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A consensus document on debridement: an update on progress

The release of the consensus document Principles of Debridement: The Diabetic Foot came as a result of the lack of clarity on the scope of debridement within podiatry, in particular, diabetes foot care (College of Podiatry et al, 2014). Since its release in June 2014, there has been much interest and several conference presentations on this subject. 

The College of Podiatry supports the advancement of podiatrists as recognised clinical specialists within a number of specialist areas and is clear that it views debridement as a core component of podiatry practice within diabetes. Diabetes foot care teams also recognise that debridement is essential at all levels of care from pre-ulceration (removing calluses to reduce high pressure areas), to active foot disease where debridement is essential to remove all necrotic tissue, bio-burden, expose wound dimensions and, ultimately, stimulate a granulating wound bed.

However, debridement is similar to any clinical skill and requires varying levels of competency. For example, the skill level required to remove calluses in the intact foot is less than that required in ulcer management when deeper tissues and structures may need to be debrided. 

Podiatrists who are members of the College are actually insured to debride fingers, lower limb stumps, and anything from the hip to the foot. The critical component is that the podiatrist must have the appropriate skills and underpinning knowledge to manage these. This allows for appropriate autonomy within practice, and we believe that this framework supports this. It sits in parallel with the autonomy we have and equips clinicians with the knowledge of the stages of clinical debridement, from preventative callus removal to more radical debridement.

The consensus development group included a panel of clinical experts who developed an outline document. This then went through an extensive consultation exercise, to which the College of Podiatry and FDUK were key contributors. The latter group is multiprofessional, comprising podiatrists and other eminent professionals within diabetes foot care. 

We believe the final document is representative of modern diabetes foot care. It can be used not only to influence current and future practice, but also protect podiatrists, helping them to identify their individual scope of practice and ensure they are working within recognised levels of practice. 

This competency-based framework approach to debridement is modelled on the Podiatry Competency Framework for Diabetic Foot Care (TRIEPodD-UK, 2012). In a similar format, it is focused on competency levels and should not be confused with NHS Agenda for Change bandings. If a podiatrist does not have the appropriate skill required for a specific competency level, then this document will support and guide them to what is required to achieve that level. 

In addition, it is aimed to protect podiatrists, providing clarity around associated areas such as the rationale for debridement, different techniques, application and the varying levels and pathways of debridement. This guidance can influence our future podiatrists — it shows the profession what is possible, demonstrates the levels of debridement that can be achieved in clinical practice and supports our professional progression of skill levels in a coherent and structured way. 

It has already been established that podiatrists, especially in the UK, can fit naturally into being leaders and experts in the management of diabetes and the lower limb. This management incorporates both hands-on clinical skills, and the skills that are essential to the often complex decision-making these
patients require. 

It only makes sense that we need clarity on what that scope of practice is, to ensure patients are managed in a timely way by the right professional with the appropriate skills. This consensus document can be used as a tool that will enable podiatrists in both the NHS and private sectors not only to define where their scope of practice lies, but it can also provide guidance to those clinicians that wish to develop their skill sets. We envisage that other areas in podiatry will follow suit and use this as a structure to set out the debridement competencies required in their specialist field of practice.

The release of the consensus document Principles of Debridement: The Diabetic Foot came as a result of the lack of clarity on the scope of debridement within podiatry, in particular, diabetes foot care (College of Podiatry et al, 2014). Since its release in June 2014, there has been much interest and several conference presentations on this subject. 

The College of Podiatry supports the advancement of podiatrists as recognised clinical specialists within a number of specialist areas and is clear that it views debridement as a core component of podiatry practice within diabetes. Diabetes foot care teams also recognise that debridement is essential at all levels of care from pre-ulceration (removing calluses to reduce high pressure areas), to active foot disease where debridement is essential to remove all necrotic tissue, bio-burden, expose wound dimensions and, ultimately, stimulate a granulating wound bed.

However, debridement is similar to any clinical skill and requires varying levels of competency. For example, the skill level required to remove calluses in the intact foot is less than that required in ulcer management when deeper tissues and structures may need to be debrided. 

Podiatrists who are members of the College are actually insured to debride fingers, lower limb stumps, and anything from the hip to the foot. The critical component is that the podiatrist must have the appropriate skills and underpinning knowledge to manage these. This allows for appropriate autonomy within practice, and we believe that this framework supports this. It sits in parallel with the autonomy we have and equips clinicians with the knowledge of the stages of clinical debridement, from preventative callus removal to more radical debridement.

The consensus development group included a panel of clinical experts who developed an outline document. This then went through an extensive consultation exercise, to which the College of Podiatry and FDUK were key contributors. The latter group is multiprofessional, comprising podiatrists and other eminent professionals within diabetes foot care. 

We believe the final document is representative of modern diabetes foot care. It can be used not only to influence current and future practice, but also protect podiatrists, helping them to identify their individual scope of practice and ensure they are working within recognised levels of practice. 

This competency-based framework approach to debridement is modelled on the Podiatry Competency Framework for Diabetic Foot Care (TRIEPodD-UK, 2012). In a similar format, it is focused on competency levels and should not be confused with NHS Agenda for Change bandings. If a podiatrist does not have the appropriate skill required for a specific competency level, then this document will support and guide them to what is required to achieve that level. 

In addition, it is aimed to protect podiatrists, providing clarity around associated areas such as the rationale for debridement, different techniques, application and the varying levels and pathways of debridement. This guidance can influence our future podiatrists — it shows the profession what is possible, demonstrates the levels of debridement that can be achieved in clinical practice and supports our professional progression of skill levels in a coherent and structured way. 

It has already been established that podiatrists, especially in the UK, can fit naturally into being leaders and experts in the management of diabetes and the lower limb. This management incorporates both hands-on clinical skills, and the skills that are essential to the often complex decision-making these
patients require. 

It only makes sense that we need clarity on what that scope of practice is, to ensure patients are managed in a timely way by the right professional with the appropriate skills. This consensus document can be used as a tool that will enable podiatrists in both the NHS and private sectors not only to define where their scope of practice lies, but it can also provide guidance to those clinicians that wish to develop their skill sets. We envisage that other areas in podiatry will follow suit and use this as a structure to set out the debridement competencies required in their specialist field of practice.

College of Podiatry, FDUK, TRIEPodD-UK (2014) Principles of Debridement: The Diabetic Foot. Available at: http://bit.ly/1xtJ6x7 (accessed 02.02.15)
TRIEPodD-UK (2012) Podiatry Competency Framework for Integrated Diabetic Foot Care. A User’s Guide. Available at: http://bit.ly/1dDOsfB (accessed 02.02.15)

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