Standardising practices improves clinical diabetic foot management: the Queensland Diabetic Foot Innovation Project, 2006–09
Peter A. Lazzarini A B G , Sharon R. O’Rourke C , Anthony W. Russell D , Patrick H. Derhy E and Maarten C. Kamp FA Allied Health Research Collaborative, Metro North Health Service District, The Prince Charles Hospital, Rode Road, Chermside, Qld 4031, Australia.
B School of Public Health, Queensland University of Technology, Kelvin Grove Campus, Kelvin Grove, Qld 4059, Australia.
C Diabetes Centre, Cairns, Queensland Health, PO Box 902, Cairns, Qld 4870, Australia. Email: sharon_o’rourke@health.qld.gov.au
D Princess Alexandra Hospital and School of Medicine, University of Queensland, Ipswich Road, Woolloongabba, Qld 4102, Australia. Email: anthony_russell@health.qld.gov.au
E Patient Safety & Quality Improvement Service, Centre for Healthcare Improvement, PO Box 128, Herston, Qld 4029, Australia. Email: patrick_derhy@health.qld.gov.au
F Metro North Health Service District, Queensland Health & School of Medicine, University of Queensland, Butterfield Street, Herston, Qld 4029, Australia. Email: maarten_kamp@health.qld.gov.au
G Corresponding author. Email: peter_lazzarini@health.qld.gov.au
Australian Health Review 36(1) 8-15 https://doi.org/10.1071/AH10978
Submitted: 10 November 2010 Accepted: 25 July 2011 Published: 24 February 2012
Abstract
Objective. The aim of this paper is to report the clinical practice changes resulting from strategies to standardise diabetic foot clinical management in three diverse ambulatory service sites in Queensland, Australia.
Methods. Multifaceted strategies were implemented in 2008, including: multidisciplinary teams, clinical pathways, clinical training, clinical indicators, and telehealth support. Prior to the intervention, none of the aforementioned strategies were used, except one site had a basic multidisciplinary team. A retrospective audit of consecutive patient records from July 2006 to June 2007 determined baseline clinical activity (n = 101). A clinical pathway teleform was implemented as a clinical activity analyser in 2008 (n = 327) and followed up in 2009 (n = 406). Pre- and post-implementation data were analysed using Chi-square tests with a significance level set at P < 0.05.
Results. There was an improvement in surveillance of the high risk population of 34% in 2008 and 19% in 2009, and treating according to risk of 15% in 2009 (P < 0.05). The documentation of all best-practice clinical activities performed improved 13–66% (P < 0.03).
Conclusion. These findings support the use of multifaceted strategies to standardise practice and improve diabetic foot complications management in diverse ambulatory services.
What is known about the topic? Diabetic foot complications are recognised as the most common reason for diabetes-related hospitalisation and lower extremity amputations. Approximately 20% of people with diabetes in Australia are at risk of developing a diabetic foot ulcer. Multifaceted strategies to reduce diabetic foot hospitalisation and amputation rates have been successful. However, most people with diabetic foot ulcers are managed in ambulatory settings where data availability is poor and studies limited.
What does this paper add? This paper demonstrates that significant improvements in evidence-based diabetic foot complication management can be achieved in diverse Australian ambulatory care settings with multifaceted strategies. This paper contributes to the body of knowledge regarding diabetic foot clinical management in ambulatory settings.
What are the implications for practitioners? Practical strategies are available to improve clinical management across a variety of ambulatory settings. Substantial literature suggests this should translate to reduced rates of hospitalisation and amputation for diabetic foot complications.
Additional keywords: ambulatory, clinical practice, foot ulcer.
References
[1] Diabetes: Australian facts 2008. Canberra: Australian Institute of Health & Welfare; 2008. Available at http://www.aihw.gov.au/publications/cvd/daf08/daf08.pdf [verified 19 December 2011].[2] Lawrence SM, Wraight PP, Campbell DA, Colman PG. Assessment and management of inpatients with acute diabetes-related foot complications: room for improvement. Intern Med J 2004; 34 229–33.
| Assessment and management of inpatients with acute diabetes-related foot complications: room for improvement.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BD2c3ltlSktw%3D%3D&md5=d02554f7e18b2a719c8bb7e016922316CAS | 15151667PubMed |
[3] National evidence based guidelines for the management of type 2 Diabetes Mellitus (NHMRC endorsed) –part 6: identification & management of diabetic foot disease. Diabetes Australia; 2005. Available at http://www.nhmrc.gov.au/publications/synopses/_files/di12.pdf [verified 19 December 2011].
