Tackling the “elephant” in the diabetic foot clinic: Raising awareness of associated modifiable risks in people with diabetic foot ulcers
Martin Fox
Vascular Specialist Podiatrist, Pennine Acute Hospitals Trust
When I first saw the Urgo Foundation innovation award call for projects, I knew it could be the perfect support platform for doing some work on a key issue within the diabetic foot population that has been increasingly concerning me. I would strongly suggest this issue is the invisible “elephant” in the room: in our clinics, in our discussions with patients and in our written patient support information.
It is, of course, the thorny, scary and difficult-to-broach issue of early deaths among people with diabetes and foot disease. An issue I have been attempting to tackle myself over the past decade, with very little (if any) guidance, is whether,
how and when to discuss this with patients and carers.
Amputation rates — the relatively visible, noisy, little brother of death in the diabetes foot outcomes family — has arguably been getting a disproportionate chunk of our energy and resources in diabetes provision for the past 20 years. There has been very little visible information for our patients in the current generation of patient information posters and leaflets on the relative risks of associated early death and amputation, or how these risks can be effectively reduced. Surely it is time we evened it out a little, clarified the associated life- and limb-threatening risks with our patients, and gave them context and control over how they can decide to best deal with them?
It is also clear from the Natoinal Institute for Health and Care Excellence (NICE, 2012) guidance that we are now expected to deliver a patient experience that meets the following three quality standards:
- Patients are supported by healthcare professionals to understand relevant treatment options, including benefits, risks and potential consequences
- Patients are actively involved in shared decision-making and supported by healthcare professionals to make fully informed choices about investigations, treatment and care that reflect what is important to them
- Patients are made aware that they have the right to choose, accept or decline treatment, and these decisions are respected and supported.
With all this in mind, I approached the Urgo application panel for some resources to create a visible awareness-raising campaign, targeting people with diabetes and foot ulcers and the clinical teams who provide treatment for them.
The aims of my project were to:
- Create an eye-catching poster campaign that raises awareness about the risks of death and amputation, informs people that these risks can be dramatically reduced, and prompts them to ask for more information
- Develop a patient information leaflet and care plan for people with diabetes and foot ulcers, which can be used alongside existing information resources to help explain the common, modifiable vascular risks associated with death and amputation and focus on clear targets, giving patients context and choice about which risks they want to tackle, when and how
- Produce a clinician support sheet with advice on facilitating difficult initial and ongoing discussions with patients about the associated risks of early death and amputation, risk-reduction choices and available support.
Prior to submitting the project application, I ‘road tested’ the concept to see if my peers working in diabetic foot clinics in north-west England and via the national FDUK network would want the poster, leaflet and support information packs for their clinics. Without their support and commitment to bring the campaign into their clinics and waiting areas, it would be very hard to get it to the target patient audience. I used a SurveyMonkey.com questionnaire and the result was a resounding “yes” (Figure 1). The response from my peers gave me the confidence and energy to submit an application for the Urgo Foundation Award.
To be fair, I did not think my project would fit the award remit: as it is not directly associated with foot ulcer management. After being short-listed for a thorough grilling by their expert panel, I was then surprised and delighted to be offered the award with both the resources and support that came with it. It is an absolute credit to Urgo that they have invested in supporting a broad range of clinical innovation projects around diabetic foot care with this annual worldwide award, working in partnership with frontline clinicians.
As the project prize monies had been divided between two winners this year, I revised my project plan to suit the £10,000 budget. A significant proportion of this money was allocated to releasing me from my NHS commitments, to put time into the concept development. I chose to aim to put in 1–2 days per month, which has worked well.
To help greatly within the award resources, Urgo then put me in touch with a creative marketing company they work with, who agreed to donate some of their expertise and time to the campaign. It works with companies on creative visual projects and has lots of experience in creating award-winning visual communication campaigns. Via telephone meetings and email communication of my concept brief and draft ideas, staff listened, challenged and moulded the original “Did you know…” concept into a few possible variants, including the “This is your early warning system” concept that I eventually settled on (Figure 2). Their constructive, thoughtful input and key advice to “believe fully in what I was doing” has been invaluable during the concept development phase of the project.
Urgo supported my attendance at the International Diabetic Foot Symposium in Den Haag in June 2015. This was valuable and timely in that my networking within the symposium gave me two very valuable insights:
There were no highly visible information, research, audit or presentations on the theme of informing people with diabetic foot disease about their disease outcomes
Discussion with a health psychologist working with the diabetic foot clinic in Edinburgh gave me some important pointers on how to word the patient information leaflet to help encourage engagement with patients about realistic, small goal setting and negotiated change choices.
