Date

London Diabetic Foot Audit 2014/15 Acute Services survey results

London Foot Care Network Meeting

NHS England - London Strategic Clinical Networks

Thursday 4 February 2016

Acute Survey 2015

https://www.surveymonkey.com/r/acutefootcare

London Acute Hospitals

3

• Barnet Hospital

• Barts Hospital

• Central Middlesex Hospital

• Charing Cross Hospital

• Chase Farm Hospital

• Chelsea and Westminster Hospital

• Croydon University Hospital

• Ealing Hospital

• Great Ormond Street Hospital

• Guy’s Hospital

• Hammersmith Hospital

• Harefield Hospital

• Hillingdon Hospital

• Homerton University Hospital

• King George’s Hospital

• King’s College Hospital

• Kingston Hospital

• Lewisham Hospital

• Moorfields Eye Hospital

• Newham University Hospital

• North Middlesex University Hospital NHS Trust

• Northwick Park Hospital

• Princess Royal University Hospital

• Queen Elizabeth Hospital

• Queen’s Hospital

• Queen Mary’s Hospital Sidcup

• Royal Brompton Hospital

• Royal Free London

• University College London Hospital

• Royal London Hospital

• Royal Marsden Hospital

• Royal National Orthopaedic Hospital

• St George’s Hospital

• St Helier Hospital

• St Mary’s Hospital

• St Thomas’ Hospital

• West Middlesex University Hospital

• Whipps Cross University Hospital

• Whittington Hospital

15 Responses

• •Central Middlesex Hospital

• •Croydon University Hospital

• •Croydon University Hospital and Community

• •Hillingdon Hospital

• •Homerton Hospital

• •King's College Hospital

• •Mile End hospital

• •North Middlesex Hospital

• •Queen Elizabeth Hospital

• •Royal Free Hospital

• •St Mary's Hospital

• •St.Pancras Hospital

• •University Hospital Lewisham

• •University Hospital Lewisham

• •West Middlesex Hospital

In 2013 Survey 18 Responses:

• Central Middlesex Hospital

• Charring Cross Hospital

• Croydon University Hospital

• Hillingdon Hospital

• Homerton Hospital

• King George Hospital

• Kings College Hospital

• Lewisham Hospital

• Mile End Hospital

• Newham University Hospital

• North Middlesex Hospital

• Northwick Park Hospital

• Queens Hospital

• Royal Free Hospital

• Royal London Hospital

• St Helier Hospital

• West Middlesex University Hospital

• Whipps Cross University Hospital

CCGs covered by these sites (29)

Barnet CCG

Barking and Dagenham

Bexley

Brent CCG

Bromley CCG

Camden CCG

Barnet CCG

City and Hackney CCG

Croydon CCG

Ealing CCG

Enfield CCG

Greenwich CCG

Hammersmith and Fulham CCG

Haringey CCG

Harrow CCG

Hillingdon CCG

Hounslow CCG

Islington CCG

Kensington and Chelsea CC

Kingston CCG

Lambeth CCG

Lewisham CCG

Newham CCG

Richmond CCG

Sutton and Merton CCG

Southwark CCG

Tower Hamlets CCG

Waltham Forest CCG

Westminster CCG

Number of podiatry chairs on site

Acute Survey 2015

2 years ago podiatry was moved out of their department to make space for urgent care. We lost a 2 chair, plus lab in outpatients. we now essentially hot desk and have access to one room

4 used for routine care, 4 for biomechanics, 1 for MDT clinic

Comments:

Days Podiatry operate (including any Multidisciplinary Team)

Acute Survey 2015

Who provides hospital podiatry service?

Acute Survey 2015

WTE of service

Acute Survey 2015

Need admin support

Comments:

Is there 24/7 cover for acute diabetic foot?

Acute Survey 2015

The cover is provided by vascular hub Reg on-call, not on site

If A&E is counted in, A&E has protocol and on hospital guidelines

Monday-Friday SOS walk-in clinic, patients must arrive 8.30am but of course acute foot turning up at 3pm will not be turned away!

If you include A&E! Mon to Saturday 9-5pm Via A & E - access to vascular and infectious disease teams who are part of the acute foot MDT.

Comments:

Is the 24/7 cover provided by A&E?

Acute Survey 2015

There is AE covered by medical/ surgical team

Comments:

Via A & E - access to vascular and infectious disease teams who are part of the acute foot MDT.

Is there a dedicated multidisciplinary foot care service provided?

Acute Survey 2015

Not at clinic but Tier 4 access at acute sites Comments:

Past four years monthly clinic with vascular surgeon, foot and ankle spec, podiatrist , microbiologist.in addition to weekly radiology/ vascular meeting and radiology/ diabetologist meetings

We do not have interventional radiology on site. All other services are but not in the MDT fashion. Joint clinic Tues with Diabetology. One combined podiatry/ orthotist clinic per month.

We all work in a virtual way by contacting as necessary

Is there a pathway from A&E to the foot care MDT?

