In the beginning…….. Diabetic patients were losing limbs, long stays in hospital, no hope of healing chronic ulcers i

2. In the beginning…….. Diabetic patients were losing limbs, long stays in hospital, no hope of healing chronic ulcers inevitable amputation. No light at the end of the tunnel, only destruction, dismay and death. …But a new era was emerging….

3. Historical Events • Launch of Sky TV • Unleaded Petrol was at 38p per litre • Inauguration of the 1st President Bush • Order of the garter opened to women • Terry Waite was kidnapped in Beirut • First ever Rugby World Cup kicks off

4. Reduce Amputations by 50% ‘ Where are we – where do we want to be, and how can we get there’?

5. Scotchcast Boot

7. The Greater Team Podiatrist Specialist Care Patients Wards District Nurses Practice Nurses G.P’s

8. 100 boots in Blackburn – 1988 Showed average healing rates of 8 weeks in neuropathic ulceration BUT How do we prevent the first ulcer? How do we keep them healed?

9. Historical Data 1988/1989 Precipitating Factors of Ulcers

12. LOW RISK Protective sensation intact (10g pressure) Optimise diabetes and blood pressure control (<139/80) Foot education/Low risk leaflet Podiatry only for problems

13. MODERATE RISK • Loss of protective sensation • No deformity • No callus • No previous ulcer • Foot education/Moderate risk leaflet • Consider Consultant opinion • Optimise diabetes and blood pressure control (<139/80) • Footwear advice and assessment Regular Podiatry (12 weekly)

14. HIGH RISK • Loss of protective sensation • Deformity and/or callus present • No previous ulcer • Optimise diabetes and blood pressure control (<139/80) • Foot education/High risk leaflet • Consultant opinion • Specialist prescribed Footwear/Shoe review Regular Podiatry (4 – 12 weekly)

15. Very High Risk • Ulcer present or • Previous ulcer • Loss of protective sensation (10 g pressure) • Foot education leaflets/ very high risk leaflet • Consultant opinion • Specialist prescribed footwear / shoe review • Optimise diabetes & blood pressure control (<130/80) Regular podiatry and review (1-4 weekly)

16. Arterial Disease • Abnormal flow • +/- History of claudication • telephone: 07793 119344 • If you suspect acute vascular insufficiency • Optimise diabetes & blood pressure control (>139/80) • Prescribe aspirin/statin • ‘Stop smoking and keep walking’ • Foot education/leaflet • Consider consultant opinion • Specialist prescribed footwear / shoe review Regular Podiatry especially nail care (1-12 weekly)

17. Referral Pathways For The Diabetic Foot Referral for Urgent Problems Referral for Non-urgent Problems Referral for Diabetic Footwear Urgent Patient Existing patient Non Urgent Patient New patient Referral letter, or fax (01254 736311) Dr G.R. Jones, Diabetes unit, RBH Prescribed footwear Same Day Referral Letter of Referral to Dr G.R. Jones, Diabetes unit, RBH Continue treatment until Outpatient Appointment Ring :- Diabetes Hot Foot line Blackburn 07866684362 Burnley 07875011972 Orthotics RBH 01254 294040 BGH 01282 804602 Orthotics RBH 01254 294040 BGH 01282 804602 Condition becomes urgent refer via REDPathway

18. N.I.C.E Guidelines recommend:- • Annual inspection and examination • Aggressive intervention to reduce morbidity • Primary and secondary care should work together to identify a package of care for at risk feet

19. N.I.C.E. ‘foot ulceration and lower limb amputation can be reduced if people who have sensory neuropathy affecting their feet are identified and offered regular podiatry and protective footwear if required’

20. Do Shoes and Orthoses work? To look at the precipitating factors responsible for new DFU compared to previous studies. Are shoes still a major factor or have thingschanged? “Change is inevitable – except from a vending machine!” Robert C. Gallagher

21. Precipitating Factors of Referred Ulcers

22. Outcomes Diabetic population and Ulcer Frequency

23. Aetiology of Foot Ulcers in Diabetic Foot Clinic

26. 100 boots in Blackburn – 1988 Showed average healing rates of 8 weeks in neuropathic ulceration BUT How do we prevent the first ulcer? How do we keep them healed?

