CLINICAL PROTOCOL FOR COMMUNITY PODIATRY PATIENTS WITH TYPE II DIABETES RATIONALE Access to Community Podiatry services and treatment intervals for Diabetic patients, will generally be determined by the patient s risk category as identified at their annual foot screening appointment. The following protocol has been adapted from NICE guidelines for the Prevention and Management of Foot Problems (NICE 2004 Clinical Guideline 10) to provide a treatment/referral pathway for Diabetic patients on Wirral with a clinical need for Podiatry intervention. TARGET GROUP This protocol applies to all staff employed within Trust Community Podiatry Services. TRAINING All staff in the Trust are required to comply with mandatory training as specified in the Trusts Mandatory Training Matrix. Clinical Staff are also required to comply with service specific mandatory training as specified within their service training matrix. RELATED POLICIES Please refer to relevant Trust policies and procedures. RISK CATEGORIES The risk category for the patient with Type II Diabetes should be determined by assessment. Guidance for Community Podiatrists regarding risk categorisation in accordance with NICE CG61 has been developed separately. Any additional investigation undertaken following the standard screening requirements (such as the use of Doppler ultrasound vascular assessment) should be recorded in the Subjective, Objective, Assessment and Plan (SOAP) consultation or assessment section of the patient record. EDUCATION LEAFLETS AND INDIVIDUAL CARE PLANS All patients with Type II Diabetes are to be given an educational leaflet produced by the Trust s Podiatry Service according to their risk category. 1/7
Any patient presenting who is new to the service or any current patient who has been diagnosed with diabetes following their last contact with the service should be issued with an Individualised Care Plan to promote self-care. CARE PLANNING ACCORDING TO RISK CATEGORORY Each Clinical Commissioning Group may vary in their chosen diabetes foot care pathway. Refer to service protocol on specific details of each contract arrangement. LOW RISK Patients found to be at low risk of foot ulceration are managed by their G.P. for their annual foot screening assessments (a small number of low risk patients may still attend community podiatry for this assessment). Low risk patients can access Community Podiatry Services for routine treatment: nail care callus reduction nail surgery biomechanical assessments. Referrals:- Referrals to the service can be from the patient, their carer, or any other member of the multi-disciplinary team and, following an initial assessment, they will be advised of how to contact the service for on-going treatment. Reviews and Frequency of Visits: For low risk routine Podiatry care, the service will generally recommend that the interval between two treatment episodes is no less than 3 months. This will be reviewed as necessary depending on individual clinical circumstances or additional Podiatric need. Follow up appointments will then be initiated and made by the patient on a self-referral basis. AT RISK PATIENTS At risk patients are managed by the Community Podiatry Service for their annual foot screening assessments and reviews. Referrals:- Referrals to the service can be from the patient, their carer, or any other member of the multi-disciplinary team and, following an initial assessment, they will be advised of how to contact the service for on-going treatment. In accordance with NICE guidelines, at risk patients will be reviewed every 3-6 months. Patients will be informed of this at their initial assessment and the advice will be reiterated 2/7
at each annual foot screening. This advice must be documented clearly in the patient s records. Follow up appointments will then be initiated and made by the patient on a selfreferral basis. HIGH RISK High risk patients are managed by the Community Podiatry Service for their annual foot screening assessments and reviews. Referrals:- Referrals will be accepted from the patient, their carer, or any other member of the multidisciplinary team. Reviews and Frequency of Visits: Once a patient has been confirmed as being high risk the Community Podiatry Service will re-call the patient to the service for regular reviews and routine treatments. When attending clinic, patients will be provided with written notification of their next appointment. The patient s suitability for certain procedures e.g. nail surgery, will be assessed on an individual basis and onward referral will be made if necessary. For high risk patients, the