MN Report: Talking to the Medical News recently, Professor Dr. Abdul Basit – a Pakistani Diabetes expert, who Heads the Baqai Institute of Diabetology, had stated that; The Diabetes disease-burden is enormous, as it affects tens of millions of people in Pakistan. No health-care system in the world can sustain such a massive load of suffering patients. The only way is to save new patients from this ailment.
Dr. Basit also said that; We have to work very efficiently and adopt a multi-pronged strategy to overcome a major challenge like Diabetes. We need to ensure capacity-building, by training our General Practitioners and district level doctors, because every patient in this poor country, does not have the resources or access to consult a Diabetes specialist.
Pakistan government needs to establish a National Health Network, which should designate and equip atleast 3000 existing clinics across Pakistan to work as diabetic centers, providing low-cost services to the patients. We can give a 4-weeks basic training in diabetes to doctors, who will then manage the designated Diabetic Clinics, and refer the more serious cases to the Diploma-holding doctors on district level, Dr. Basit added.
Working towards the establishment of a comprehensive Prevention & Care system for Diabetic Foot Ulcers, Pakistan can take guidance from the effectively structured models, that are successfully operating in the developed world. Those systems can be customized to suit Pakistan’s needs and modified to work within out limited resources. Here we will discuss one of the successful “Foot-care” systems.
The Foot-Care System in Ireland
The HSE is an organizations that provides public health and social care services to everyone living in Ireland. It has launched a National Diabetes Programme with a clearly defined Clinical Strategy, operated by a Programmes Directorate. Following are some excerpts and guidelines from a report prepared by HSE Ireland:
Diabetic foot disease is one of the most common, serious, feared and costly complications of diabetes. Patients with diabetes are at a 15 to 40 fold higher risk of a lower limb amputation than a non-diabetic patient. Eighty percent of lower limb amputations in diabetes are preceded by the development of a foot ulcer. Diabetic foot disease is costly, with patients frequently requiring admission to hospital, investigations, surgery and a prolonged hospital stay.
International studies and guidelines show that targeted foot care and proper screening of risk casescan result in a reduction in the incidence of foot ulcers in patients with diabetes. The target was to reduce foot ulcers, lower limb amputations and reducing hospital costs, by engaging podiatrists to the care of the diabetic foot.
It is hoped that over time, the number of diabetes podiatrists will increase. A national model of foot care will be adapted by all health care professionals involved in the care of the diabetic foot, including practice nurses, primary care physicians, podiatrists, diabetes nurse specialists, tissue viability and public health nurses, orthotists, registrars and consultants.
The National Diabetes Programme in Ireland was established in June 2010. In 2011 funding was received to establish a national multidisciplinary foot care service for people with diabetes. Foot care management in diabetes is based on three categories of risk.
1. Patients “at low risk of diabetic foot disease” will be managed preventatively through annual screening and regular foot inspections/examinations by primary care nurses*.
[Definition: A low risk foot patient has normal foot pulses, normal vibration and sensation to 10g monofilament, no history of foot ulceration, no significant foot deformity, or no visual
2. Patients “at risk of diabetic foot disease” may be stratified as either moderate risk or high risk. All patients will be under regular surveillance by primary care nurses/general
– Moderate risk patients will be referred by the GP to the podiatrist, either in the community or inthe hospital, for an annual review. These patients will remain under the clinical governance of the GP and podiatrist.
– [Definition: The moderate-risk patient has either impaired peripheral sensation or impaired
circulation or significant visual impairment or a structural foot deformity].
– High risk patients will be called to be seen at least annually by the diabetes foot protection
team in one of the 16 designated centres, and will be under the governance of the foot
protection team for their foot care.
– [Definition: The high-risk patient has an abnormality that predisposes them to foot ulceration.
This can be impaired sensation and impaired circulation, or a previous foot ulcer, previous
lower limb amputation or previous Charcot foot].
3. Patients with “active diabetic foot disease”, defined as patients with an active foot ulcer (defined as a full thickness skin break) or a Charcot foot, will be actively managed by a
multidisciplinary specialist foot care service, in conjunction with vascular surgery, orthopaedics and orthotics input as required. This will be available in the model 4 indicative hospitals.
The evidence-base suggests that an effective care pathway for diabetes foot care will benefit patients and may specifically reduce adverse outcomes such as chronic or recurrent foot ulceration, infection and lower limb amputation.
