risk
(normal sensation, palpable pulses), 2) increased risk
(neuropathy or absent pulses), 3) high risk (neuropathy
or absent pulses plus deformity or skin changes or
previous ulcer) or 4) ulcerated foot within the preceding
15 months
NDA Foot Exam
Main
Main heading
heading32pt
32pt
Locality Update
NDA Foot Exam
Main
Main heading
heading32pt
32pt
Locality Update
Care Process - Foot examination
Year of audit
England %
Berkshire West %
2006 - 07
73.6
76.0
2007 – 08
77.1
76.1
2008 – 09
82.9
80.7
2009 - 10
82.3
78.9
2010 - 11
84.4
84.7
NDA Foot Exam
Main
Main heading
heading32pt
32pt
Locality Update
NDA Foot Exam
Main
Main heading
heading32pt
32pt
Foot Screening
That HCP should have the skills necessary to:
a. identify the presence of sensory neuropathy (loss of ability to feel
monofilament, vibration or sharp touch) and/or the abnormal build up
of callus
b. identify when the arterial supply to the foot is reduced (absent
foot pulses, signs of tissue ischaemia, symptoms of intermittent
claudication)
c. identify deformities or problems of the foot (including bony
deformities, dry skin, fungal infection) that may put it at risk
d. identify other factors that may put the foot at risk (which may
include reduced capacity for self-care, impaired renal function, poor
glycaemic control, cardiovascular and cerebrovascular disease).
Putting Feet First: national minimum skills framework: March 2011
NDA Foot Exam
Main
Main heading
heading32pt
32pt
a. sensory neuropathy
• Place the calibrated tuning fork on the
inter phalangeal joint of the first toe.
• Ask the patient to tell you when
vibration can no longer be felt and
measure the point on the scale when
this happens.
• Neuropathy exists where the point on
the scale is below 4. A result of 4 and
above indicates that neuropathy is not
present.
NDA Foot Exam
Main
Main heading
heading32pt
32pt
a. sensory neuropathy
Test five sites on each foot.
If the patient responds yes to the application of pressure then mark + ve
If the patient responds no to the application of pressure then mark – ve.
A score of 6 and below = neuropathy. Score 7 and above=no neuropathy.
NDA Foot Exam
Main
Main heading
heading32pt
32pt
a. sensory neuropathy
Foot Screening
Main
Main heading
heading32pt
32pt
Neuropathy
Sensory neuropathy
Increased susceptibility to
foot ulceration
Motor neuropathy
Increased prominence
metatarsal heads
Digital clawing
Loss anterior tibial muscle
group power (foot drop)
Autonomic neuropathy
A-V shunting
Reduced sweating
Temperature gradient
Rubor
Diabetic Neuropathic Pain
Possible prevalence 16.2%
Of these 12.5% may not report
symptoms to HCP (Daousi 2004)
Main
Main heading
heading32pt
32pt
NDA Foot Exam
Main
Main heading
heading32pt
32pt
b. reduced arterial supply
NDA Foot Exam
Main
Main heading
heading32pt
32pt
c. identify deformities
NDA Foot Exam
Main
Main heading
heading32pt
32pt
c. identify deformities
NDA Foot Exam
Main
Main heading
heading32pt
32pt
d. other risk factors
• reduced capacity for self-care
• cardiovascular disease
• impaired renal function
• poor glycaemic control
Main
Main heading
heading
32pt
32pt
A neuropathy
B vascular
C deformity
D other
Basic patient
education
Urgent referral to
Podiatry
Refer to Podiatry
Refer to Podiatry
Education
Inform
patient
risk
rating
NDA Foot Exam
Main
Main heading
heading32pt
32pt
Why it is important
NDA Outcomes
Main
Main heading
heading32pt
32pt
Minor Amputations
Main
Main heading
heading32pt
32pt
Diabetes Footcare Profile
NDA Outcomes
Main
Main heading
heading32pt
32pt
Major Amputations
Main
Main heading
heading
32pt
32pt
Diabetes
Footcare
Profile
Main
Main heading
heading32pt
32pt
Diabetes Footcare Profile
Main
Main heading
heading32pt
32pt
Diabetes Footcare Profile
NDA to include
Main
Main heading
heading32pt
32pt
Diabetes footcare
The National Diabetes Audit is expanding to cover:
Diabetes footcare
This audit will cover the structures, processes and
outcomes of foot care services for people with diabetes.
The audit is currently being developed and piloted by
NHS Diabetes and is expected to be handed over to the
NDA for national roll out in 2013.
NDA to include
Main
Main heading
heading32pt
32pt
Diabetes footcare
14 Pilot sites, >490 new ulcers (baseline data only)
Main
Main heading
heading
32pt
32pt
Diabetes
Footcare
Website
http://www.berkshirewest.nhs.uk/page_sa.asp?fldKey=310
• Diabetic Foot Care Pathway
• Referral form
• Emergency contact details
• Patient leaflets
Foot Screening
Main
Main heading
heading32pt
32pt
Training
AIM
To have an understanding of how to carry out an annual foot
assessment for patients with diabetes.
OBJECTIVES
To understand and gain confidence with assessment tools.
To identify neuropathy, ischemia and foot deformity.
To understand the process of annual review and when to refer on for
Podiatry treatment and education.
DATE
TIME
VENUE
FRI 15TH MAY 2013
10-12 am
West Berkshire Community Hospital
FRI 12TH JULY 2013
10-12 am
GP room Wokingham Hospital
THURS 15TH AUG 2013
10-12 am
West Berkshire Community Hospital
FRI 18TH OCT 2013
10-12 am
GP room Wokingham Hospital
Main
Main heading
heading32pt
32pt
QUESTIONS?