1. Bucks Putting Feet First Inpatient Service
Erin Lee
Clinical Lead Podiatrist

2. Bucks Integrated Podiatry Service
MDFT
Diabetes
Vascular
Podiatry
FCA
Nurse
High Risk Podiatry clinic
Based in Community
Ulcer Podiatry clinics Based in Hospital Sites
DOM visits in Community
PFF Inpatient Service Based In Hospital Sites
Foot screening
Treatment as inpatient
Education
General Podiatry clinics Based in Community

3. Aims Of Our PFF Inpatient Service
Recommendation –
Routine basic assessment and care of the diabetic foot within 48 hours of admission.
Expert assessment and management of existing ulcer/Charcot
Education for patient.
Prevention of new onset foot disease in patients admitted to hospital for unrelated reasons.
Education for ward staff.

4. Hospital sites Stoke Mandeville Hospital Wycombe General Hospital
Beds 545: Medical, Surgical, Spinal and women and children
36,956 Non elective admission.
Wycombe General Hospital
Beds 121: Cardiac, Stroke, surgical Urology and ITU.
Amersham General Hospital
Beds 63: Rehabilitation

5. Case For Change NICE Guideline 119 (2011)
National diabetes Inpatient audit.
Bucks in 2013 Keogh Action plan and the Keogh Rapid response review Report.

6. Relevant Departments Engaged
Meeting with:
Dr S Gardner - Lead Diabetic Consultant,
Morag Thomson AHP / Therapy Lead community division
Podiatry service manager,
Podiatry clinical Lead
How would this service work?
Nurses on ward
Nursing issues in Keogh report - Capacity
Educate ward staff -costly

7. Started process in 2012
Nov 2012 band 6 podiatrist was release from duties to complete a pilot.
For 1 week at one site – SMH
Developed a screening tool to be used on ward with PFF guide as an aid.
Kit included
Locate which patients have diabetes.
15 Wards visited and 37 Patient with diabetes identified.
Results presented at board level with first draft business case.
Locating patient with Diabetes:
Diabetic Nurses
Ward handover sheets
Bed boards
“Think Glucose” Programe

8. Sept 2013 next pilot
Funding for locum Podiatrist enabling podiatry to under take 12 months pilot at all 3 Hospital sites.
Sept 2013 – July 2014
National Diabetes Inpatient Audit reflected this positively:
“Patient that received a foot risk assessment during stay?”
2011 – 8.5%
2012 – 4.4%
2013 – 42.3%
2015 – 13.2%

9. Limitation to the service
Duplication of patients screened
Multiple Podiatrist performing screening
Lack of good Communication
Patient were not screened within 48 hours
Identifying which patient are diabetic on the wards
Follow up for those identified as High and Active Risk
Patient with active foot - Capacity
Patient living outside area
Increase in admin

10. Next business case more informed
2 WTE Band 3 Podiatry assistants
2 WTE Band 6 Podiatrist
Equipment needed
Jan 2015 Business case signed off

11. Recruitment of Band 3 Podiatry assistance and Training package.
2 weeks observing
Observe DEG talks all 4 sessions for an over view of diabetes
Observe 2 High risk Community Clinics – High risk patients
Observe Ulcer clinics
Observe MDFT clinic
2 Whole day Theory training
Why are we doing PFF – Overview of how the service will look
What type of patient will we be screening and why
Overview of circulation – including practical checking foot pulses palpating and with doppler
Overview of neurological – 10g Monofilament – Including practical session
Noting deformities
Ulceration signs and symptoms
Terminology and abbreviations
Anatomy
How to classify a diabetic patient according to PFF
Leaflets and education
Out coming patient – Registering on RIO and follow up appointment
Half day session with Frances Registering patients on RIO
Assigned a Band 6 Mentor to each FCA the FCA will then be asked to check foot pulses and neurological status of each patient attending clinic with their Mentor supervision. Also entering this information onto the RIO notes.
The FCA will then have competencies signed off.
Ward visits
Each FCA will be accompanied to wards: gaining confidence and protocol for attending ward

12. Band 6 Podiatrist Training program
2 weeks observing
Observe DEG talks all 4 sessions for an over view of diabetes
Observe 2 High risk Community Clinics – High risk patients
Observe Ulcer clinics
Observe MDFT clinics and then participating
10 week Ulcer clinic placement at SMH and WGH
Competencies lead training
Certificate in Diabetes

13. What's involved: Band 3 Assistance: Screening tool Education leaflets
Outcome letter to GP
Built in Audit
Admin - Registering
Follow up podiatry care
if required in appropriate
Clinic.

14. Number of patient screened
Current situation
Service started Jan 2016
Data collected from Jan – Oct 2016
Hospital Site
SMH
WGH
AGH
Total
Number of patient screened
278
362 63
703

15. Break Down of Risk Rating
SMH
WGH
AGH
Total (%)
Active Foot 59 30 12
101 (14%)
High Risk 49 46 8
103 (15%)
Moderate Risk 99
152 27
278 (40%)
Low Risk 62
125 16
203 (29%)
Declin/Bilat 9
18 (2%)
Total
278
362 63
703

16. Not known to Podiatry No Active open referral in past 6 months.
Data only from SMH and AGH
No of Patients
Total %
Active Ulcer /Charcot 25
35%
High Risk 28
49%

17. 24 Patients with active Foot ulcer Not known our Podiatry Service
13 Male 11 Female
54% of patient over 80 (Ranging 46 – 97)
14 patient lived in south of county, 8 Live in North county and 2 Live out of area.
4 Patient live in Nursing Home.
8 patient had pass away within 3 months of screening.
7 Patient were described as having pressure ulceration.
2 Patient went on to have minor amputation.
2 Patient went on to have major amputation.
Thought we may find Pattern with GP practices however this was not the case.
Look to engage the GP practices in the south of the county.
Approach TVN to work with them in preventing pressure Ulceration in our diabetic population.
2 going on to have Major amputation complete a full RCA – why not referred onto Podiatry

18. Ever Evolving Service Limitation:
Identifying diabetic patient on wards.
Not yet achieving our target of screening within 48 hours.
Introduce Root Cause Analysis to MDFT.
PFF Inpatient ward round with Diabetes team.
Rota for all Band 6 Podiatry staff to be involved in PFF Inpatient.
Education program for ward staff.
Work along side TVN to prevent hospital acquired pressure in feet.
Diabetic team looking to re introduce “Think Glucose to wards

19. Thank You