4. Multidisciplinary Team Member Involvement
Diabetes foot care involves a wide range of professional groups from local HSE areas as well as patients and their carers. Central to diabetes foot care are patients, carers, podiatrists, practice nurses and other primary care nurses, general practitioners, diabetes specialist nurses, diabetes consultants, orthotists, vascular surgeons and orthopaedic surgeons. Other groups with an important input into diabetes foot care are tissue viability nurses, physiotherapists, infectious disease service, radiology consultants, ward nurses and ED staff.
Integrated Model of Management/Care Pathway for People with Diabetic Foot Problems starts at the point of diagnosis of diabetes and continues indefinitely. It will/must be flexible to respond to the needs of the patient as developments occur during the course of their disease progression. This integrated model of management/care pathway for the diabetic foot is intended to provide a structure and organization to the foot-care needs of patients with diabetes. The key feature is foot care being provided by an appropriate healthcare professional at a frequency appropriate to the patients needs. It is hoped that this will make the overall service more patient focused and efficient.
Routine diabetes foot screening will be provided by the primary care team with referral on to podiatrists and secondary care guided by a national integrated model of care for the diabetic foot . In this way, patients with low risk diabetic foot disease will not require foot screening by the podiatry services and will be treated in primary care and patients with complex diabetes foot problems will be managed by community or hospital based podiatrists as part of a foot protection/multidisciplinary foot team in designated foot care centres.
5. The FOOT PROTECTION TEAM is the group of professionals involved in the care of the person with the “AT RISK FOOT” who will observe, advise, treat and educate patients and where necessary prescribe footwear and orthotics in order to protect feet from developing active foot disease.
6. The FOOT CARE SERVICE is the multidisciplinary team working together in the model 4 hospital looking after the “ACTIVE FOOT”, working closely with vascular and orthopaedic surgeons and orthotists. It should also be stressed that this model of care has been devised to allow a structured national programme to be put in place, to reduce end stage diabetic foot disease.
7. Diabetes Foot Screening : aims to allow categorisation into Low, At Risk or Active Foot Disease. Based on this assessment the patient should be allocated to a risk group . Routine diabetes foot screening should ensure that:
• All patients with diabetes are offered annual screening & regular foot examinations from early diagnosis.
• Foot review and screening is carried out by appropriately trained staff.
• Foot care education is provided to individuals according to their clinical and personal needs.
• Patients are regularly assessed for their risk of foot ulceration.
8. Routine Foot Screening Process
Examination of newly diagnosed diabetes mellitus or previously low risk patient should include:
– Foot Inspection, Inspection of skin, nails and for structural foot deformity.
• Examination of footwear.
• Vibration perception testing (128 Hz tuning fork) and cutaneous pressure perception testing
with a 10g monofilament sensation.
• Palpation of foot pulses.
After this the patients should be assigned to a risk category. Screening process to be fully documented and findings are recorded in GP database for audit purposes.
9. Management of the disease: The diabetes foot protection clinic should take place on a monthly basis at minimum, within a model 3 or model 4 hospital, with input, where necessary, from vascular, orthopaedics & orthotics. A Podiatrist should review the high risk foot at least once every 12 months. If ulceration is present, then refer within 24 hours or the next working day to the multidisciplinary foot care service (model 4 hospital). Review educational needs of the patient.
If there is a problem with footwear then referral to a podiatrist/orthotist for footwear , assessment and orthoses provision as required. Refer to vascular and/or orthopaedics where necessary. If there is other foot pathology such as nail conditions, corns, callus or verrucae, then these can be dealt with during the examination by the podiatrist & make referral to community podiatrist. The Hospital podiatrist should work closely with community podiatrist while caring for high risk feet.
10. Foot care education includes:
Nail care, Skin / nail examination., Emollient use, Footwear, Daily self-examination of foot, Not walking bare foot, Checking footwear & hosiery before putting it on, Avoidance of constrictive hosiery, “Breaking shoes in” never to be attempted, No hot water bottles, Checking bath and shower temperature, Avoid home remedies e.g. corn plasters, Know what to do and find appropriate person to contact, if foot problems develop, Patients should have a high-risk foot information sheet.
For complete details about this Diabetic Foot Care Programme, visit: www.hse.ie