The NADC Collaborative Interdisciplinary Diabetes High Risk Foot Service Standards
Professor Stephen TwiggMBBS(Hons-I), PhD(Syd), FRACPHon. Chair of the NADC Foot Network;Medical Director Dept of Endocrinology and the Diabetes High Risk Foot Service,Royal Prince Alfred Hospital, Sydney;Kellion Professor of Endocrinology, Stan Clark Chair in Diabetes,Faculty of Medicine and Health, Sydney Medical School, Charles Perkins Centre,The University of Sydney NSW AUSTRALIA
nadcNational Association of Diabetes Centres
The Agenda
• The status of diabetes foot care outcomes in Australia
• Integrated foot care as a national health priority, including the importance of diabetes High-Risk Foot Services (HRFS)
• The NADC Foot Network and setting of collaborative interdisciplinary HRFS standards
nadcNational Association of Diabetes Centres
The Agenda
• The status of diabetes foot care outcomes in Australia
• Integrated foot care as a national health priority, including the importance of diabetes High-Risk Foot Services (HRFS)
• The NADC Foot Network and setting of collaborative interdisciplinary HRFS standards
nadcNational Association of Diabetes Centres
Some Diabetes-Related Complications
Significant Clinical Variation Occurs in Diabetes
https://www.safetyandquality.gov.au/wp-content/uploads/2017/06/Key-findings-and-recommendations.pdf
- Australia
Australian rate:23 per 100,000
Two fold the UK, ~half the USA
Australian Atlas of Healthcare Variation
https://www.safetyandquality.gov.au/atlas/
- Australian Capital Ci.es
Australian Atlas of Healthcare Variation
https://www.safetyandquality.gov.au/atlas/
States andTerritories
The Agenda
• The status of diabetes foot care outcomes in Australia
• Integrated foot care as a national health priority, including the importance of diabetes High-Risk Foot Services (HRFS)
• The NADC Foot Network and setting of collaborative interdisciplinary HRFS standards
nadcNational Association of Diabetes Centres
Ø The National Diabetes Strategy 2016-2020 was released November, 2015.
Ø A main goal in the strategy is to:
- ‘Reduce the occurrence of diabetes-related complications and improve quality of life among people with diabetes’.
Ø The NDSS are prioritising a diabetes foot care project:
- For people with diabetes- For foot care education and delivery systems
in diabetes
Ø The NDS outcome process has a diabetes complications focus.
http://www.health.gov.au/internet/main/publishing.nsf/content/
Ø 2017 Atlas: key recommendations for Diabetes –
Local Hospital Networks, Primary Health Networks and the Aboriginal
Community Controlled Health Service sector should promote appropriate
care for the management of people with diabetes using:
• The guidelines General Practice Management of Type 2 Diabetes 2016–18 as the routine model of care
• The Australian National Diabetes Strategy 2016–2020 to ensure the
provision of integrated models of care
• Performance management frameworks to assess compliance of care with
relevant diabetes treatment guidelines.
Ø Integration across all health care systems in chronic disease
https://www.safetyandquality.gov.au/wp-content/uploads/2017/06/Key-findings-and-recommendations.pdf
14/10/18
12
NHMRC of Australia
Clinical Care Guidelines
An access site :http://www.nhmrc.gov.au/guidelines/publications/cp102
https://www.bakeridi.edu.au/Assets/Files Foot_FullGuideline_23062011.pdf
Health Pathways: Where Should ParticularFoot Complications in Diabetes Ideally be Managed?
Community care
Inter-disciplinary
High-Risk Foot Service (HRFS)
Ambulatory
Inpatient care
Bergin SM et al., for the ADFNMed J Aust. 2012;197(4):226-9.