interval between two treatment episodes will be no more than 3 months (subject to patient agreement) All high risk patients will be rebooked following each visit to Community Podiatry. Any patient who makes an informed decision to decline to be rebooked will have their decision recorded in the health records, with an explanation of benefits of attending and risks of not attending recorded at the consultation. They will be issued with a standard letter explaining that this was their preference. The letter will contain an explanation of the potential health risks of not attending for on going reviews and advising them on the benefits how to re-access the service should they choose to. A copy of this letter will be stored in their electronic record for reference and a copy shared with the GP Cancelled Appointments and Documentation All high risk patients who contact the service to cancel their appointment will be rebooked, within 5 working days. It is the responsibility of the member of staff cancelling the appointment to ensure the patient is rebooked as soon as is practicable, based on clinical need and recorded in the health records. The appointment will be determined by availability, to include embargoed appointments, which will not necessarily be at the clinic normally attended by the patient. Any alternative appointments declined by the patient must be recorded in the patient record. If a patient fails to attend for their treatment/review and makes no further contact with the service in the next 7 days, they will be sent another appointment in writing, within 5 working days, and a copy shared with the GP. 3/7
All letters will be sent out centrally from the Podiatry Administration office. When required, clinicians should phone the office with notification of the content and type of letter they require. Full details will be kept in the patients records along with a copy of the letter and any subsequent response from the patient/gp. If the patient fails to attend for two consecutive appointments, or refuses a follow up appointment, a letter will be sent to the patients GP for their information, within 5 working days. Podiatry Assistants:- If the patient fails to attend for a Podiatry Assistant appointment, the Podiatry Assistant must consult with a Podiatrist to establish clinical need within 2 working days, and record this consultation in the patient record. Podiatry assistants rebooking high risk patients must consult with a podiatrist within two working days to establish clinical need. Any consultation with a Podiatrist must be documented in the patient record. EMERGENCY REFERRALS INTO SECONDARY CARE If any patient presents with a new ulceration or has a static, non-responsive (no signs of healing in) or deteriorating area of ulceration, swelling or discolouration (may indicate deep infection), critical ischaemia or suspected Charcot Foot an urgent appointment with the Diabetic Team at Arrowe Park Hospital (APH) / Clatterbridge Hospital must be arranged immediately (urgently within the same working day) as detailed below. Before any referral to Wirral University Teaching Hospital (WUTH) Diabetic Team can be made, the patient must be under the care of a Diabetic Consultant at APH or Clatterbridge Hospitals. It is the responsibility of the referring clinician to ensure that any patients they refer to WUTH are registered with a consultant. This can be confirmed by phoning the relevant Diabetic Clinics on the numbers shown below. For all patients ring 604 7720 or 604 7210 and inform the Choose and Book Office that the patient has a diabetic foot ulcer. The patient will be booked into the next available diabetes podiatry clinic. The referral must also be faxed to 604-7172 Then arrange an appointment with the Diabetes Team explaining a faxed referral will be sent from the patients GP. Without a fax referral from the patients GP, WUTH will refer patients back to community care without treatment. Emergency referrals must be fully documented in the patients health records 4/7
