The NADC Collaborative Interdisciplinary Diabetes High Risk Foot Service Standards Professor Stephen Twigg MBBS(Hons-I), PhD(Syd), FRACP Hon. Chair of the NADC Foot Network; Medical Director Dept of Endocrinology and the Diabetes High Risk Foot Service, Royal Prince Alfred Hospital, Sydney; Kellion Professor of Endocrinology, Stan Clark Chair in Diabetes, Faculty of Medicine and Health, Sydney Medical School, Charles Perkins Centre, The University of Sydney NSW AUSTRALIA nadc National Association of Diabetes Centres
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The NADC Collaborative Interdisciplinary Diabetes High Risk Foot Service Standards
Professor Stephen TwiggMBBS(Hons-I), PhD(Syd), FRACPHon. Chair of the NADC Foot Network;Medical Director Dept of Endocrinology and the Diabetes High Risk Foot Service,Royal Prince Alfred Hospital, Sydney;Kellion Professor of Endocrinology, Stan Clark Chair in Diabetes,Faculty of Medicine and Health, Sydney Medical School, Charles Perkins Centre,The University of Sydney NSW AUSTRALIA
nadcNational Association of Diabetes Centres
The Agenda
• The status of diabetes foot care outcomes in Australia
• Integrated foot care as a national health priority, including the importance of diabetes High-Risk Foot Services (HRFS)
• The NADC Foot Network and setting of collaborative interdisciplinary HRFS standards
nadcNational Association of Diabetes Centres
The Agenda
• The status of diabetes foot care outcomes in Australia
• Integrated foot care as a national health priority, including the importance of diabetes High-Risk Foot Services (HRFS)
• The NADC Foot Network and setting of collaborative interdisciplinary HRFS standards
Pressure Off-loading: After Ulcer Healing –including Orthotics and Custom made Footwear
The Ideal Shoe
2015: A document for clinicians and administrators to improvequality, safety and consistency in the delivery of foot care forpatients with serious foot complications.
Aims to improve:ü Patient experiencesü Health outcomesü Effective use of resources
The Agenda
• The status of diabetes foot care outcomes in Australia
• Integrated foot care as a national health priority, including the importance of diabetes High-Risk Foot Services (HRFS)
• The NADC Foot Network and setting of collaborative interdisciplinary HRFS standards
nadcNational Association of Diabetes Centres
National Association of Diabetes Centres -Foot Network (NADC-FN)
MISSIONØTo establish and maintain reduced morbidity and mortality from
diabetes-related foot disease
AIMØTo realise a coordinated national process of prioritising high quality and
accessible foot assessment and management across the spectrum of foot disease in diabetes.
Promoting excellence in diabetes care
National Association of Diabetes Centres -Foot Network (NADC-FN)
Ø NADC FN Working Party (WP) Membership (stakeholders):• National Association of Diabetes Centres• Australian Diabetes Society• Wounds Australia • Advanced Practicing Podiatrists - High Risk Foot Group• Australian Podiatry Council (APodC)• Diabetic Foot Australia (DFA)• Pedorthic Association of Australia (PAA)• Agency for Clinical Innovation (ACI)• Australian Diabetes Educators Association (ADEA)• Australian Primary Care Nurses Association (APNA)• Diabetes, Obesity and Metabolic Translational Research Unit (DOMTRU)
National Association of Diabetes Centres -Foot Network (NADC-FN) Interdisciplinary HRFS
Working Party Initiative • Using a HRFS standards setting document 2015, derived from the NSW State Dept of
Health Agency for Clinical Innovation
• WP consensus review process face to face held on June 23rd, 2017, onwards
• The standards were set with accompanying indicators• Standards and indictors directly translated into a HRFS accreditation program
• Indicators include participating in annual foot audits and collecting a minimal data set
• Two levels of standards established: ‘Core’ and ‘Centre of Excellence’ Standards
• The business case for integrated foot care supporting HRFS can then be further put to local, state and national Health Departments
• A FN Reference Group supports the FN WP as required.
Promoting excellence in diabetes care
The NADC Collaborative Interdisciplinary Diabetes High Risk Foot Service Standards - Finalised
• Consolidated standards:1. Interdisciplinary approach2. Coordination and administration3. Evidence-based clinical management4. Access and defined intake criteria5. Continuity of care and communication6. Equipment7. Wound care 8. Quality improvement
• Core Indicators• Centre of Excellence Indicators
Staff
Equipment
patient outcomes
Processoutcomes
nadcNational Association of Diabetes Centres
…and key additional Collaborators!
The NADC Collaborative Interdisciplinary Diabetes High Risk Foot Service Standards – Finalised and Released!
