CPR for the Foot - The approach in Scotland
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Presentation made at the Irish Association of Prosthetists and Orthotists meeting in Dublin featuring the work of the Scottish Foot Action Group in managing diabetic foot disease
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CPR for the Foot - The approach in Scotland
- 1. CPR for the Foot Check - Protect - Refer
- 2. CPR Concept On admission to hospital every patient with diabetes • Should have their feet CHECKED • If at risk they are PROTECTED • If they have a problem immediately REFER Scottish Diabetic Foot Action Group
- 3. Diabetes Expenditure 10% of the UK NHS Budget £9 Billion perYear £286 per Second No drop in the ocean? Diabetes Expenditure 10% of the UK NHS Budget £9 Billion perYear £286 per Second 2.9 million people affected in the UK Lifetime risk of foot ulceration - 25%
- 5. Diabetic Foot Ulceration Three Great Pathologies Neuropathy Ischemia Infection
- 6. 0 25 50 75 100 Mortality Rate Prostate Cancer Breast Cancer Hodgkin's disease Neuropathic Ulcer Colon Cancer Ischemic Ulcer Peripheral Artery Disease Lung Cancer Pancreatic Cancer
- 7. Improved Survival of the Diabetic Foot The role of a specialised foot clinic ME Edmonds et al QJ Med 1986;August; 60(232):763-71
- 8. ➡ Earlier Discharge ➡ No limb loss ➡ Reduced Distress ➡ Reduced Cost ➡ Reduced Litigation Means Prevention
- 9. Prevention Boulton et al; Lancet Nov 2006 “becomes cost effective if we reduce incidence of foot ulcers and amputation by 25%”
- 10. Foot Care Audit • England & Wales 2014-2016 • 11,073 patients - 13,034 new ulcer episodes at 173 specialist care services • One third still had ulcers 24 weeks after assessment • One in Twenty had died • Less severe ulcers = twice as likely to be alive at 12 weeks
- 11. Low Risk Moderate Risk High Risk Ulcerated 5 % Active Ulcers or Infection - revascularisation or amputation Multidisciplinary management 15 % High Risk Intensive foot protection 20 % Moderate Risk Regular foot protection60% Low Risk Routine annual screening Risk Stratification
- 14. Patient Information Leaflets Foot Screening in Scotland
- 15. Patient Information Leaflets Foot Screening in Scotland
- 16. Scottish Audit of 1048 in-patients • 2.4% of in-patients with diabetes developed a new foot lesion whilst in hospital • 57% had NOT had their feet checked • 60% of those ‘at risk’ had no pressure relief in place.
- 17. Consequences • Additional, preventable cost to the NHS in Scotland estimated at £203,000 for this group • Cost to prevent estimated at < £20,000 • If even 75% of ulcers could be prevented then total NHS Scotland saving = £15m • NOT including cost of potential litigation
- 19. CPR Strategy • Patient is in bed - there is no ulcer - prevention is required • Patient is in bed - patient has an ulcer - total pressure relief to encourage healing • Patient is in bed and is ambulant - protection is needed both in bed and during ambulation
- 20. Problem is one of Mechanics Paul Brand "The whole problem is one of mechanics, not of medicine. The biological responses to these denervated limbs are qualitatively similar to those of normal limbs. It is the permitted pattern of mechanical stress that is different"
- 22. Prevent Ulceration Strategy according to individual risk Low Risk Moderate Risk High Risk Ulcerated
- 23. Prevent Ulceration Strategy according to individual risk Low Risk Moderate Risk High Risk Ulcerated Improve Extrinsic Influences
- 24. Pressure Time Tissue Damage is Likely “Safe” Reswick & Rogers
- 25. Preventing Ulceration Means Controlling the Mechanical “Environment” Pressure Friction Shear Force Altered Sensation AlteredTissue Mechanics and Structural Anatomy
- 26. Pressure Not Just a Surface Effect
- 27. Pressure Not Just a Surface Effect
- 32. PRAFO Options Infant Paediatric Adult Bariatric Standard APU Dual HD Kodel Fleece Pad & Strap Terry Adjustable device for L & R
- 33. Advantages of PRAFO • Zero pressure and shear on the heel • Adjustable to accommodate deformity • Designed for recumbent and ambulant usage • Only device with METAL upright to resist deformity development • Each device size adjustable and for L & R
- 34. L & R Heels Progressive Problem
- 36. Clinical Effectiveness Prize Derek Jones,William Munro, Duncan Stang 156 weeks later
- 37. CPR Strategy • Patient is in bed - there is no ulcer - prevention is required • Patient is in bed - patient has an ulcer - total pressure relief to encourage healing • Patient is in bed and is ambulant - protection is needed both in bed and during ambulation Check - Protect - Refer
- 38. Extending the CPR Strategy To all foot and heel ulcers • 20,000 hospital inpatients at any one time • at home, in nursing/ care homes?? • 400,000 persons annually Diabetes PVD MS Intensive Care Bariatric Stroke rehab Burns Elderly/General Immobility
- 39. Cost of Pressure Ulcers • DOH in UK - Estimates £1,064 for a Grade 1 ulcer to £24,214 for a Grade 4 ulcer • Hospital Stay - £450 to £650 per day • Increased risk of litigation • Nursing time - community visits, dressings • May require “high tech” pressure relief