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CPR for the Foot
Check - Protect - Refer
CPR Concept
On admission to hospital every patient with
diabetes
• Should have their feet CHECKED
• If at risk they are PR...
Diabetes Expenditure
10% of the UK NHS Budget
£9 Billion perYear
£286 per Second
No drop in the ocean?
Diabetes Expenditur...
Diabetic Foot
Ulceration
Diabetic Foot
Ulceration
Three Great Pathologies
Neuropathy Ischemia Infection
0
25
50
75
100
Mortality Rate
Prostate Cancer
Breast Cancer
Hodgkin's disease
Neuropathic Ulcer
Colon Cancer
Ischemic Ulce...
Improved Survival of
the Diabetic Foot
The role of a specialised foot clinic
ME Edmonds et al
QJ Med 1986;August; 60(232):...
➡ Earlier Discharge
➡ No limb loss
➡ Reduced Distress
➡ Reduced Cost
➡ Reduced Litigation
Means
Prevention
Prevention
Boulton et al;
Lancet Nov 2006
“becomes cost effective if
we reduce incidence of
foot ulcers and amputation
by ...
Foot Care Audit
• England & Wales 2014-2016
• 11,073 patients - 13,034 new ulcer
episodes at 173 specialist care services
...
Low Risk
Moderate Risk
High Risk
Ulcerated
5 % Active Ulcers or Infection -
revascularisation or amputation
Multidisciplin...
Patient Information
Leaflets
Foot Screening in Scotland
Patient Information
Leaflets
Foot Screening in Scotland
Scottish Audit of 1048
in-patients
• 2.4% of in-patients with diabetes developed a new
foot lesion whilst in hospital
• 57...
Consequences
• Additional, preventable cost to the NHS in Scotland
estimated at £203,000 for this group
• Cost to prevent ...
CPR Strategy
• Patient is in bed - there is no ulcer - prevention is
required
• Patient is in bed - patient has an ulcer -...
Problem is one of
Mechanics
Paul Brand
"The whole problem is one of mechanics, not of medicine.
The biological responses t...
Factors
Ischaemia Infection
Acute
Wound
Chronic
Wound
Repeated “Trauma”
At
Risk
Neuropathy
Prevent Ulceration
Strategy according to individual risk
Low Risk
Moderate Risk
High Risk
Ulcerated
Prevent Ulceration
Strategy according to individual risk
Low Risk
Moderate Risk
High Risk
Ulcerated
Improve
Extrinsic
Influ...
Pressure
Time
Tissue Damage
is Likely
“Safe”
Reswick & Rogers
Preventing Ulceration Means
Controlling the Mechanical
“Environment”
Pressure
Friction
Shear Force
Altered Sensation
Alter...
Pressure Not Just a
Surface Effect
Pressure Not Just a
Surface Effect
PRAFO Options
Infant Paediatric Adult Bariatric
Standard APU Dual HD
Kodel Fleece Pad & Strap Terry
Adjustable	device	for	...
Advantages of PRAFO
• Zero pressure and shear on the heel
• Adjustable to accommodate deformity
• Designed for recumbent a...
L & R Heels
Progressive
Problem
Two Months
Later
Refused Amputation
Clinical Effectiveness Prize
Derek Jones,William Munro, Duncan Stang
156 weeks later
CPR Strategy
• Patient is in bed - there is no ulcer -
prevention is required
• Patient is in bed - patient has an
ulcer -...
Extending the CPR
Strategy
To all foot and heel ulcers
• 20,000 hospital
inpatients at any one
time
• at home, in nursing/...
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 ...
Anatomical	Concepts	(UK)	Ltd	
h>ps://www.anatomicalconcepts.com
CPR for the Foot - The approach in Scotland
CPR for the Foot - The approach in Scotland
CPR for the Foot - The approach in Scotland
CPR for the Foot - The approach in Scotland
CPR for the Foot - The approach in Scotland
CPR for the Foot - The approach in Scotland
CPR for the Foot - The approach in Scotland
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CPR for the Foot - The approach in Scotland

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. 1. CPR for the Foot Check - Protect - Refer
  2. 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. 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%
  4. 4. Diabetic Foot Ulceration
  5. 5. Diabetic Foot Ulceration Three Great Pathologies Neuropathy Ischemia Infection
  6. 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. 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. 8. ➡ Earlier Discharge ➡ No limb loss ➡ Reduced Distress ➡ Reduced Cost ➡ Reduced Litigation Means Prevention
  9. 9. Prevention Boulton et al; Lancet Nov 2006 “becomes cost effective if we reduce incidence of foot ulcers and amputation by 25%”
  10. 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. 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
  12. 12. Patient Information Leaflets Foot Screening in Scotland
  13. 13. Patient Information Leaflets Foot Screening in Scotland
  14. 14. 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.
  15. 15. 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
  16. 16. 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
  17. 17. 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"
  18. 18. Factors Ischaemia Infection Acute Wound Chronic Wound Repeated “Trauma” At Risk Neuropathy
  19. 19. Prevent Ulceration Strategy according to individual risk Low Risk Moderate Risk High Risk Ulcerated
  20. 20. Prevent Ulceration Strategy according to individual risk Low Risk Moderate Risk High Risk Ulcerated Improve Extrinsic Influences
  21. 21. Pressure Time Tissue Damage is Likely “Safe” Reswick & Rogers
  22. 22. Preventing Ulceration Means Controlling the Mechanical “Environment” Pressure Friction Shear Force Altered Sensation AlteredTissue Mechanics and Structural Anatomy
  23. 23. Pressure Not Just a Surface Effect
  24. 24. Pressure Not Just a Surface Effect
  25. 25. PRAFO Options Infant Paediatric Adult Bariatric Standard APU Dual HD Kodel Fleece Pad & Strap Terry Adjustable device for L & R
  26. 26. 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
  27. 27. L & R Heels Progressive Problem
  28. 28. Two Months Later Refused Amputation
  29. 29. Clinical Effectiveness Prize Derek Jones,William Munro, Duncan Stang 156 weeks later
  30. 30. 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
  31. 31. 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
  32. 32. 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
  33. 33. Anatomical Concepts (UK) Ltd h>ps://www.anatomicalconcepts.com

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