CONSENT Valid consent must be given voluntarily by an appropriately informed person prior to any procedure or intervention. No one can give consent on behalf of another adult who is deemed to lack capacity regardless of whether the impairment is temporary or permanent. However such patients can be treated if it is deemed to be within their best interest. This must be recorded within the patient s health records with a clear rationale stated at all times. Refer to Trust Patient Information and Consent Policy for further information and guidance or the Clinical Protocol for Assessing Mental Capacity and Best Interests. WHERE TO GET ADVICE FROM Advice regarding care planning can be obtained from the Specialist Diabetes Podiatrists and the Podiatry Diabetes Co-ordinator. INCIDENT REPORTING Clinical incidents or near misses must be reported via the Trust s incident reporting system. SAFEGUARDING In any situation where staff may consider the patient to be a vulnerable adult, they need to follow the Trust Safeguarding Adult Policy and discuss with their line manager and document outcomes. EQUALITY ASSESSMENT During the development of this protocol the Trust has considered the clinical needs of each protected characteristic (age, disability, gender, gender reassignment, pregnancy and maternity, race, religion or belief, sexual orientation). There is no evidence of exclusion of these named groups. If staff become aware of any exclusion that impact on the delivery of clinical care, a Trust Datix incident form would need to be completed, and an appropriate action plan put in place. ASSOCIATED PODIATRY SERVICE DOCUMENTS Clinical Protocol for Annual Diabetic Foot Screenings REFERENCES CG10 Type 2 Diabetes Foot care: NICE Guideline (2004) Clinical Protocol for Assessing Mental Capacity and Best Interests. Patient Information and Consent Policy Procedure for Vascular Assessment by Doppler Ultrasound 5/7
CONTROL RECORD Title Clinical Protocol for Community Podiatry Patients with Type II Diabetes Purpose To ensure compliance with care planning recommendations for diabetic patients undertaken by podiatrists in accordance with NICE Guidance CG10 Author Quality and Governance Service (QGS) Equality Assessment Integrated into procedure Yes No Subject Experts Podiatry Service Lead Document Librarian QGS Groups consulted with :- Clinical Policies and Procedures Group Infection Control Approved April 2013 Date approved by Quality, Patient Experience and Risk Aim QPER May 2013 Group Method of distribution Email Intranet:- Staff Zone Archived Date Location:- Datix Library in QGS Access Via QGS VERSION CONTROL RECORD Version Number Author Status Changes / Comments Version 1 Service Lead N New protocol to outline clinical standards of care for podiatry patients with Type 11 Diabetes Status New / Revised / Trust Change 6/7
Low Risk Normal sensation Palpable pulses No previous ulcers No foot deformity Normal vision No callus Management Annual foot screening and education by practice nurse or community podiatrist. Refer to community podiatrist if patient unable to self care. Advise when, who and how to contact if required. Advice Inspect feet daily. Avoid walking barefoot. First aid. Don t smoke Contact number. Access to service. At Risk WIRRAL DIABETIC FOOT CARE REFERRAL PATHWAY DIABETIC RISK CATEGORIES Reduced sensation Absent pulses (abnormal vascular results) Neuropathic pain Foot deformity Management Community Podiatry review within 3-6 months Review need for vascular assessment /specialist footwear /insoles/treatment for painful neuropathy /glycaemic control. Provide appropriate education. And ensure Annual foot check by community podiatry or HPC registered podiatrist Advice As for Low Risk & Footwear supportive, cushioning, fastening. Avoid extremes of temperature i.e. baths, fires, hot-water bottles 7/7 High Risk Reduced sensation Absent pulses Foot deformity (Charcot) Skin changes Previous ulcer Arterial leg surgery Amputation Management Community Podiatry review and treatment where required within 1-3 months Evaluate provision of specialist foot wear/insoles. Refer on where necessary. Review need for vascular assessment. Provide appropriate education. And ensure Annual Foot Check by community podiatry or HPC private podiatrist Offer next appointment. Advice Enhance foot care education As for Low & At Risk Prescriptive footwear compliance. Check footwear for wear & tear and foreign bodies. Emergency New Ulcer Swelling Discolouration (may indicate deep infection or acute ischaemia) or critical ischaemia or suspected Charcot Refer to Diabetes Team/A&E NOW For all patients ring 604 7720 or 604 7210 URGENTLY and inform the Choose and Book Office that this patient has a diabetic foot ulcer. This patient will be booked urgently to the next available Diabetic Podiatry Clinic appointment. Please also fax the referral to 604 7172 Please refer to the antibiotic protocol when commencing treatment. Review Time Yearly Review by GP 3-6 monthly by Podiatry 1-3 monthly by Podiatry Now Other risk factors: peripheral vascular disease, age, plantar callous, poor footwear, foot deformities, social deprivation and isolation, poor vision and smokers