DEMO Evidence Based Diabetic Foot Risk Screening Tool --

Level 1 Summary

HNHB LHIN Wide Foot Care Working Group

Presented in Partnership

Presented byFeet First Steps To Health

Diabetic Foot Care Program

Connie Comtois-Spitman- Presenter LHIN Wide Foot Care Best Practices

Working Group/ Provider Team - Producer Lori Makarchuk-OTN / Operations

Diabetes Action Group Report 2008 Recommendations

All individuals diagnosed with diabetes in the HNHB LHIN receive an annual foot exam by a regulated health care professional

Health care providers within the LHIN provide evidence based foot care that is appropriate to the provider/ seek appropriate referral

No cost Diabetic foot care service be made available to those found to be at high risk

Goal

Develop LHIN wide, Multidisciplinary

community initiative for the evidence based

assessment , education and treatment of basic

foot care issues related to diabetes.

Diabetic Foot Screening Tool Users

•Level 1 Point of contact// Multidisciplinary Diabetes Health Care team. MD, NP, BSN, RN,RD, Pharm,( may be RPN, homecare under medical directive), Diabetic Educators CDE

•Level 2 Specialized foot care Chiropodist/ Podiatrist/ Physician

( in addition, BSN, RN, ENT with advanced training)

• Level 3 Specialized High Risk Referral, Neurologist, Vascular Surgeon, Orthopod, Infectious Disease, Plastics, Derm etc

Summary60 sec Diabetic Foot Screening Tool

Vascular assessment ( Pulse, Cap refill, appearance)

Neurological assessment ( monofilament/ vibration on-off method, pain report)

Skin/ Nails ( condition/ self care/ deformity) Footwear/ hosiery assessment ( condition/fit/

appropriateness)

Vascular assessment REVIEW

Capillary refill time ( 3 sec or less)

Presence of Pedal Pulses ( Dorsalis Pedis)

Skin Temperature( Hot/ Cold)

Dependant Rubor/ Erythema/ Odema ( red, irritated, swolen )

Neurological Assessment for Sensory Loss Includes

Monofilament testing score 10 sites ( x/10 )

*using Semmes Weinstein 10g monofilament

Vibration test

*using on/ off method 128 MHz tuning fork to dorsal aspect great toe proximal to nail.

Skin Assessment REVIEW

Identification of lesions toes, dorsum, plantar, heel, toes, between toes

• Presence of corns, callus, blisters

• Open areas eg Fissures/ Ulceration

( duration/ appearance should be documented)

Nail Assessment REVIEW

Thickness ( normal, crumbled, broken)

Discolored ( black, brown, yellow, reddish)

Bruised, loose or missing

Condition/ Self care manageable?

Footwear/ Hosiery Assessment

Look for signs of wear, including integrity of materials inside and on the sole

Fit and distortion of shoe shape Fit of stockings indicated by indentation on

legs/ toes Appropriateness ie thermal in winter, or

walking shoes for daily activity etc Can they retain the foot?

60 second Foot Screen Algorithm

60 Second Foot Screen for Patients with Diabetes

STOP-LOOK TOUCH ASSESS

STEP2 Touch-10 seconds

Temperature - Hot

0=foot warm

1=foot is cold

Temperature-Cold

0=foot is warm

1=foot is cold

Range of Motion

0=full range to hallux

1=hallux limitus

2=hallux rigidus

3=hallux amputation

Erythema

0= no

1= yes

Score = 0-5( Low risk) yearly screen Score = 6-11 ( Low/ Moderate) screen every 6 months Score =12 to 17 Moderate screen every 3 months Score =18 to 23 High risk screen every 1-2 months

STEP3 Assess-30 seconds Sensation-Monofilament Testing

0=10 sites detected

2= 7 to 9 sites detected 3= 0 to 6 sites detected Vibration on-off method 0=Present 2=Absent

Ask- 4 questions

Are your feet ever numb?

Do they ever tingle?

Do they ever burn?

Do they ever feel like insects are crawling on them? 0= no to all questions

2= yes to any questions

Pedal Pulses

0 = present 1 = absent

Dependant Rubor

0 = no

1= yes

STEP 1 Look-20 seconds

Skin

0=intact/healthy

1=dry, fungas,callus

2=heavy callus

3=open ulcer

or previous ulcer

Nails

0=well kept

1=unkempt/ragged

2=thick, damaged,

infected

Deformity

0=no deformity

1=mild deformity

2=major deformity

Footware

0=appropriate

1=inappropriate

2=causing trauma

Resource Flow Chart

Self Management Goal Setting / Problem Solving

Patient

Education

High Risk InterventionVascular, Ortho

Nero, Endo Wound Care

(Level 3)

Level 1 Foot ScreenRefer to Foot Care Program

RN / PRN Chiropodist / Podiatrist (Level 2 )

Evidence Based Vascular Assessment

Capillary Refill time (1)protocol Dorsalis Pedis Pulse (2)location and

assessment

1 http://www.nlm.nih.gov/medlineplus/ency/article/003394.html

2 A. Mowlavi et al, Postgrad Med J, 2002. 78:746-747

Evidence Based Neurological Assessment

Validity of the Semmes Weinstein 10g monofilament examination Level 1/ Class A Evidence

Assessment using Superficial pain sensation and vibration by on-off method are both well established with Level 1/ Class A Evidence

Recommendation of minimum of Annual Screening for the patient with the Diabetic Foot, although more frequent screens may be indicated based of level of risk

Feng Y. , Schlosser FJ, Sumpio BE, J Vasc Surg 2009 Sep 50(3) 675-82: Kamel N et al J Diabetes Complications 2005 Jan-Feb 19(1)47-53OlaleyeD., Perkins BA.,Bril V Diabetes Res Clin Pract. 2001 Nov.54(2)115-28:

Diabetes Guidelines Reviewed

Canadian Diabetes Association-Clinical Practice Guidelines or the Prevention and Management of Diabetes in Canada 2008

Registered Nurse’ Association of Ontario-Reducing Foot Complications for People with Diabetes ( Nursing Best Practice Guideline) 2007

Best Practice Recommendations for the Prevention, Diagnosis and Treatment of Diabetic Foot Ulcers: Update 2010 Canadian Association Wound Care

Diabetes Care Program Nova Scotia( Best Practice Clinical Guideline Diabetic foot care

LEAP ( Lower Extremity Amputation Prevention)

LHIN Wide Foot Care Best Practices Working Group/ Provider Team

Connie Comtois-Spitman-(Chair) NHCHC Feet First Steps to Health ( Chiropodist)

Dr. Vance Pegado- DRCC (Physician Lead ) Bo Fusek- DRCC ( CDE) Crystal Poyton- Quest CHC ( PHCNP) Michelle Overholt- Grandriver CHC (PHCNP CDE) Cathy Jager- Joseph Brant CHC ( CDE) Elenore Wormald-Medical Group Niagara

FHT( CDE)

Acknowledgments

North Hamilton Community Health Centre Feet First Steps to Health Diabetic Foot Care

Program Hamilton/ Niagara Quest Community Health Centre Diabetes Regional Coordination Centre Ontario Telehealth Network References are available upon requestContact: comtois-spitman@nhchc.ca/