[4] National Diabetes Services Scheme (NDSS). Australian diabetes map. http://www.ndss.com.au/Australian-Diabetes-Map/Map/ [verified 19 December 2011].
[5] Singh N, Armstrong DG, Lipsky BA. Preventing foot ulcers in patients with diabetes. JAMA 2005; 293 217–28.
| Preventing foot ulcers in patients with diabetes.Crossref | GoogleScholarGoogle Scholar | 1:CAS:528:DC%2BD2MXktVyqtA%3D%3D&md5=8e1f49dc1f10bb08e14210fa6961cc8eCAS | 15644549PubMed |
[6] Tapp RJ, Shaw JE, de Courten MP, Dunstan DW, Welborn TA, Zimmet PZ. Foot complications in type 2 diabetes: an Australian population-based study. Diabet Med 2003; 20 105–13.
| Foot complications in type 2 diabetes: an Australian population-based study.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BD3s%2FntFehug%3D%3D&md5=9c5ec1d36890abe35e2f22d3001a7d82CAS | 12581261PubMed |
[7] van Houtum WH, Rauwerda JA, Ruwaard D, Schapper NC, Bakker K. Reduction in diabetes-related lower-extremity amputations in the Netherlands: 1991–2000. Diabetes Care 2004; 27 1042–6.
| Reduction in diabetes-related lower-extremity amputations in the Netherlands: 1991–2000.Crossref | GoogleScholarGoogle Scholar | 15111518PubMed |
[8] Patout CA, Birke JA, Horswell R, Williams D, Cerise FP. Effectiveness of a comprehensive diabetes lower-extremity amputation prevention program in a predominantly low-income African-American population. Diabetes Care 2000; 23 1339–42.
| Effectiveness of a comprehensive diabetes lower-extremity amputation prevention program in a predominantly low-income African-American population.Crossref | GoogleScholarGoogle Scholar | 10977029PubMed |
[9] Canavan RJ, Unwin NC, Kelly WF, Connolly VM. Diabetes- and nondiabetes-related lower extremity amputation incidence before and after the introduction of better organized diabetes foot care: continuous longitudinal monitoring using a standard method. Diabetes Care 2008; 31 459–63.
| Diabetes- and nondiabetes-related lower extremity amputation incidence before and after the introduction of better organized diabetes foot care: continuous longitudinal monitoring using a standard method.Crossref | GoogleScholarGoogle Scholar | 18071005PubMed |
[10] Trautner C, Haastert B, Mauckner P, Gatcke LM, Giani G. Reduced incidence of lower limb amputations in the diabetic populations of a German city, 1990–2005: results of the Leverkusen Amputation Reduction Study (LARS). Diabetes Care 2007; 30 2633–7.
| Reduced incidence of lower limb amputations in the diabetic populations of a German city, 1990–2005: results of the Leverkusen Amputation Reduction Study (LARS).Crossref | GoogleScholarGoogle Scholar | 17644615PubMed |
[11] Wraight PR. Improving clinical outcomes for patients with diabetes related foot complications. 2005. PhD dissertation, The University of Melbourne.
[12] Jessup RL, Spring AA, Grollo A. Current practice in the assessment and management of acute diabetes-related foot complications. Aust Health Rev 2007; 31 217–22.
| Current practice in the assessment and management of acute diabetes-related foot complications.Crossref | GoogleScholarGoogle Scholar | 17470042PubMed |
[13] McGill M, Nube V, Clingan T, Constantino M, Bolton T, Palmer E, Yue D. Diabetes amputation program: a structured systematic approach. The Diabetic Foot 2003; 6 172–6.
[14] Perrin B. A retrospective audit of a diabetic foot clinic. Australas J Podiatr Med 2006; 40 23–9.
[15] Ogrin R, Miller J, Tennant J. Lessons to be learnt from data collection in a high risk foot clinic. Prim Intent 2007; 15 96–104.
[16] Tapp RJ, Zimmet PZ, Harper CA, de Courten MP, Balkau B, McCarty DJ, Taylor HR, Welborn TA, Shae JE. Diabetes care in an Australian population: frequency of screening examinations for eye and foot complications of diabetes. Diabetes Care 2004; 27 688–93.
| Diabetes care in an Australian population: frequency of screening examinations for eye and foot complications of diabetes.Crossref | GoogleScholarGoogle Scholar | 14988286PubMed |
[17] McDermott RA, Tulip F, Schmidt B. Diabetes care in remote northern Australian Indigenous communities. Med J Aust 2004; 180 512–6.
