The DIAFOOT Project: developing and implementing an evidence based acute diabetic foot care bundle
description
Transcript of The DIAFOOT Project: developing and implementing an evidence based acute diabetic foot care bundle
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.