7. Wound care products- access to and rational use of products
8. Quality improvement- parameters to support internal audits, benchmarking- research and education
•Medical Data
The HRFS Team
Telemedicine in Interdisciplinary HRFS: The ‘hub and spoke’ Concept Realised
DubboLismoreNowraOrange
GraftonPort Macquarie
GriffithForbesQuirindi
Mullumbimby E-mail
NSW Rural and Regional •Standardised wound images
Standard 8 – Data Collection
• Relates to quality improvement for HRFS • Collecting valuable data to assist service development • Quality improvement plans are undertaken and supported by
collecting clinically significant data relevant to the HRFS
nadcNational Association of Diabetes Centres
Service Development
Quality Improvement
Data InterpretationData AnalysisData Collection
Standard 8 - The Challenges
• Data collection is time consuming, onerous • Collaborative input to data fields • Needs to be useful – center dependent • Centre based – not easy to externally benchmark• The future - NADC looking at developing an online data tool to assist
centers to achieve this standard and thrive
nadcNational Association of Diabetes Centres
Standard 8 – Core Service Indicators
• Annual clinical audit• HRFS collects minimum data and develops KPIs – center relevant • Key data are reported, shared with the NADC annually• Quality improvement cycle that addresses any serious adverse event(s)• Routine and ongoing education and professional development in high
risk foot care is provided for all HRFS staff
nadcNational Association of Diabetes Centres
RPA
Less Delay In Presentation of Patients to the Service (Days Between Ulcer Development Historically and HRFS Presentation)
• 1995 - 1999• 55 days [17-140]
• 2000 - 2003• 49 days [22-122]
• 2004 - 2007• 33 days [17-90]
• 2008 - 2012• 30 days [14-66]; since 2012 median has reduced to 18 days.
Ttrend = 3.7, p =0.0002; Bolton T, et al WDC 2014
A Clinical Audit Process Example:RPA Hospital Interdisciplinary High Risk Foot Service: Longer Term Data
RPA
Time to Access Interdisciplinary HRFS Care Relates to Ulcer Severity
00.10.20.30.40.50.60.7
Months
0 1 2 3
Grade
Bolton T et al., ADA Abs 2013; IDF Abs 2014 n=1486 Foot ulcers
Standards Facilitate Accreditation
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‘One Vision’ – Australian Diabetes HRFS Standards Accredited Sites
Belgium
Morbach S. et al
In some initial investigations, the NADC located 120 services that either identify themselves as HRFS or offer services to individuals at high risk.
‘Core Centres’, and ‘Centres of Excellence’
One ‘vision’
Health Care Professional Educational Projects:ADS NDSS - Promoting Optimal Diabetes Foot Care
https://diabetessociety.com.au/diabetesfoot/
• The Foot Examination
• Preventive foot care
• Managing basic diabetes foot complications
• State-based and national programs for interdisciplinary HRFS• Incl. Best Practice in Diabetes Centres Workshops
Audiovisual resources:
Supportive Regional and International Approaches
IDF-Western Pacific Region- Train the Foot Trainer Foot Care Education International Working Group on the Diabetic Foot
Major Challenges in Diabetes Foot Care in Australia Can be Realised
Ø The geography and fewer people living in rural areas
ØRoutine stratifying foot complications risk in people with diabetes
Ø Preventive foot care specifically for those at increased risk
Ø Providing timely access to accredited diabetes interdisciplinary high risk foot services
Ø Achieving sustained outcomes in diabetes HRFS
Ø Providing efficient hospital inpatient foot care in diabetes and integrated care across systems
Ø Adequate funding models and incentives at all levels
ØContinuing education to clinicians and patients Adapted: Bergin SM et al. Med J Aust. 2012;197(4):226-9; Lazzarini P et al MJA 2018
The Agenda - Realised
• The status of diabetes foot care outcomes in Australia addressed
• Described integrated foot care as a national health priority, including the importance of diabetes High-Risk Foot Services (HRFS)
• The NADC Foot Network and setting of collaborative interdisciplinary HRFS standards
nadcNational Association of Diabetes Centres
AcknowledgementsØNational bodies:
• The National Association of Diabetes Centres and the Australian Diabetes Society§ Ms Natalie Wischer, Ms Leanne Mullan, Michaela Watts§ Prof. Sophia Zoungas, Prof. Sof Andrikopoulos, Prof. Jonathan Shaw
• NADC FN Working Party and Reference Group members• Kellion Diabetes Foundation • Diabetes Australia Ltd: A/Prof. Greg Johnson• National Diabetes Services and Supply scheme• Federal Dept of Health and Ageing• NHMRC of Australia
ØState Bodies:• ACI Network NSW Dept of Health• NSW Diabetes Task Force
ØLocal bodies:• Ms Vanessa Nube, Head of Podiatry, SLHD and NSW DoH ACI FN Co-chair• Diabetes Centre, Dept of Endocrinology, Royal Prince Alfred Hospital, Sydney• Maari Ma Aboriginal Health Service, Broken Hill, NSW