Acute Survey 2015

Comments:

Being ratified However can be missed due to staff turnover in A&E

Yes but for Tower Hamlets only.

A&E must bleep a member of the vascular wound care team, or make a referral

Are all hospital in-patients with an active foot ulcer discharged back to the MDT?

Acute Survey 2015

we are an integrated wound care team & may not come back to hospital but will receive care in their own home

Comments:

It is encouraged some are housebound and get referred back to community wound team

80% of in-patients seen reside outside Tower Hamlets. If known, discharge summary is sent to their local MDT for follow-up

some of it is a virtual clinic for those unable to attend the outpatient clinic e.g. those at the end of life Patients who have been sent from another hospital ('spoke team') may be repatriated to their original consultant

What staff are involved during scheduled 'clinics/meetings' of the MDT?

Acute Survey 2015

What staff are involved during scheduled 'clinics/meetings' of the MDT?

Acute Survey 2015

Comments: Orthotist available all day Thursday and Wednesday pm

Orthotist/ TVN on site, plastics weekly visit for urgent cases if needed, wound care nurse available, vascular reg

We run a fortnightly joint vascular clinic, have fortnightly MDT with radiology. We have no joint working with infectious disease/plastic surgeon but will cc correspondence to them as necessary..

Radiologist can be contacted as they do 'hot reporting'. Infectious diseases is not on site. Also have joint clinics with physiotherapist on Wednesday PM,

What staff are involved during scheduled 'clinics/meetings' of the MDT?

Acute Survey 2015

What other health care professionals are available other than in the MDT

Acute Survey 2015

Comments:

dvt nurse, dermatologists, psychiatry

Podiatric Surgeon

What tests and results do podiatry have direct access to?

Acute Survey 2015

Comments: None of the above but can be quickly accessed via Tier 4 None ultrasound, nuclear medicine

Podiatrists remit only allow for radiology and microbiology.

Is there a dedicated clinical session for the treatment of painful neuropathy?

Acute Survey 2015

Pain team referral if needed for complex cases Comments:

Managed in hospital pain clinic Patients seen by MDT are started on medication for neuropathic pain and referred to the pain team if this treatment is not effective.

What proportion of patients with the following conditions, are seen by vascular services within the following time frames?

Acute Survey 2015

Comments:

Vascular on site Tues & Thursdays with 24/7 sos access

I do not know the time frame of the of the above

seen by vascular services if presenting foot has an ischaemic element

Vascular surgeons available on site on Tuesdays and Fridays only. Diabetologist can transfer acute foot to vascular on the day.

Within 24 hrs 80-95% are seen

Impossible to complete as severity dictates whether urgent (A&E at 'spoke' hospital) if all 100% or 0% if mild severity

Any limb threatening infection or acute ischaemia - are all seen within 24 hrs

This will depend on level of severity of ischaemia - critical ischaemics will be seen within 24 hours, neuro-ischaemics (with a lesser degree of reduced blood flow) may be assessed by podiatry prior to seeing a vascular surgeon (longer than 48 hours).

Are you able to admit patients for surgical debridement?

Acute Survey 2015

Comments: yes via tertiary centre I can refer to Tier 4 where this would be an option

no A&E at CMH. We have to send them to NPH

not directly but via the diabetologist If needed, otherwise mainly done in clinic.

all are sent to Guys & St. Thomas's Hospital Admission via general medicine, vascular surgery or infectious disease teams

Is outpatient parenteral antibiotic therapy available?

Acute Survey 2015

Comments: DN administer via picc line Only after being admitted!

Is rapid access to the MDT available to GPs?

Acute Survey 2015

Comments: Urgent cases same day, direct access for GP and self referral for pts Available but normally sent to SOS clinic.

Is Topical Negative Pressure available on the ward

Acute Survey 2015

Comments: And Op funded by hospital. No community commissioning Managed by TVN

Is an orthotist available in the podiatry clinic?

Acute Survey 2015

Comments: Joint clinic every Wednesday am I would have to access Acute Site On site Podiatrist able to directly refer to orthotist who is based at sister site We have access to an orthotist provided by the trust but is not directly linked to the foot clinic.

If called from their clinics A developing part of the service joint clinics are run in the podiatry dept

Are 'off the shelf offloading devices' available?

Acute Survey 2015

Comments: Padding OSSUR rebound boot, Pullmans AFO via orthotist

Is access to total contact casting and scotch casting available?

Acute Survey 2015

Comments: TCC via plaster room good links with plaster technician same day urgent service when needed Only contact casting. Scotch casting not available as too expensive TCC through the plaster room No current capacity, making removable devices

Is there an agreed structured, tailored diabetes education programme for foot care offered to all patients with diabetes?

Acute Survey 2015

Is there an agreed structured, tailored diabetes education programme for foot care offered to all patients with diabetes?

Acute Survey 2015

Comments: Contracted out to another service, not clear how well it is working DESMOND Leaflets given, have access to Desmond 1-1 at time of podiatry appointment. Intermediate Care now funded to develop such a programme.

