r The podiatrists man the clinic’s emergency service throughout the week, and undertake specialist wound care of ulcers, including debridement, plaster casting for indolent ulcers and Charcot osteoarthropathy.
The podiatrists play a part in diagnosing problems, call in other members of the team, as appropriate, and also educate patients, their families and friends and other health care professionals.
They also provide routine preventive foot care. r The physician plays a key role in the diagnosis of foot complications and is also crucial in the diagnosis and management of infection, working closely with the medical microbiologists.
The physician also decides on the need for admission and facilitates this admission, liaises with all members of the foot team and is responsible for the medical care of patients, including the management of diabetes and its complications. r The nurses are also involved in ensuring optimal care of diabetes and its complications and also play an important role in the investigation of the ischaemic patient, using Doppler sonography and transcutaneous oxygen, and also in the assessment and management of the patient with neuropathy including those with painful neuropathy.
The health care assistant prepares the dressing trolleys and also assists in addressing the ulcers. r The orthotists measure and take casts for the manufacture of insoles, shoes, orthotics and braces; they also deliver footwear education to patients and staff.
The orthotists carry out joint consultations in the podiatry rooms and then measure and cast the patients in the orthotists’ rooms, which are adjacent to the foot clinic. r An important role of the surgeon is to take part in joint consultation when the foot is infected and to decide on the need for incision and drainage, surgical debridement and digital or ray amputations.
Historically, in our multidisciplinary team, the orthopaedic surgeon works with the neuropathic patients, and an important role is to assess their suitability for surgical treatment of osteomyelitis.
The vascular surgeon works in conjunction with the interventional radiologist to assess those patients suitable for revascularisation of the ischaemic foot. r The diabetic foot practitioner works closely with the physician and ward staff to ensure that all inpatients receive rapid and optimal treatment, that the feet are inspected on a daily basis so that deterioration or failure to progress are detected quickly, there are no delays in organising investigations, results are acted upon promptly and patients are discharged home, with a good care plan, as quickly as possible, for follow-up in the outpatient diabetic foot clinic. r Other members of the team include the microbiologist, the physiotherapist, the rehabilitation physician and the psychiatrist, whose roles are very important but who often do not work within the foot clinic.
Many of the above roles have changed and developed over time, and some aspects of each role will vary according to the skills and interests of the individual. There may be areas of overlap, and it is important that all members of the team understand the roles of their colleagues
JWBK089-38 JWBK089-Boulton April 22, 2006 18:39 Char Count= 0
422 ASPECTS OF ESTABLISHING A MULTIDISCIPLINARY DIABETIC FOOT CLINIC
and support them where necessary, so that patients and their families receive uniform messages. There is no room for interdisciplinary rivalries within the close team of the diabetic foot clinic.
SUPPORT STAFF
Diabetic foot clinics benefit from the presence of the following support staff, who have the following roles: r The receptionist greets patients on arrival at the clinic, makes appointments, fields telephone calls and extracts and files notes safely and securely.
There is a direct telephone line into the clinic to allow patients to seek immediate advice, in the form of a helpline. r The secretary provides a secretarial and clerical service for the clinical staff, writing and posting letters and reports, organising clinical meetings and courses and contacting other hospital and community staff as necessary. r The managers support the work of the diabetic foot clinic, maintaining its complement of personnel, and support the development of novel procedures and new approaches to the management of the diabetic foot. r The cleaner ensures that the entire department, including clinics, offices, corridors, windows and recreational areas are kept clean and tidy according to local infection-control policies.
THE FOOT CLINIC TIMETABLE It is not possible for the entire team to be working together throughout the entire week, as most people have additional responsibilities and commitments outside the area of diabetic foot disease.
However, it is useful if all members of the team are accessible in emergency, in addition to having a formal commitment to work within the diabetic foot clinic with other team members at certain times.
The podiatrists should be based within the diabetic foot clinic throughout the entire working week, if at all possible, to maintain an emergency diabetic foot service, where ‘walk-in’ patients can be seen immediately.
The consultant physician in our team carries a pager so that he is accessible to give advice at all times.
We do not think it is demeaning for a senior physician to carry a pager, and regard it as an essential practice for the diabetic foot physician to be contactable at all times during the work- ing day.
The physician also works within the diabetic foot clinic for specific sessions during the week, conducts two ward rounds per week and takes part in the joint vascular ward round.
A nursing presence is ideal, as many patients are elderly and ischaemic with multiple co- morbidities.
They are prone to hypoglycaemic episodes of which they are often unaware and which require early diagnosis and intervention.
We often treat infection with intramuscular antibiotics, initially administered in the clinic by the nurses and then given once daily at home by the community nurses.
The orthotists should work within the diabetic foot clinics for a regular period each week and should be available in emergency.
They should keep a supply of shoes and devices so that no patient with a diabetic foot ulcer ever has to leave the clinic wearing the very pair of shoes that caused the ulcer.
JWBK089-38 JWBK089-Boulton April 22, 2006 18:39 Char Count= 0
REFERENCES 423
The surgeons , both vascular and orthopaedic , should attend joint clinics every week, if possible.
We have developed a joint vascular clinic that enables the team to organise rapid vascular assessments including duplex angiography.
A decision is made as to the suitability of angioplasty, and this is now often performed as a day case procedure in the radiology depart- ment.
A vascular radiology meeting attended by the diabetic foot clinic staff together with the interventional radiologist, and vascular laboratory scientists and vascular surgeons, is held ev- ery week, where angiograms are reviewed and joint decisions are made.
Following angioplasty, the patients are followed up closely in the joint vascular clinic.
The joint orthopaedic clinic, which is currently held monthly, reviews patients with indolent neuropathic ulcers and acute Charcot osteoarthropathy and considers whether surgical intervention might be beneficial.
It is important that there is continuity of care for the patient who is admitted from the diabetic foot clinic.
Thus, the consultant physician who works in the foot clinic is also responsible for the care of the patients when they are admitted to the hospital.
The diabetic foot practitioner looks after the feet from day to day and is aided by the nurses from the clinic, who carry out vascular investigations including transcutaneous oxygen measurements.
All diabetic feet on the ward should also be checked every day by a member of the diabetic foot team.
CONCLUSION The pathology of the diabetic foot can be overwhelming.
However, it is not an incurable condi- tion and the outcome of treating diabetic foot problems is related to the amount of care that is given.
With the appropriate diligence and attention to detail, most legs can be saved.
The diabetic ischaemic foot does respond to treatment but does so very slowly, and it is important to have a di- abetic foot clinic in which to monitor and look after these patients on a long-term basis.
Reports from Sweden,3 Denmark,4 Italy5 and the Netherlands6 have also shown a reduction in major am- putations, and all four reports stressed the importance of a multidisciplinary service.
Successful management of the diabetic foot needs the expertise of a multidisciplinary foot care service.