The DIAFOOT Project: developing and implementing an evidence based acute diabetic foot care

bundle

Dr Nida ChammasClinical Lead DIAFOOT project

NIHR CLAHRC NW LondonFebruary 2014

N Chammas

Background

• 15% of diabetic patients will develop a diabetic foot ulcer

• Lifetime risk is 25%

• 20% of diabetic admissions to hospital due to foot problems

• Total expenditure on inpatient care for foot ulceration and amputation in 2010–11 is at £257 million. 11

Diabetic foot ulcers precede >80% of amputations in Diabetic patients

(100 people per week)

Mortality

DFU patients have 2.4 times the mortality rate of non-ulcerated diabetic patients.

Financial Impact

£700 million per year in England

E Ramhamadany

DIAFOOT Project

£104,000

Nida Chammas

Khalid Ahmed

Professor Edmonds

EssamRamhamadany

Sandra Wilson

CLAHRC

NICE

£104,000

THE DIAFOOT PROJECTfunded by NIHR CLAHRC NW

London

AIM

To implement the current national guidelines for inpatient management of acute diabetic foot problems

• NICE guidelines 2011 • Diabetes UK ( Putting Feet First)2009

Sandra Wilson

Diabetic Foot care bundle

Nida Chammas

Junior DrsDan Brown Patients

EssamRamhamadany

Sandra Wilson

CLAHRCTeam

Khalid Ahmed

Elaine Hui

INFECTION ?(Fever, Low BP, Red and/or warm

foot, pain without trauma)

YES

DEFORMITY(Foot does not look normal)

YES

ULCER(S)

URGENTLY REQUEST DOCTOR TO COMPLETE FOOT ASSESSMENT FORM, COMPLETE WOUND ASSESSMENT CHART & FOLLOW INTRANET GUIDELINES ON WOUND MANAGEMENT. REFER TO TISSUE VIABILITY NURSES FOR THEIR INPUT

Ƒ Doctor contacted, bleep number:Date: Time:

YES

ISCHAEMIA ?(Absent foot pulses, Cold or

gangrenous foot)

YES

PATIENT LABEL

Ward: Date:

Time: Name (Print) :

Signature:

Ƒ NO

NURSES’ DM FOOT ASSESSMENT FILE IN AUDIT BOX

Summary: Foot problems are the commonest cause of non-traumatic limb amputations in diabetic patients. This document is based on Diabetes UK (2008) and NICE guidelines (2011) and aims to prevent complications of Diabetic Foot disease and ensure accuracy of diagnosis. Please complete it for ALL diabetics at initial assessment.

URGENTLY REQUEST DOCTOR TO COMPLETE FOOT ASSESSMENT FORM. REFER TO TISSUE VIABILITY NURSES FOR THEIR INPUT

Ƒ Doctor contacted, bleep number :Date: Time:

EXPOSE FEET BY REMOVING ALL

LAYERS

Nurses DM foot assessment for audit V1.7 lwj

URGENTLY REQUEST DOCTOR TO COMPLETE FOOT ASSESSMENT FORM. REFER TO TISSUE VIABILITY NURSES FOR THEIR INPUT

Ƒ Doctor contacted, bleep number:Date: Time:

URGENTLY REQUEST DOCTOR TO COMPLETE FOOT ASSESSMENT FORM. REFER TO TISSUE VIABILITY NURSES FOR THEIR INPUT

Ƒ Doctor contacted, bleep number:Date: Time:

Other comments:

Ƒ Referred to Tissue viability nurses via fax for: Ulcer/ infection/ Ischaemia/ Deformity (delete as appropriate) on date/ at time:

Ƒ NO

Ƒ NO

Ƒ NO

? ULCER(S)LEFT RIGHT

Y N Y N

Ulcer (s)

Ensure bed-rest / non-weight bearing crutches

Request XRay / MRI (if appropriate) foot

Start antibiotics pending micro results

TICK WHEN DONEYOU SHOULD NOW…

Discuss with general surgeons if crepitus / gas on imaging

YES TO ANY? INFECTIONLEFT RIGHT

Y N Y N

Warmth / erythema

Crepitus

Ensure bed-rest / non-weight bearing crutches

Request XR / MRI foot

Urgently discuss with orthopaedics/ podiatry

TICK WHEN DONEYOU SHOULD NOW…YES TO ANY

Ensure bed-rest / non-weight bearing crutchesRequest XRay / MRI of affected foot

Start antibiotics (see intranet guidelines)

YOU SHOULD NOW…

Confirm referral made to tissue viability

YES TO ANY

YES TO ANY

Assess CV risk factors

Measure ABPI (ABPI = ………..)

Urgently discuss with vascular if ABPI <0.5

TICK WHEN DONE

YOU SHOULD NOW…Ensure bed-rest / non-weight bearing crutches

? ISCHAEMIA LEFT RIGHT

Loss of DP pulse Y N Y N

Loss of PT pulse

Reduced temp

Gangrene

Colour change

PATIENT LABEL

Ward:Date & Time:Doctor’s Name:Signature: Bleep:

? CHARCOTLEFT RIGHT

Y N Y N

Deformity / Fracture

Pain without trauma

Unexplained warmth / erythema

Colour change

ACUTE DIABETIC FOOT CARE BUNDLE FILE IN NOTESSummary: Foot problems are the commonest cause of non-traumatic limb amputations in diabetic patients. This document is based on Diabetes UK (2008) and NICE guidelines (2011) and aims to ensure accuracy of diagnosis, prevent complications of Diabetic Foo t (DF) disease and provide guidance on what to do if there is evidence of disease. Please complete within four hours of admission for ALL diabetic patients with suspected DF disease.

Take tissue sample (swab / deep sample)

TICK WHEN DONE

Acute Diabetic Foot assessment notes V1.8 lwj

Ƒ NO TO ALL

Ƒ NO TO ALL

Ƒ NO TO ALL

IF DF DISEASE IS DIAGNOSED, A NAMED CONSULTANT PHYSICIAN IS TO BE ACCOUNTABLE FOR THE CARE OF

THE PATIENT WITHIN 24 HOURS OF ADMISSION

Consultant name: Date: Time:

Check if foot sensation is reduced, Y / N (circle)

Check if fever / shock is present, Y / N (circle)

Ƒ NO TO ALL

EXPOSE FEET BY REMOVING ALL LAYERS

C Stacey

C Stacey

N Chammas

Results

• Implementation for 60 consecutive weeks (December 2011 to January 2013)

• 991 patients screened• 254 (25.6%) identified as potential DF disease.• 99 (38.9%) patients assessed by a doctor. • 50% of patients had signs of ulceration; 43%

had at least two or more signs of DF

Summary

Approximately one thousand patients were screened and nearly 1 in 10 patients identified as positive for acute DF disease were assessed by a doctor.

This demonstrates that a significant proportion of admissions were influenced by this quality improvement project.

Conclusion

The DIAFOOT project represents a service improvement model, promoting new strategies for implementation of evidence-based practice.