CPR for the FootCheck - Protect - Refer

CPR Concept

On admission to hospital every patient with diabetes

• Should have their feet CHECKED

• If at risk they are PROTECTED

• If they have a problem immediately REFER

Scottish Diabetic Foot Action Group

Diabetes Expenditure

10% of the UK NHS Budget

£9 Billion per Year

£286 per Second

No drop in the ocean?

Diabetes Expenditure

10% of the UK NHS Budget£9 Billion per Year£286 per Second

2.9 million people affected in the UK

Lifetime risk of foot ulceration - 25%

Diabetic Foot Ulceration

Diabetic Foot Ulceration

Three Great Pathologies

Neuropathy Ischemia Infection

0

25

50

75

100

Mortality Rate

Prostate CancerBreast CancerHodgkin's diseaseNeuropathic UlcerColon CancerIschemic UlcerPeripheral Artery DiseaseLung CancerPancreatic Cancer

Improved Survival of the Diabetic FootThe role of a specialised foot clinic

ME Edmonds et alQJ Med 1986; August; 60(232):763-71

➡ Earlier Discharge➡ No limb loss➡ Reduced Distress➡ Reduced Cost➡ Reduced Litigation

MeansPrevention

Prevention

Boulton et al; Lancet Nov 2006

“becomes cost effective if we reduce incidence of

foot ulcers and amputation by 25%”

Foot Care Audit• England & Wales 2014-2016

• 11,073 patients - 13,034 new ulcer episodes at 173 specialist care services

• One third still had ulcers 24 weeks after assessment

• One in Twenty had died

• Less severe ulcers = twice as likely to be alive at 12 weeks

Low Risk

Moderate Risk

High Risk

Ulcerated

5 % Active Ulcers or Infection - revascularisation or amputationMultidisciplinary management

15 % High RiskIntensive foot protection

20 % Moderate RiskRegular foot protection60% Low Risk

Routine annual screening

Risk Stratification

Patient Information Leaflets

Foot Screening in Scotland

Patient Information Leaflets

Foot Screening in Scotland

Scottish Audit of 1048 in-patients

• 2.4% of in-patients with diabetes developed a new foot lesion whilst in hospital

• 57% had NOT had their feet checked

• 60% of those ‘at risk’ had no pressure relief in place.

Consequences

• Additional, preventable cost to the NHS in Scotland estimated at £203,000 for this group

• Cost to prevent estimated at < £20,000

• If even 75% of ulcers could be prevented then total NHS Scotland saving = £15m

• NOT including cost of potential litigation

CPR Strategy

• Patient is in bed - there is no ulcer - prevention is required

• Patient is in bed - patient has an ulcer - total pressure relief to encourage healing

• Patient is in bed and is ambulant - protection is needed both in bed and during ambulation

Problem is one of Mechanics

Paul Brand

"The whole problem is one of mechanics, not of medicine.The biological responses to these denervated limbs are

qualitatively similar to those of normal limbs. It is the permitted pattern of mechanical stress that is different"

Factors

Ischaemia Infection

Acute Wound

Chronic Wound

Repeated “Trauma”

At Risk

Neuropathy

Prevent UlcerationStrategy according to individual risk

Low Risk

Moderate Risk

High Risk

Ulcerated

Prevent UlcerationStrategy according to individual risk

Low Risk

Moderate Risk

High Risk

Ulcerated

Improve Extrinsic Influences

Pres

sure

Time

Tissue Damage is Likely

“Safe”

Reswick & Rogers

Preventing Ulceration MeansControlling the Mechanical

“Environment”

Pressure

Friction

Shear Force

Altered Sensation

Altered Tissue Mechanics

and Structu

ral Anato

my

Pressure Not Just a Surface Effect

Pressure Not Just a Surface Effect

PRAFO OptionsInfant Paediatric Adult Bariatric

Standard APU Dual HD

Kodel Fleece Pad & Strap Terry

AdjustabledeviceforL&R

Advantages of PRAFO

• Zero pressure and shear on the heel

• Adjustable to accommodate deformity

• Designed for recumbent and ambulant usage

• Only device with METAL upright to resist deformity development

• Each device size adjustable and for L & R

L & R Heels

Progressive Problem

Two Months Later

Refused Amputation

Clinical Effectiveness PrizeDerek Jones, William Munro, Duncan Stang

156 weeks later

CPR Strategy

• Patient is in bed - there is no ulcer - prevention is required

• Patient is in bed - patient has an ulcer - total pressure relief to encourage healing

• Patient is in bed and is ambulant - protection is needed both in bed and during ambulation

Check - Protect - Refer

Extending the CPR Strategy

To all foot and heel ulcers

• 20,000 hospital inpatients at any one time

• at home, in nursing/care homes??

• 400,000 persons annually

DiabetesPVDMS

Intensive CareBariatric

Stroke rehabBurns

Elderly/General Immobility

Cost of Pressure Ulcers• DOH in UK - Estimates £1,064 for a Grade 1

ulcer to £24,214 for a Grade 4 ulcer

• Hospital Stay - £450 to £650 per day

• Increased risk of litigation

• Nursing time - community visits, dressings

• May require “high tech” pressure relief

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