Primary and Secondary
Preventive care
Tertiary Hospital
care
Tertiary Ambulatory
care
Diabetic High Risk Foot Service (HRFS)
Foot Education and Regular Community Podiatry
General InformationLow
High
Ulcer present
Stratification of Intensity of Care Required Based on Foot Ulcer Risk
Ulcer Risk
NHMRC Clinical Care Guidelines: Diabetes and Foot Disease 2011
Not Everyone with Diabetes Requires the Same Intensity of Foot Care: Risk Stratification
Risk Profile Risk Characteristics Recommendations Frequency
0 No risk factors No specific referralPodiatry care (private) for general foot problems.(+/- GP Management Plan(GPMP) /Team Care Arrangement (TCA))
Annual
1 Peripheral Neuropathy Podiatry care and High risk education(Public or Private care setting) GPMP/TCA
6 months
2 Peripheral Neuropathy and Deformity OR Peripheral Arterial Disease
Podiatry care and Education(Public or Private care setting) GPMP/TCA
3 months
3 Previous Ulcer or Amputation As above 1-3 months4 Active foot ulceration, infection or suspected
acute charcot�s arthropathy /neuropathic fracture.
Prompt High Risk Foot Service Referral (assess urgency)
Until issues resolved
Not Everyone with Diabetes Requires the Same Intensity of Foot Care: Risk Stratification
Risk Profile Risk Characteristics Recommendations Frequency
0 No risk factors No specific referralPodiatry care (private) for general foot problems.(+/- GP Management Plan(GPMP) /Team Care Arrangement (TCA))
Annual
1 Peripheral Neuropathy Podiatry care and High risk education(Public or Private care setting) GPMP/TCA
6 months
2 Peripheral Neuropathy and Deformity OR Peripheral Arterial Disease
Podiatry care and Education(Public or Private care setting) GPMP/TCA
3 months
3 Previous Ulcer or Amputation As above 1-3 months4 Active foot ulceration, infection or suspected
acute charcot�s arthropathy /neuropathic fracture.
Prompt High Risk Foot Service Referral (assess urgency)
Until issues resolved
Typical Interdisciplinary High Risk Foot Service (HRFS) Entrants
for People with Diabetes
Precipitants of Diabetic Foot Ulcers Tight fitting foot-wear
Burns Penetrating injury
Neuropathy and Arterial Assessments
Peripheral Neuropathy assessment
• Neuropathy Assessment: • Ankle reflexes• Vibration perception• 128 Hz tuning fork• Biothesiometer•10g S-W Monofilament
• Arterial Assessment:• Clinical• Ankle Brachial Pressure Index• Low threshold for arterial Doppler Ultrasonography
Andros, G etal.Diabetes Metab. Res. Rev. 2002; 20: S29-S33
Miranda-Palma B, etal.Diabetes Res. Clin. Pract. 2005; 70(1): 8-12
Treat Foot Ulcers in Diabetes
ØA multifaceted, patient targeted approachØAssessmentØTreatment
ØPressure offloading ØDebridémentØAntibioticsØRevascularisation This alone
Is not ideal!
Inter-disciplinary High-Risk Foot Service Delivery
TogetherEveryone Achieves More
Holistic patient care is required in an integrated manner,including shared decision making.
Many other team members
Diabetes High-Risk Foot ServiceInter-disciplinary Team Members
Differing Types of Diabetes Foot Ulcer
The Diabetes HRFS Has A Supportive Evidence Base
ØThe Diabetes HRFS can:
Ø Prevent hospital admissions
Ø Reduce length of hospital stay
Ø Reduce major amputations
Ø Be cost-effective
References:
Some Biomechanical Factors Associated with Hallux Ulcers, and Their Measurement
Vacuum Assisted Device (VAD) Healing as a Negative Pressure Wound Therapy (NPWT) in Complex Wounds
AmputationTime toUlcer Closure
162 pts, 16 weeks, 18 Centres,Partial foot amputation, wound av 20cm2
Armstrong DG et.al, Lancet 2005; 366: 1704-10
Pressure Off-loading: After Ulcer Healing –including Orthotics and Custom made Footwear
The Ideal Shoe
2015: A document for clinicians and administrators to improvequality, safety and consistency in the delivery of foot care forpatients with serious foot complications.
