National Diabetes Audit - Foot Examination Keith Hilston – Podiatry Diabetes Lead, May 2013.

National Diabetes Audit - Foot Examination

Keith Hilston – Podiatry Diabetes Lead, May 2013

Main heading 32ptMain heading 32ptContent

• Why foot examination is important

• National / Local picture

• Foot screening (examination)

• Outcomes

Main heading 32ptMain heading 32pt NDA Foot Exam Why important – risk classification

Total adult population with diabetes Level of risk Berkshire Population

1-4%

Patients with active foot disease

170 – 680 (358)

4-8%

Patients with a history of diabetic foot disease: risk of reulceration 40 – 50% per year. HIGH RISK

680 – 1360

(849)

20%

Patients with established risk factors for diabetic foot disease: risk of ulceration 3 – 7 % per year. MODERATE RISK

3400

(1097)

LOW 70%

Patients at LOW RISK of diabetic foot disease: risk of ulceration 99.6% ulcer free after 2 years

11900

Main heading 32ptMain heading 32pt NDA Foot Exam Why important – Quality of Life

Main heading 32ptMain heading 32pt NDA Foot Exam Why important – Mortality

Main heading 32ptMain heading 32pt NDA Foot Exam Why important – Cost

Main heading 32ptMain heading 32pt NDA Foot Exam National Update • Halving amputation rates in 5 years

• Develop Quality Improvement Framework

• Audit and publish local outcome data annually

Main heading 32ptMain heading 32pt

Main heading 32ptMain heading 32pt NDA Foot Exam Locality UpdateIndicator 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

Main heading 32ptMain heading 32pt NDA Foot Exam 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

Main heading 32ptMain heading 32pt NDA Foot Exam Foot ScreeningThat 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

Main heading 32ptMain heading 32pt NDA Foot Exam 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.


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.

Main heading 32ptMain heading 32pt Foot Screening NeuropathySensory neuropathyIncreased susceptibility tofoot ulcerationMotor neuropathy Increased prominence metatarsal headsDigital clawingLoss anterior tibial musclegroup power (foot drop)Autonomic neuropathyA-V shunting Reduced sweating Temperature gradient RuborDiabetic Neuropathic PainPossible prevalence 16.2%Of these 12.5% may not report symptoms to HCP (Daousi 2004)

Main heading 32ptMain heading 32pt NDA Foot Exam b. reduced arterial supply

Main heading 32ptMain heading 32pt NDA Foot Exam c. identify deformities

Main heading 32ptMain heading 32pt NDA Foot Exam d. other risk factors

• reduced capacity for self-care

• cardiovascular disease

• impaired renal function

• poor glycaemic control


Education

Urgent referral to Podiatry

Refer to Podiatry

Refer to Podiatry

Basic patient education

A neuropathy B vascular C deformity D other

Inform patient

risk rating

Main heading 32ptMain heading 32pt NDA Foot Exam Why it is important

Main heading 32ptMain heading 32pt NDA Outcomes Minor Amputations

Main heading 32ptMain heading 32pt Diabetes Footcare Profile

Main heading 32ptMain heading 32pt NDA Outcomes Major Amputations

Main heading 32ptMain heading 32pt Diabetes Footcare Profile

Main heading 32ptMain heading 32pt NDA to include 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.

Main heading 32ptMain heading 32pt NDA to include Diabetes footcare

14 Pilot sites, >490 new ulcers (baseline data only)

Main heading 32ptMain heading 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

http://www.berkshirewest.nhs.uk/page_sa.asp?fldKey=310

Main heading 32ptMain heading 32pt Foot Screening Training

AIM To have an understanding of how to carry out an annual foot assessment for patients with diabetes. OBJECTIVESTo 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


QUESTIONS?

National Diabetes Audit - Foot Examination Keith Hilston – Podiatry Diabetes Lead, May 2013.

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