| 15139828PubMed |
[18] Porter C, Greenfield C, Larson A, Gilles M. Improving GP diabetes management – a PDSA audit cycle in Western Australia. Aust Fam Physician 2009; 38 939–44.
| 19893848PubMed |
[19] Ellis E, Ballance K, Lunt H, Lewis D. Diabetes outpatient care before and after admission for diabetic foot complications. J Wound Care 2010; 19 150–2.
| 1:STN:280:DC%2BC3c3kvFaiuw%3D%3D&md5=c37053cc55e5d8c9060715c4bbbeb7b7CAS | 20379126PubMed |
[20] Del Aguila MA, Reiber GE, Koepsell TD. How does provider and patient awareness of high-risk status for lower extremity amputation influence foot-care practice? Diabetes Care 1994; 17 1050–4.
| How does provider and patient awareness of high-risk status for lower extremity amputation influence foot-care practice?Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DyaK2M%2FnvF2hsQ%3D%3D&md5=7b9c9fcfb8ea13f97f3bdc6277fe8d48CAS | 7988305PubMed |
[21] Bergin SM, Brand CA, Colman PG, Campbell DA. An evaluation of community-based resources for management of diabetes-related foot disorders in an Australian population. Aust Health Rev 2009; 33 671–8.
| An evaluation of community-based resources for management of diabetes-related foot disorders in an Australian population.Crossref | GoogleScholarGoogle Scholar | 20166917PubMed |
[22] Wrobel JS, Charns MP, Diehr P, Robbins JM, Reiber GE, Bonacker KM, Haas LB, Pogach L. The relationship between provider coordination and diabetes-related foot outcomes. Diabetes Care 2003; 26 3042–7.
| The relationship between provider coordination and diabetes-related foot outcomes.Crossref | GoogleScholarGoogle Scholar | 14578237PubMed |
[23] Maher L, Gustafson D, Evens A. NHS sustainability model. NHS Institute for Innovation and Improvement; 2007. Available at www.institute.nhs.uk/sustainability [verified 7 February 2012].
[24] Type 2 diabetes – prevention and management of foot problems: clinical guideline 10. National Institute for Clinical Excellence (NICE); 2004. Available at http://www.nice.org.uk/CG010NICEguideline [verified 7 February 2012].
[25] International Working Group on the Diabetic Foot. Diabetes and foot care: time to act. Brussels: International Diabetes Federation; 2005.
[26] Wraight PR, Lawrence SM, Campbell DA, Colman PG. Creation of a multi-disciplinary, evidence-based, clinical guideline for the assessment, investigation and management of acute diabetes related complications. Diabet Med 2005; 22 127–36.
| Creation of a multi-disciplinary, evidence-based, clinical guideline for the assessment, investigation and management of acute diabetes related complications.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BD2M%2FjsVSktw%3D%3D&md5=6d6f7c80b78816836f5875f8bac26f4aCAS | 15660728PubMed |
[27] Antibiotic version 13, 2006. In eTG complete [Internet]. Melbourne: Therapeutic Guidelines Limited. Available at https://online-tg-org-au.cknservices.dotsec.com/ip/ [verified 19 December 2011].
[28] Schaper NC. Diabetic foot ulcer classification system for research purposes: a progress report on criteria for including patients in research studies. Diabetes Metab Res Rev 2004; 20 S90–5.
| Diabetic foot ulcer classification system for research purposes: a progress report on criteria for including patients in research studies.Crossref | GoogleScholarGoogle Scholar | 15150820PubMed |
[29] McIver FB, Mitchell CA, Finn CP, Kamp MC. Standardising practices through from design and education improves insulin management. Aust Health Rev 2009; 33 434–41.
| Standardising practices through from design and education improves insulin management.Crossref | GoogleScholarGoogle Scholar | 20128759PubMed |
[30] Edelson GW, Armstrong DG, Lavery LA, Caicco G. The acutely infected diabetic foot is not adequately evaluated in an inpatient setting. Arch Intern Med 1996; 156 2373–8.
| The acutely infected diabetic foot is not adequately evaluated in an inpatient setting.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DyaK2s%2Fmsl2itA%3D%3D&md5=9977fa0ff143e5946e621ab06f07b3baCAS | 8911244PubMed |
[31] Kawamoto K, Houlihan CA, Balas EA, Lobach DF. Improving clinical practice using clinical decision support systems: a systematic review of trials to identify features critical to success. BMJ 2005; 330 765
| Improving clinical practice using clinical decision support systems: a systematic review of trials to identify features critical to success.Crossref | GoogleScholarGoogle Scholar | 15767266PubMed |
