Audit of foot amputations

Gill SpyerMarch 2009

Background• 20-40% people with diabetes have PVD• 20-40% people with diabetes have neuropathy• Both predispose to ulcer formation, subsequent

polymicrobial infection and amputation• Classification into low, medium, high risk and

those with ulcers• 5% people with diabetes per year develop ulcers.

Integrated Foot care

• 51% patients at high risk of foot ulceration receiving chiropody

• 33% low risk also receiving chiropody? Misappropriation of resources

• Primary care educational programme on recognition, examination and management diabetic foot

• Referral guidelines

“Provision of an integrated care arrangement for the diabetic foot has a positive impact on primary care staff’s knowledge and patients attitudes leading to an increased number of appropriate referrals to acute specialist services”.

Donohoe et al. Diabetes Care (2000);17, 581-87

Primary Care Annual reviewExamination – Risk Assessment

Agreed care plan

Specialist foot service-Ulcer with spreading infection/gangrene/cellulitis within 24 hours-Active ulceration not healing within 1 week-Suspected Charcot’s-Severe neuropathic pain-Footwear assessment for patients with foot deformity or ulceration

Diabetes liaison podiatrist (DLP)High risk- 1st assessment-Non palpable foot pulses and/or-Inability to feel monofilament in 3 or more sites + 1 or more of …-Non infected foot ulcer-Past history of Charcot-Past history of ulceration/amputation-Moderate neuropathic pain-Symptoms attributable to PVD

Referral from DEVHC foot service to DLP with agreed care plan-Resolving ulceration which has been optimally treated-High risk patients with healed but recurring episodes of ulceration-Resolving Charcot’s who have prescribed footwear and stable foot temp.

Referral from diabetic foot clinic to community podiatry (copy to DLP) with care plan-Patients with foot deformity who have prescribed footwear-Patients who had suspected Charcot’s but no Charcot found

Community podiatry-Non palpable foot pulses +/or-Inability to feel monofilament in 3 or more sites-Presence of hypertrophic nails/corns/callous-Presence of digital deformities(if past history ulceration/amputation but appropriate for patient to see Community Podiatrist –discuss with DLP

General Advice

Integrated Diabetic Foot care pathway

High RiskHigh Risk Medium Risk

Low Risk

Care of people with foot care emergencies and foot ulcers. NICE guidelines (CG10)

• Foot care emergency (new ulceration, swelling, discolouration). Refer to multidisciplinary foot care team within 24 hours.

• Expect that team as a minimum to - investigate and treat vascular insufficiency- initiate and supervise wound management- ensure effective means of distributing foot pressure- try to achieve optimal glucose levels and control of risk factors for CVS disease

Specialist Foot Service

• Podiatrist with expertise in managing “the diabetic foot”

• Orthotist• Diabetes specialist nurse• Doctor• 10 sessions per week• Emergency hotline for acute/urgent problems

Aim of audit

• To assess whether a randomly selected cohort of patients with lower extremity amputations were referred to the acute foot service prior to admission with an acute foot problem.

Search Criteria

• 20 most recent patients with diabetes and a lower extremity amputation

Results• 20 patients identified between March and June

2008• 19 had at least 1 LEA in audit period• 1 no amputation. 1 had an elective amputation

for a non acute, non diabetes related mechanical foot problem. Both subsequently excluded.

• Age 63.5 (15) years; range 37-87• Male 12, female 6• Type 1 3, type 2 15

HbA1c

16 patients 2 patients

Risk Factors

Level of amputation

Toes/forefoot16 (70%)

Below knee5 (22%)

Through knee2 (8%)

Number of amputations in audit year

14 (78%)

2 (11%)

1 (5.5%(

1 (5.5%)

Indication for admission

1 (6%)

Care prior to amputation

• 10 (56%) shared care• 4 (22%) under care of vascular surgeons• 3 (17%) under care of the community• 1 (5%) referred from North Devon

Seen by chiropodist in the last year

Yes13(72%)

Don’t Know4 (33%)

No 1 (5%)

Seen by Chiropodist prior to amputation

Yes 11 (61%)

No 5 (28%)

Don’t know2 (11%)

Angiography• Vascular patients - Ischaemic 3, Neuroischaemic 1- Angiography 4/4- Revascularisation 3/4 • Foot clinic patients- Neuropathic 5, neuroischaemic 5- Angiography 2- Revascularisation 2/2• Others - Neuropathic 1, neuroischaemic 3- Angiography 0/4

Examination of feet should include - testing of foot sensation using a 10g monofilament or vibration (biothesiometer) - palpation of foot pulses - inspection for foot deformity/footwear

NICE Guideline CG10

In patient foot assessment

• 10 patients seen in foot clinic (where pulses and sensation were assessed). - 3 (30%) had pulses assessed on ward. - None had sensation assessed on ward

• 8 patients not seen in foot clinic. - 6 (67%) had pulses assessed on ward. - None had sensation assessed on ward

How are we doing overall?

• Surrogate markers of the quality of foot care include - Proportion of patients with neuropathic ulcers undergoing amputation- Amputation rates

Type of lesion

Neuroischaemic9 (50%)

Neuropathic6 (33%)

Ischaemic3 (17%)

Incidence of amputations in patients with diabetes

ICP

Findings

• Resources such as shared care and the acute foot service are not always being used

• Those patients that bypass the acute foot service specifically miss out on advice regarding glycaemic control and footwear assessment

• Patients are not having a risk assessment on admission to the ward

Recommendations• Education re referral pathways and indications for

shared care. • Increase in capacity. The number of foot clinics in

secondary care has been increased by 60%.• All patients admitted with an acute foot problem

should have a risk assessment and the results documented in the notes. The necessary equipment should be available on the ward.

• Podiatrist to cover ward based patients?