Aims to improve:ü Patient experiencesü Health outcomesü Effective use of resources
The Agenda
• The status of diabetes foot care outcomes in Australia
• Integrated foot care as a national health priority, including the importance of diabetes High-Risk Foot Services (HRFS)
• The NADC Foot Network and setting of collaborative interdisciplinary HRFS standards
nadcNational Association of Diabetes Centres
National Association of Diabetes Centres -Foot Network (NADC-FN)
MISSIONØTo establish and maintain reduced morbidity and mortality from
diabetes-related foot disease
AIMØTo realise a coordinated national process of prioritising high quality and
accessible foot assessment and management across the spectrum of foot disease in diabetes.
Promoting excellence in diabetes care
National Association of Diabetes Centres -Foot Network (NADC-FN)
Ø NADC FN Working Party (WP) Membership (stakeholders):• National Association of Diabetes Centres• Australian Diabetes Society• Wounds Australia • Advanced Practicing Podiatrists - High Risk Foot Group• Australian Podiatry Council (APodC)• Diabetic Foot Australia (DFA)• Pedorthic Association of Australia (PAA)• Agency for Clinical Innovation (ACI)• Australian Diabetes Educators Association (ADEA)• Australian Primary Care Nurses Association (APNA)• Diabetes, Obesity and Metabolic Translational Research Unit (DOMTRU)
National Association of Diabetes Centres -Foot Network (NADC-FN) Interdisciplinary HRFS
Working Party Initiative • Using a HRFS standards setting document 2015, derived from the NSW State Dept of
Health Agency for Clinical Innovation
• WP consensus review process face to face held on June 23rd, 2017, onwards
• The standards were set with accompanying indicators• Standards and indictors directly translated into a HRFS accreditation program
• Indicators include participating in annual foot audits and collecting a minimal data set
• Two levels of standards established: ‘Core’ and ‘Centre of Excellence’ Standards
• The business case for integrated foot care supporting HRFS can then be further put to local, state and national Health Departments
• A FN Reference Group supports the FN WP as required.
Promoting excellence in diabetes care
The NADC Collaborative Interdisciplinary Diabetes High Risk Foot Service Standards - Finalised
• Consolidated standards:1. Interdisciplinary approach2. Coordination and administration3. Evidence-based clinical management4. Access and defined intake criteria5. Continuity of care and communication6. Equipment7. Wound care 8. Quality improvement
• Core Indicators• Centre of Excellence Indicators
Staff
Equipment
patient outcomes
Processoutcomes
nadcNational Association of Diabetes Centres
…and key additional Collaborators!
The NADC Collaborative Interdisciplinary Diabetes High Risk Foot Service Standards – Finalised and Released!
1. Multi-disciplinary approach - staff skills sets, % presence, interdisciplinary communication
2. Coordination and administration- champion, co-ordinator, administrative support
3. Evidence-based clinical management- local guidelines, patient protocols, regular guidelines/protocols reviews
4. Access and defined intake criteria- documented intake criteria, timing of access documented, area provision
5. Continuity of care and communication- ward consultations, direct admissions, handover, inpatient processes
6. Equipment- offloading equipment, orthotics lab and devices, NPWT, TCC onsite
7. Wound care products- access to and rational use of products
8. Quality improvement- parameters to support internal audits, benchmarking- research and education
•Medical Data
The HRFS Team
Telemedicine in Interdisciplinary HRFS: The ‘hub and spoke’ Concept Realised
DubboLismoreNowraOrange
GraftonPort Macquarie
GriffithForbesQuirindi
Mullumbimby E-mail
NSW Rural and Regional •Standardised wound images
Standard 8 – Data Collection
• Relates to quality improvement for HRFS • Collecting valuable data to assist service development • Quality improvement plans are undertaken and supported by
collecting clinically significant data relevant to the HRFS
nadcNational Association of Diabetes Centres
Service Development
Quality Improvement
Data InterpretationData AnalysisData Collection
Standard 8 - The Challenges
• Data collection is time consuming, onerous • Collaborative input to data fields • Needs to be useful – center dependent • Centre based – not easy to externally benchmark• The future - NADC looking at developing an online data tool to assist
centers to achieve this standard and thrive
nadcNational Association of Diabetes Centres
Standard 8 – Core Service Indicators
• Annual clinical audit• HRFS collects minimum data and develops KPIs – center relevant • Key data are reported, shared with the NADC annually• Quality improvement cycle that addresses any serious adverse event(s)• Routine and ongoing education and professional development in high
risk foot care is provided for all HRFS staff
nadcNational Association of Diabetes Centres
RPA
Less Delay In Presentation of Patients to the Service (Days Between Ulcer Development Historically and HRFS Presentation)
• 1995 - 1999• 55 days [17-140]
• 2000 - 2003• 49 days [22-122]
• 2004 - 2007• 33 days [17-90]
• 2008 - 2012• 30 days [14-66]; since 2012 median has reduced to 18 days.