Another very important element of the project during the concept development phase has been attending an Amputee Support Group, facilitated by vascular nurse specialist Debbie Ruff at Oldham Royal Infirmary, to discuss the campaign concept and draft posters/leaflets. This group has provided me with essential stakeholder input from patients and carers who have lived through lower-limb amputation. Their support for the central campaign concept of openly and actively comparing the mortality outcomes associated with lower-limb disease and vascular disease to the outcomes of cancer, was a game-changer in helping me to decide to continue with this theme.
A significant minority of healthcare professionals working in diabetes care have voiced concern about using the comparison between mortality rates from cancer and following diabetes-related lower-limb amputation (although it is common in the literature). Their concerns were about scaring patients and families and not being sure of if, how and when to discuss it. The clear message from patients and carers, however, is that this message needs to get out loud and clear, earlier in the disease, before limbs and lives are lost. This message is reflected in the cancer literature where more formal academic analysis has suggested that “most cancer patients want detailed prognostic information but prefer to negotiate the extent, format, and timing of the information they receive” (Hagerty et al, 2004).
The Amputee Support Group also helped me to decide to simplify the campaign target audience to just people with diabetes and foot ulcers. I had originally wanted to include people with peripheral arterial disease as well, but after consulting, I felt that this might complicate the campaign somewhat. The peripheral arterial disease campaign will have to wait for another opportunity.
A further SurveyMonkey.com questionnaire I sent out to key podiatrists nationally and regionally who work in diabetes care has reinforced their commitment to taking on the campaign and using it in their own clinics (Figure 3). Their responses and comments have also helped me to fine-tune the key campaign visuals and messages.
The “This is your early warning” diabetes foot ulcer risk awareness raising campaign will be showcased at the Wounds UK/FDUK Conference in Harrogate in November 2015. The posters, patient information leaflets, care plans and clinician support sheets, when finalised, will then be made available for interested diabetes foot teams to adopt and introduce.
It is hoped that this campaign will raise awareness of the “elephant in the room” of diabetic foot disease, allowing patients and carers to become more informed and engage in positive health change discussions with healthcare professionals when they feel ready — discussions that have the
potential to help reduce related morbidity and mortality.
Acknowledgments and thanks
The Urgo Foundation Team; Amputee Support Group — Pennine Hospitals Acute Trust; Lisa Smith and Debbie Ruff, vascular nurse specialists, Pennine Acute Hospitals Trust; and Emily McBride, health psychologist.
Diabetic foot ulcers: Back to basics
Alexandra Whalley
Advanced Podiatrist, Diabetes, Bolton Diabetes Centre, Bolton Foundation Trust
In 2013, I was lucky enough to be sponsored by Urgo to attend the Wounds UK/FDUK Conference in Harrogate, as I had been successful in my submission of a poster to the conference. I was invited to the gala dinner and it was at this event that the successful 2013 Urgo Foundation Award candidate was announced. The winner was a tissue viability team from Leeds who were planning research into the problems associated with pressure sores experienced by wheelchair-bound athletes, their inspiration being the previous year’s London 2012 Paralympics. The research proposal looked really exciting and the winning team showed such passion in presenting their ideas.
That evening, the 2014 Urgo Foundation prize was launched with the specific objective of supporting innovative and original projects on diabetic foot ulcer care. The prize fund was £20,000 dedicated to supporting research. With my background as a specialist podiatrist, working within a consultant-led, multidisciplinary diabetes team, I was immediately inspired to submit an application.
The online application form was straightforward and relatively easy to complete. Applicants were asked to give a brief overview of the project (the idea, target population, justification, development and resources/budget).
Following the submission deadline, three successful applicants were to be shortlisted and asked to prepare their projects in greater detail with a view to presenting to the Urgo Foundation Award board. A couple of weeks later, I received a letter to say I was one of the successful applicants and I was invited to present my project to the board in Manchester.
Panic then ensued. The invitation to present to the board had requested that I elaborate on a few points from my application. The time slot I was given was 45 minutes, which was to include my presentation and any questions from the board. Having the support of the wider team and knowing that I was passionate and extremely knowledgeable about my project, I decided that I had nothing to lose having come this far.
Having prepared a short presentation (taking care to answer the key points as requested), I asked one of the consultants in my multidisciplinary team to accompany me on the day for moral support and to help with any difficult questions. Looking back, he struggled to get a word in edgeways!