Desmond in community

yearly patient education conference on site, and patient open days

For all the new patients

Provided through Desmond & Daphne

Education occurs at a one to one level for patients with ulcers/Charcots. Education is also provided as part of the Type 1 Diabetes pateint programme, but patients do not have to attend this.

Do you have a policy in place that requires all patients with diabetes admitted to hospital to have a foot examination recorded?

Acute Survey 2015

Do you have a policy in place that requires all patients with diabetes admitted to hospital to have a foot examination recorded

Acute Survey 2015

Comments:

Trying to implement , but NICE guideline recommendation impossible as monofilament not practical. Trying to rollover DSFPTeam stickers and looking into Ipswich touch toes test using podiatry assistant. 50% cases seen by podiatry assistant but may not be within24hrs But patients admitted via the foot clinic do this recorded in notes Yes - but it is rarely followed currently in development The results of the 2014 diabetes inpatient survey showed that this was particularly poor. A new training programme for nursing teams has been developed.

Is your organisation taking part in the National Diabetic Footcare Audit?

Acute Survey 2015

Comments: But Failing miserably as difficult to regulate/complete in time Started Jan 2015

34

What continuing education in diabetes care is available to MDT and podiatry staff regarding diabetic foot? • Postgraduate & regular in-house training

• Access to courses, use of reflective practice in groups, case studies and review

• on going

• Courses, radiology meeting

• in-house, CPD, conference

• Attend conferences, read journals, study days

• None

• MDT meeting, study days, conferences.

• Diabetic Foot Master class and foot forum, local fortnightly MDT meetings, also staff regularly present and attend international conferences such as DFSG, DUK and ISDF etc

• Diabetic Foot and FDUK conferences, case studies, journals

• Diabetes forum meetings/occasional Diabetes training days

• Rotations, information sharing sessions.

• In-house training placements, access to diabetic foot module, conference attendances, post graduate MSc courses,- all tailored to individual needs

35

Does your organisation undertake any research? • Not foot specific

• Have reviewed new wound care products.

• Osteomyelitis paper Charcot paper Currently involved in explorer study

• National diabetic foot audit

• Not routinely for foot. Happy to participate

• not presently

• Yes.

• No

• Charcot, infection, dressing evaluations, diabetic foot outcomes and modalities of peripheral vascular disease assessment

• Audits not research

• Yes - but not in relation to the foot done a range of clinical audits in relation to diabetes = ulceration rates, neuropathy/ischaemia levels etc

• Yes. Current research into medical devices and dressings. Hoping to expand this - possible drug and cellular level research.

Summary of main findings From the responding acute sites:

• 15 responses (18 in 2013).

• 29 CCGs covered by these acute sites.

• Average 4.54 Podiatry Chairs per site (2.38 in 2013).

• All have 5 day working – one acute site also working Saturday morning.

• Provision of service equal between ‘in house’ and ‘community’ but also some Trusts

employ both teams.

• Majority of acute podiatry from Band 7 and above.

• There are no HCAs or administrative support in the majority of sites.

• 24/7 acute site cover for the diabetic foot is mostly covered by A & E and vascular

services.

• 20% of acute sites have no dedicated multidisciplinary foot care service.

• 13% of acute sites have no pathway from A & E to the foot care MDT.

• Not all hospital in-patients with an active foot ulcer are referred back to the MDT.

• Most MDTs in clinic and MDT meetings comprise podiatry, diabetology and vascular

surgery. Other specialties are poorly represented other than externally to the MDT.

• Tests and results for radiology, microbiology etc are not available to all acute

podiatry teams.

• 87% of acute sites have no dedicated clinical sessions for painful neuropathy

although some access their hospital Pain Team.

Acute Survey 2015

Summary of main findings From the responding acute sites continued:

• Rapid access to vascular services within 24-48 hours for diabetic ischaemic foot infections is highly variable.

• 20% of acute sites cannot admit patients directly for surgical debridement. Admissions have to be made by consultants or referred to other hospitals.

• Outpatient parenteral antibiotic therapy is available at 93% of sites.

• Rapid access to the foot care MDT for GPs is available at 93% of sites.

• Topical Negative Pressure is available in at least 93% of sites (one non-response).

• 40% of clinics do not have an orthotist available in the podiatry clinic.

• All acute sites have access to basic ‘off the shelf’ offloading devices and the majority also use more specialist devices.

• Total contact casting is available at 87% of acute sites; some supplied by the plaster technician.

• Whilst 80% of acute sites state that patients have access to agreed structured, tailored education programmes, the majority are provided in the community and are related to Type 2 Diabetes education eg DESMOND.

• 53% of acute sites do not have a policy in place that requires all patients with diabetes admitted to hospital to have a foot examination recorded.

• 93% of acute sites are taking part in the National Diabetic Foot Audit.

• There is variation in continuing education in diabetes care available

to MDT and podiatry staff regarding diabetic foot. In one case there is no CPD.

• 4 of 15 acute sites are undertaking foot related research.

Acute Survey 2015