27. Bespoke footwear Stock footwear Diabetic specification Custom made insoles Modular footwear

28. Continuous follow-up (Orthotic & Podiatric) • 2-3 servicable pairs of shoes • Long term care (>2yrs) • Weaning process • Long term healing • “A neuropathic patient is a footwear patient for life” (Ulbrect J 15/05/08)

29. Footwear Follow-up Study 100 consecutive patients recalled after 2 years Then followed up for a further 7 years

30. Results 2 Years 5years 10Years

31. Conclusion from footwear follow-up study Prescribed footwear is effective when worn, inspection is a vital part of follow up although this is written into guide lines it is not usually adhered to. The importance of footwear review needs more emphasis at all levels of care

32. That’s ok but is it cost effective? £

33. G H Nuttall P/O BSc(hons) MBAPO • I am asked (told) to provide footwear for diabetic patients. • 20% of my working week is dedicated to working within the East Lancashire Diabetic Foot Team. • I am expected to provide orthosis that will prevent high risk feet from ulcerating & healed ulcerated feet from re-ulcerating. • Ensure patients have TWO serviceable pairs of footwear.

34. Am I of value in treating feet ?(or am I just an expensive accessory?) Effective? Efficient? Contribution? Cost effective?

35. Cost Savings by Orthotics 39 88 30 66 Cost saving of £102,000 Cost saving of £147,000 Cost saving of £282,000 Cost saving of £392,000

36. Allied Health Professions input to the Diabetes pathway • The cost on the NHS to heal one ulcer is £3k to £7.5k. Should this progress to amputation the cost is estimated to escalate to £65k. This is much more than the cost of preventative orthoses. • For every £1 spent in orthotics the NHS saves £4. Hutton and Hurry 2009, Orthotic Service in the NHS: Improving Service Provision. York Health Economics

40. Ulceration/Hot Foot REFERpatients to a multidisciplinary foot care team within 24 hours if any of the following occur: • new ulceration (wound) • new swelling • new discolouration (redder, bluer, paler, blacker, over part or all of foot). (NICE Guideline – Type 2 diabetes: prevention and management of foot problems) REFER non-healing wounds from 0 – 4 weeks duration

41. Treatment of Ulceration Pressure relief (preferably non removable) Medical management (CVS, oedema, diabetes, infection) Debridement and dressings And…….. a team

42. Pressure Relieving Devices Aircast Walker DH shoe DARCO walker Podo-med Padding & strapping Half shoe

43. Nothing works like casting

44. Cast Variations Modified TCC Focused Rigidity Cast Bi-valved cast Heel ulceration

45. Innovations from Diabetic footService • Scotchcast Boot • Bespoke casting • Screening Programme • Effective and efficient orthotic service • Hot foot line • House shoe • Charcot data and register

46. HOME? NOT SO SWEET HOME Lomax G McLaughlin C Jones G R Kenwright C Blackburn Royal Infirmary

47. HOME? NOT SO SWEET HOME “THE GREATEST NUMBER OF STEPS PER DAY ARE TAKEN IN THE PATIENTS OWN HOME.” David Armstrong et al. (American Podiatric Medicine 2001)

48. HOME? NOT SO SWEET HOME PRESCRIBED INSOLES AND FOOTWEAR CAN PREVENT FOOT PATHOLOGY (TOVEY F.I. 1987)

49. HOME? NOT SO SWEET HOME Footwear is most effective when worn for a minimum of 60% of the day. (Chanteleau, E. Haage, P.) Most effective when worn for 100% of the ambulatory time.

50. HOME? NOT SO SWEET HOME AIM OF STUDY To assess what proportion of patients who had been prescribed Diabetic footwear were wearing at home.