Integrated care for the diabetic foot: impact on outcomes Gerry Rayman Ipswich Hospital Suffolk The Ipswich Diabetic Foot Clinic

Wound Healing Lose footwear Untreated Infection Amputation Referred to Foot Clinic Off- loading Off-loading and treatment of infection Replace footwear

Screening to characterise risk Pathways Health care professional Patients and carers Coordination of Interventional procedures

Ipswich Diabetic Foot Unit Main Treatment Room

‘Hot Line’ Patient held record Community nurse Community Podiatrist Secondary Care Diabetologist Podiatrist Orthotist Vascular & Orthopaedic surgeons Radiologist Primary Care GPs Practice nurses Community nurses Podiatrists DSNSenior Podiatrist

Integrated care

Fast tracking

Possible admission routes for the acute diabetic foot Acute foot lesion Vascular surgeon General surgeon Orthopaedic surgeon On call gen physician Care of elderly Diabetes team Discharged home There needs to be a clear pathway for the acute diabetic foot

Amputation rates per 100,000 gen. population Amputation rates per 100,000 gen population 2.82

OrganisationPopulation size YearChange in major amputation rates Estimated savings based on bed days alone( £ 200/d) Ipswich Hospital NHS Trust 335, Reduced by 75% £ 386,000/yr Southampton540, Reduced by 60% £ 754,000/yr Middlesbrough273, Reduced by 75%N/A Northampton NHS Trust 350, Reduced by 53%N/A Kings College Hospital Inner city hospital- population not clearly defined Estimated reduction >70% (difficult to assess as population not clearly defined) N/A UK Evidence for effectiveness of Multi-disciplinary foot teams and provision of inpatient foot care service

Larsson J, Eneroth M, Apelqvist J, Stenstrom A. Acta Orthop 2008

The trend of Total amputations in diabetes in Finland Number of 1 st Amputations per 10,000diabetics in Finland Lepantalo 2006

Total Amputations (major and minor) per 10,000 diabetics

Trends in LEA in people with diabetes in England (HES data) Type 1Minordecreased 11.4% Majordecreased 41.0% Type 2Minorincreased 95.0% Majorincreased 83.5% Vamos EP; EASD 2009

Why is care patchy across the UK?

Not rocket science Not on the agenda

Not all plain sailing Loss of in patient foot nurse Foot protection team not supported in primary care Community podiatry not full integrated Education of community staff relies on good will- no funding

Southampton (520 admissions) LOS from 50 days to 18.5 days Major amputations reduced by 60%

Bed days –Invest to Save Amputation Other foot Total Reduction65% Saving ~£400,000

“I marvel that society would pay a surgeon a large sum to remove a patient’s leg but nothing to save it”. George Bernard Shaw

“I marvel that the health service should continue wasting large sums on the disasters arising from poor diabetic foot care but little or none to develop integrate services to prevent them in the first place” Gerry Rayman