Implementation of Clinical Guidelines. London: Royal College of General Practitioners; 1995.
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38 Practical Aspects of Establishing a Multidisciplinary Diabetic Foot Clinic M. Edmonds and A. Foster
INTRODUCTION When the diabetic foot clinic at King’s College Hospital was set up in 1981, it led to a 50% reduction in major amputations and was able to prevent almost all major amputations of neuropathic feet.1 With the onset of modern techniques to revascularise the ischaemic leg and active management of early infection, it was able to achieve a further 50% reduction in major amputations of the ischaemic foot.2 In this chapter, we discuss both the setting up of this diabetic foot clinic and the manner in which the clinic has grown, changed and gradually evolved over many years.
The main thrust of the clinic has been to provide rapid multidisciplinary treatment to patients with active foot problems and then to follow them up to attempt to prevent recurrence.
It has acted as a first-aid centre for patients who can attend in an emergency without an appointment.
This is a crucial part of its role, as diabetic foot problems progress extremely quickly.
Delays of a few days, and sometimes a few hours, cannot be accepted.
The diabetic foot can deteriorate with alarming rapidity, and any delays can lead to the loss of a leg that could have been saved, or to the need for many months of treatment for ulcers and infections, or to the death of the patient.
The clinic has also acted as a focal point for regular follow-up treatment of diabetic patients, who identify the diabetic foot clinic as a specific forum committed to the care of the foot.
While the situation we describe is not, of course, the only way of organising care for patients with diabetic foot problems, the multidisciplinary, hospital-based diabetic foot clinic has proved to be a very successful way of reducing amputations and improving outcomes for diabetic patients with foot problems.
WHAT ARE THE AIMS OF A DIABETIC FOOT CLINIC? The aims of the King’s College Hospital diabetic foot clinic have been twofold: first, to provide the best possible multidisciplinary care for patients with foot problems, and secondly, to
The Foot in Diabetes, 4th Edition. Edited by Andrew J.M. Boulton, Peter R. Cavanagh and Gerry Rayman. C 2006 John Wiley & Sons, Ltd. ISBN: 0-470-01504-7
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WHERE TO SITE THE DIABETIC FOOT CLINIC 419
investigate the pathogenesis of these problems and to research new treatments. The natural history of the diabetic foot is to progress from the at-risk foot to ulceration and then to infection and necrosis. The aim is to intervene early and to prevent further progression by close attention to the wound, and to the microbiological, mechanical, vascular, metabolic and educational aspects of treatment. The specific aims are
r to provide good wound care including sharp debridement, dressings and advanced wound healing products; r to diagnose infection early and treat it aggressively; r to provide an efficient offloading service by the provision of footwear education, footwear, orthotics, braces and casts; r to diagnose ischaemia early and to manage it aggressively; r to encourage patients to achieve optimal metabolic control of hyperglycaemia, hypertension, hyperlipidaemia and encourage patients to cease smoking; r to educate patients, their families, their friends and other health care professionals in ways of preventing and treating diabetic foot problems.
An important role of the diabetic foot clinic is to research into the pathogenesis and treat- ment of diabetic foot problems. Foot clinics should investigate new treatments. In order to carry out useful research, it may be necessary to link up with other diabetic foot clin- ics so as to carry out multicentre studies that are sufficiently powered to give meaningful results.
WHERE TO SITE THE DIABETIC FOOT CLINIC The authors strongly believe that optimal management of the foot with problems is in the hospital-based diabetic foot clinic.
It needs to be able to manage emergencies by having the capability to perform urgent investigations, carry out debridements, start immediate antibiotics, including parenteral antibiotics, organise rapid vascular and orthopaedic opinions and arrange emergency admissions.
The clinic ideally should be open 5 days a week and be sited on the ground floor with easy wheelchair access.
Arrangements should be made for diabetic foot emergencies, which present in the evenings or weekends to be seen in the emergency department.
The physician who started our diabetic foot clinic worked within a hospital with support from podiatrists, orthotists, surgeons and nurses, and it was therefore decided that the foot clinic should be based at the hospital.
