GLASGOW, SCOTLAND — Implementation of a dedicated multidisciplinary foot clinic working in collaboration with a community foot protection team cut amputation rates by up to 75% at a hospital in the eastern English town of Ipswich, according to data reported at the Diabetes U.K. Annual Professional Conference.
Ipswich Hospital National Health Service Trust initially set up a foot clinic for patients with diabetes in 1987, but the arrangement did not work very well, according to Dr. Gerry Rayman, a consultant in diabetes and endocrinology at the hospital.
“It was only done once a week with only one treatment room, so the clinic was overcrowded, appointments were delayed, and there was insufficient time to counsel patients, thereby increasing cross-infection risk,” said Dr. Rayman.
Other problems included delayed or inappropriate referrals, conflicts over wound care, and low levels of awareness about the clinic on the hospital's wards. “People were sent out from hospital with dressings not appropriate in the community, and patients were kept in hospital far too long,” he continued. The result was that “patients admitted to hospital with diabetes would end up with heel problems, even though it was preventable, and there were several unnecessary amputations.”
In 1997, Dr. Rayman and his colleagues agreed to develop the patient-centered foot service by giving it a designated area, running it 5 days a week, and appointing a specialized podiatrist and a part-time diabetes specialist nurse linked to the foot clinic and the wards. The team also worked on improving communication between community and inpatient services with a series of meetings and education programs involving surgeons, interventional radiologists, family doctors, and practice nurses.
The team started surveying the wards twice a week to find patients in need of the service, and took quick action: angioplasty and intervention within a week on urgent cases, within 24 hours on limb-threatening cases, and usually within 2–3 weeks in other cases.
There has been a steady increase in usage since the service was set up. New patient referrals have climbed from just over 100 a year in 2000 to 250 in 2005, and total patient visits have risen from 2,500 to just below 5,000.
“What we have seen is a dramatic increase in new referrals. Not surprisingly, follow-up outpatient appointments have increased dramatically too,” said Dr. Rayman.
A prospective audit of the new program was performed during 1997–2000 and then again during 2002–2006, after a break enforced by funding problems. The audit involved identification of all inpatients with diabetic foot problems through visits and phone calls to relevant wards twice a week.
“Everyone coming in who required amputation was identified [without] relying on hospital coding, which misses about 20%,” said Dr. Rayman. The results were striking.
“When audit started, there was a fall in amputation rates, particularly in major amputations. When we lost inpatient surveillance [from 2000 to 2002], amputations went up, but now they have gone down again,” said Dr. Rayman. “We have had a 50%–75% reduction in amputation rates compared to 1995.”
Dr. Rayman said he is convinced that the findings are robust. “We have a very small community, with no cross-boundary referrals, so we can easily identify people who leave our community. Therefore we feel our data are very reliable.”
However, he added, “This is just one model. … This system may not be applicable in other geographical locations or with other personnel.”