Suzanna Parkyn - Lyell McEwin Hospital - Managing 'High Risk' Feet Presenting to Emergency
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A pilot study to facilitate and refine the referral pathways of patients attending the Emergency Department with a ‘high risk’ foot complaint. Lyell McEwin Hospital, Adelaide South Australia Suzanna Parkyn
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Transcript of Suzanna Parkyn - Lyell McEwin Hospital - Managing 'High Risk' Feet Presenting to Emergency
A pilot study to facilitate and
refine the referral pathways of
patients attending the Emergency
Department with a ‘high risk’ foot
complaint.
Lyell McEwin Hospital, Adelaide
South Australia
Suzanna Parkyn
SA Health
Northern Adelaide
> Salisbury Playford
Lyell McEwin Hospital
SA Health
Index of Disadvantage
http://www.abs.gov.au/ausstats/[email protected]/Products/4367.0~2007-2008~Main+Features~Index+of+Disadvantage?OpenDocument
SA Health
NALHN Population - snapshot
> Projected to grow by around 23.6% by
2016
> NALHN has the highest prevalence in
type 2 diabetes, hypertensive disease and
high cholesterol across metropolitan
Adelaide (A Social Health Atlas of Australia 2011)
> Circulatory system disease increases with
advancing age and NALHN is expected to
have significant population growth in the
over 64 years age group.
SA Health
Foot Disease Burden
> Data from the Australian Institute of Health and Welfare
(AIHW) suggest that one Australian loses a lower limb
every 3 hours as a direct result of diabetes-related foot
disease
> 30% increase in diabetes-related amputations in
Australia over the past decade, with 8% of diabetes-
related deaths being attributable to foot disease.
> Foot complications resulting from diabetes are the most
common cause of amputation and diabetes-related
hospitalisation.
> Recurrence rates for foot ulceration range from 20%–
80% annually, with many of these ulcers leading to
amputation.
SA Health
SA Health
Lower limb amputations associated
with diabetes
> Australian Data
Amputation
$26,700 direct hospital cost per amputation
Addition of indirect costs >$100,000
Average 26 bed days
Ulceration
$13,000
13 bed days
2004/2005 2012 evidence
Bed days $130,000 $200,000
Amputations $3400 $4300
Deaths $1000 $1000++
SA Health
Financial Cost to Health System
> Potential saving $382.18 if sent to Podiatry from triage
> Potential further costs avoided:
• Amputation of a toe > $11524
• Acute Amputee Rehabilitation costs $801 per bed day
> Costs from DoH-supplied Casemix Prices 2011-12
Cost
ED Triage Category 4 or 5 $458.32
Podiatry Outpatients $76.14
SA Health
Project Description
> To facilitate and refine the referral pathway for
patients presenting to the emergency department
with a ‘high risk’ foot complaint.
> Create appropriate
and timely pathways
> Reassess patient flow
and management.
> Improve partnerships
SA Health
Potential Outcomes
> Demonstrate the potential of the Diabetes Interdisciplinary Foot Team
> Focus on right care, right time and right place
> Improve patient care in emergency department settings
> Improve efficiencies and help facilitate the “4 Hour Rule”.
> Future prevention of
‘high risk’ foot conditions
SA Health
Stakeholders
> Key Stakeholders• Diabetes Interdisciplinary Foot Clinic
• Director of ED
• Podiatry Department
• Medical teams
• ED Triage Nurses
• ED NP
• ED Liaison Nurses
• Vascular Department TQEH
• Patients!
SA Health
The Diabetes Interdisciplinary Foot Team
> Weekly Clinics
> Attended by • Podiatrists
• Endocrine Physicians
• Vascular Surgeons
• Diabetes Educators
• Hospital at Home
• Infectious Diseases
• Dietician
• Doppler technician
> Foot clinic patients call podiatry if concerned rather than ED
> Direct hospital admissions if required
SA Health
SA Health
SA Health
Results
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10
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70
2012/2013 2013/2014 2014/2015
Number of Referrals
Total Referrals: 136Average Age : 67 years. Range 24-96Male to Female: 96:39 (2.5 x more males)
SA Health
0
20
40
60
80
100
120
Diabetes PVD Neuropathy
0
10
20
30
40
50
60
70
80
90
Risk Factors
Presenting Complaint
SA Health
Discharge Location
0
10
20
30
40
50
60
70
80
SA Health
Treatment received
0
10
20
30
40
50
60
70
80
SA Health
Issues Identified
> Presenting too late
• High number of immediate amputations
• Admissions for IV Abx
> Complex patients
> New patient presentations to Multi-
Disciplinary services
• 18/136 (13.2%) previously known to Foot Clinic
SA Health
Case Studies
> Case One
• Infected toe. T2DM
• Seen in Emergency with plan for admission
• Foot Clinic team called. Infection was
complicated by Ingrown nail.
• Nail removed in ED. Stat dose of IV Abx, Script
for orals
• Follow up appointment in Foot clinic in 1 week
• Pt discharged within one hour of being seen by
Foot team, instead of admission
SA Health
Case Studies
> Case 2
• Infected left foot
• T2Dm, neuropathy, recent trauma
• Immediate referral to Foot team
• Seen within hour by Endo and Podiatry
• Acute new foot ulcer requiring IV Abx, unlikely
to have OM
• H@H team organised by Foot clinic
• Twice daily IV Abx until PICC line available
• Weekly Multi-D Foot clinic appointments to
further monitor, image, offload and manage
diabetes.
SA Health
Case Studies
> Case 3
• Systemically unwell patient with large foot ulcer
• Sepsis caused by gangrenous right foot
• Bone and tendon on view
• Foot team contacted immediately
• Urgent IV Abx and surgery debridement
required
• Photographs taken and sent to offsite vascular
surgeon
• Patient transferred for immediate surgical
intervention that day.
• Timely intervention by the specialist team.
SA Health
Podiatrist Role in ED
> Initial point of contact for Diabetes
Interdisciplinary Foot team
> Independent clinicians who can diagnose
• Specialist wound and foot care
• Imaging – Xray and ultrasound
• Pathology
• Musculoskeletal
• Ingrown nail surgery
• Advanced scope-prescribing
SA Health
The Future
> Increase education sessions
> Advertise further to GPs
> Patient held records
> Potential changes to vascular services
> Management of inpatient journey
> Increased podiatry services to ED
SA Health
References
> Australian Institute of Health and Welfare. Diabetes: Australian facts 2008. Canberra: AIHW, 2008. (AIHW Cat. No. CVD 40; Diabetes Series No. 8.) http://www.aihw.gov.au/publication-detail/?id=6442468075(accessed Mar 2012).
> Shan M Bergin, Jan B Alford, Bernard P Allard, Joel M Gurr, Emma L Holland, Mark W Horsley, Maarten C Kamp, Peter A Lazzarini, Vanessa L Nube, Ashim K Sinha, Jason T Warnock and Paul R Wraight(2012) A limb lost every 3 hours: can Australia reduce amputations in people with diabetes? The Medical Journal of Australia
> http://www.apodc.com.au/wp-content/uploads/2013/03/2012-Federal-Budget-APodC-Submission.pdf
> Armstrong DG, Wrobel J, Robbins JM. Guest editorial: are diabetes related wounds and amputations
worse than cancer? Int Wound J 2007; 4: 286-87.