Ttrend = 3.7, p =0.0002; Bolton T, et al WDC 2014
A Clinical Audit Process Example:RPA Hospital Interdisciplinary High Risk Foot Service: Longer Term Data
RPA
Time to Access Interdisciplinary HRFS Care Relates to Ulcer Severity
00.10.20.30.40.50.60.7
Months
0 1 2 3
Grade
Bolton T et al., ADA Abs 2013; IDF Abs 2014 n=1486 Foot ulcers
Standards Facilitate Accreditation
42
‘One Vision’ – Australian Diabetes HRFS Standards Accredited Sites
Belgium
Morbach S. et al
In some initial investigations, the NADC located 120 services that either identify themselves as HRFS or offer services to individuals at high risk.
‘Core Centres’, and ‘Centres of Excellence’
One ‘vision’
Health Care Professional Educational Projects:ADS NDSS - Promoting Optimal Diabetes Foot Care
https://diabetessociety.com.au/diabetesfoot/
• The Foot Examination
• Preventive foot care
• Managing basic diabetes foot complications
• State-based and national programs for interdisciplinary HRFS• Incl. Best Practice in Diabetes Centres Workshops
Audiovisual resources:
Supportive Regional and International Approaches
IDF-Western Pacific Region- Train the Foot Trainer Foot Care Education International Working Group on the Diabetic Foot
Major Challenges in Diabetes Foot Care in Australia Can be Realised
Ø The geography and fewer people living in rural areas
ØRoutine stratifying foot complications risk in people with diabetes
Ø Preventive foot care specifically for those at increased risk
Ø Providing timely access to accredited diabetes interdisciplinary high risk foot services
Ø Achieving sustained outcomes in diabetes HRFS
Ø Providing efficient hospital inpatient foot care in diabetes and integrated care across systems
Ø Adequate funding models and incentives at all levels
ØContinuing education to clinicians and patients Adapted: Bergin SM et al. Med J Aust. 2012;197(4):226-9; Lazzarini P et al MJA 2018
The Agenda - Realised
• The status of diabetes foot care outcomes in Australia addressed
• Described integrated foot care as a national health priority, including the importance of diabetes High-Risk Foot Services (HRFS)
• The NADC Foot Network and setting of collaborative interdisciplinary HRFS standards
nadcNational Association of Diabetes Centres
AcknowledgementsØNational bodies:
• The National Association of Diabetes Centres and the Australian Diabetes Society§ Ms Natalie Wischer, Ms Leanne Mullan, Michaela Watts§ Prof. Sophia Zoungas, Prof. Sof Andrikopoulos, Prof. Jonathan Shaw
• NADC FN Working Party and Reference Group members• Kellion Diabetes Foundation • Diabetes Australia Ltd: A/Prof. Greg Johnson• National Diabetes Services and Supply scheme• Federal Dept of Health and Ageing• NHMRC of Australia
ØState Bodies:• ACI Network NSW Dept of Health• NSW Diabetes Task Force
ØLocal bodies:• Ms Vanessa Nube, Head of Podiatry, SLHD and NSW DoH ACI FN Co-chair• Diabetes Centre, Dept of Endocrinology, Royal Prince Alfred Hospital, Sydney• Maari Ma Aboriginal Health Service, Broken Hill, NSW