On the day, I was last to present to the board. The timetable was running about 40 minutes late and I was starting to get a little nervous. Martin Fox appeared from the room following his presentation and reassured me that all had gone well.
The panel included Professor Mike Edmonds, Dr Joanne McCardle, Dr Paul Chadwick, Jill Cundell and representatives from Urgo. I was made to feel very welcome and, after introductions, launched into my presentation. The panel asked probing questions and were able to offer their advice regarding my proposal.
The following day, I was contacted by Urgo with the exciting news that my project had been accepted and that the grant was to be shared between myself and Martin Fox (£10,000 each). I was thrilled and honoured to have been successful in my application.
I have been employed by the NHS in Bolton since qualifying in 1991. It was one of the first NHS trusts to establish a podiatry-led, foot-screening service for diabetes. At that time, as part of the North West Diabetes Foot Care Study (Abbott et al, 2002), we demonstrated that foot screening resulted in a lower incidence of foot ulceration. In line with NICE’s diabetic foot care guidelines (NICE, 2004), we have an established foot protection team within the community setting and a multidisciplinary footcare team based over two sites (Bolton Diabetes Centre and Royal Bolton Hospital).
Due to restructuring and re-profiling of NHS services over more than 20 years, diabetes podiatry services in Bolton have changed quite dramatically. One podiatry team working across both the hospital and community settings became two teams (one community-based and one hospital-based), contracted by two separate trusts. The podiatry-led foot screening service at GP surgeries became a joint eye and foot screening service delivered by retinal screening technicians who are fully supported by podiatrists experienced in diabetes care. These background, organisational changes mirror the experiences of many of my colleagues working in the NHS and can be confusing and unsettling for staff, as well as patients.
In Bolton, there are now approximately 19,300 people registered with diabetes, representing 7.2% of the total population (Bolton Diabetes Register, 2015). Despite the services described, foot ulcer incidence data show the ulceration rate is rising in Bolton (Figure 4). To understand these data further, there is a need to review local diabetes footcare pathways and ask key questions, including:
- Do patients with diabetes have knowledge and understanding of their risk of foot complications?
- Do we provide an accurate and efficient foot screening service?
- Do we offer timely, preventative podiatry-based interventions in patients at risk of foot complications?
- Do we have clear pathways of care that patients and healthcare professionals understand and use?
- Are we doing enough to prevent new foot ulcers or do we need to ‘go back to basics’?
With this in mind, I aim to perform a root cause analysis on all cases referred to Bolton Diabetes Centre presenting with a foot ulcer for the first time in my Urgo Foundation project. As part of the analysis, patients will be asked a series of questions to determine their knowledge regarding foot screening, risk status, education, podiatry treatment and what to do in the event of a foot-related emergency. Data will then be collected regarding their foot screening, interventions from the foot protection team, timescales from first presentation of ulcer to assessment by the multidisciplinary footcare team, along with cardiovascular and diabetes control data.
The study aims to focus on the quality of care for people with diabetes, clinical pathways and empowering patients to understand their condition. The key objective is to ensure that podiatric care for people with diabetes in Bolton is of the highest quality and meets the patients’ clinical needs, with the further intention of sharing any lessons learned with other diabetic footcare providers.
The £10,000 received from Urgo has provided the funding to backfill my clinical time while I undertake this important study. Urgo, along with the award board, are reassuringly always at hand to offer advice, support and their expertise along the way. I would urge anyone who is thinking about applying for the grant in the future to most definitely give it a go. The icing on the cake was a dance with Olympic swimmer and BBC One’s Strictly Come Dancing star, Mark Foster, who presented my award at last year’s Wounds UK/FDUK conference (Figure 5)!
Work on the project continues. Initial findings have already highlighted some common themes and areas of concern, in particular patients’ perception of foot screening (i.e. the lack of understanding in relation to the importance of foot screening, the implications of their risk status, the potential consequences and what to do in the event of an emergency).
We aim to highlight and address some of these key issues in a number of ways, including a diabetic foot awareness campaign, improved structured patient education/literature, and ensuring patients receive timely and appropriate preventative podiatric care (in line with both their clinical needs and identified risk status). We also want to ensure we meet all the criteria as per the recently-published NICE guidance (NICE, 2015) and the ‘Putting Feet First’ campaign (Diabetes UK, 2012).
By improving patients’ understanding, perception of foot screening and associated risks in conjunction with appropriate clinical interventions we hope to see a reduction (via on-going audit) in the incidence of foot ulceration, particularly among those people who have never had a previous foot ulcer. We hope to present our results and lessons learned in 2016. Once again thanks to the Urgo Foundation for its continued support.