This prevented the need for extra staff-travelling time, avoided the necessity of expensive duplication of services such as X-ray, microbiology and other investigative methodologies and made it much easier for the team members to make extra visits to the clinic at short notice.
Specimens could be delivered and reported on without delays.
Investigations could be undertaken without necessitating yet another journey to a different site for the patient.
Rapid admissions and support for very sick patients were quickly available, and as the clinic grew over the years and the proportion of patients who were ischaemic increased, this aspect of work of the clinic became very important.
An established diabetic foot clinic
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420 ASPECTS OF ESTABLISHING A MULTIDISCIPLINARY DIABETIC FOOT CLINIC
will succeed in salvaging many diabetic feet in patients who will continue to attend the foot clinic for the rest of their lives, and will eventually suffer from peripheral vascular disease together with most or all the complications of diabetes.
The diabetic foot clinic is a magnet for the most frail and complicated of diabetic patients.
These patients, if they develop a diabetic foot infection, can become destabilised and very sick with alarming rapidity.
Timely access to support services is thus essential.
WHAT IS A MULTIDISCIPLINARY DIABETIC FOOT CLINIC?
Establishing a multidisciplinary diabetic foot clinic involves the setting up of a clinical area where different members of the multidisciplinary team will work together within the same space at the same time.
A podiatrist working in a separate room within a diabetic clinic is not the ideal diabetic foot clinic.
A diabetic foot clinic is a place where patients can regularly be seen by multidisciplinary team members who work together regularly, at specific times, within the same clinic and usually within the same clinical room, and where multidisciplinary case conferences can be conducted.
In 1981, our first diabetic foot clinic was based within the podiatry room at our hospital, where a joint clinic was held on Thursday mornings with a physician, a podiatrist, an orthotist and a surgeon.
It was born out of a desire of these professionals to work together on a regular basis.
Subsequently, there was an ever-increasing number of new referrals and this resulted in the clinic being held, eventually, throughout the week.
Now the podiatry room is an open layout room with five podiatry chairs where podiatric treatment and casting and multidisci- plinary consultations are carried out.
The open plan layout of the room is to accommodate relatives, who take part in the care of the patient, and visitors to the clinic, including commu- nity and hospital staff and students from all disciplines.
The benefits of privacy and separate treatment cubicles must be weighed against the advantages of a large open plan room where patients and staff can gain valuable lessons from observation, and where it is easier for the multidisciplinary team to work together.
In the presence of neuropathy and ischaemia, there is lack of usual signs and symptoms, and diagnosis is difficult.
Thus, joint consultation between the disciplines is helpful.
If a large, open plan approach is chosen, then this area can double up as an education room.
The need for good infection control procedures is of key impor- tance within the diabetic foot clinic.
We have held separate clinics for patients known to have methicillin-resistant Staphylococcus aureus (MRSA) infection or other infections with resistant organisms.
In 1983, an investigations room was added to the diabetic foot clinic, to facilitate neu- rological and vascular investigations.
It is now equipped with a neurothesiometer, thermal discrimination equipment and Doppler stethoscopes to measure ankle, brachial pressure in- dex, toe, brachial pressure index and also an apparatus to measure transcutaneous oxygen.
The investigations room also contains a small inner room for confidential discussions with patients and/or relatives.
The work of the diabetic foot clinic should not be confined to management of diabetic foot outpatients: it should also take part in the management of patients who are admitted as inpatients, working closely with staff on the ward.
Ward staff may include a ‘diabetic foot practitioner’.
This is a new role, which overlaps aspects of the roles within podiatry, nursing and medicine, and the diabetic foot practitioner works closely with the physician and surgeon on the wards.
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CLINICAL STAFF AND THEIR ROLES WITHIN THE DIABETIC FOOT CLINIC 421
CLINICAL STAFF AND THEIR ROLES WITHIN THE DIABETIC FOOT CLINIC In our diabetic foot clinic, we have established the following clinical roles for staff members: