The Royal Free Hospital (RFH) has a well-established Multidisciplinary Foot Team (MDFT), of which podiatry is a fundamental part. This service works to reduce major amputations and has been shown to reduce length of stay and improve patient outcomes. Originally, service provision was over 5 days with open access to healthcare professionals. However, referral to treatment time was often delayed due to capacity issues and patients were not able to access the podiatry service in a timely fashion as outlined in NICE guidance NG19 “Diabetic foot problems: prevention and management”.
A 3-year audit of inpatients referred to the RFH podiatry service showed that 60-70% were admitted via A&E and there was a lag time between admission and being seen by the MDFT. This audit also showed missed clinical opportunities in which could have resulted in more opportunity for limb salvage. This lead to the creation of the Ambulatory Acute Foot Service (AAFS). A podiatrist is available 7 days a week to ensure rapid access to specialist foot care. Their role as a podiatry “pathfinder” ensures specialist assessment, treatment and referral into the correct pathway as inpatient, outpatient, or for community care.
Aims and objectives
• Fast track acute foot patients from A&E to prevent admissions, involve the MDFT if admission is required and ensure no delay in starting treatment
• Establish 7-day service to decrease delay from referral/A&E attendance.
• Ensure correct diagnostics have been implemented to facilitate;
• Earliest possible targeting of antibiotic therapy in line with Trust and National policies to reduce antibiotic resistance.
• Early diagosis of severe tissue infection, osteomyelitis, gangrene etc. requiring emergency surgery.
• Early diagnosis of Charcot’s Neuroarthropathy, requiring immediate specialist casting techniques and/or orthopaedic input.
• Timely revascularisation.
• Earliest possible discharge from hospital (as MDFT is involved directly from point of admission, with no delay in ward referral).
• Establish agreed pathways within RFH to facilitate elective treatment, day case surgery and prevention of admission.
• Establish agreed pathways within RFH for ‘out of hours’ care and follow up patients seen outside podiatry service times within 24 hours.
• Establish agreed pathways with partner hospitals and podiatry community services.
• Improve access to urgent foot care as requested by the RFH Acute Foot Patient Group.
• Monitor and coordinate re-attendances by patients who are already under care of the MDFT allowing rapid review in the AAFS.
• Audit attendances to A&E, clinical outcomes and patient experience.
Reasons for implementing your project
RFH became a vascular hub in 2012 for North Central London leading to expansion of the podiatry service. The creation of the Vascular Hub increased number of acute diabetic foot conditions referred into RFH.
An audit of inpatients referred to the RFH podiatry service in 2014 showed that 67% of inpatients seen by the MDFT were admitted via A&E. Hospital data shows that over 2800 patients were discharged from A&E following a foot related attendance in the same 6 month period in 2014, of whom, around 900 had soft tissue damage (ie foot wounds) which could have been potentially treated by a podiatrist, rather than requiring an A&E attendance.
There have been a number of recently documented examples of missed clinical opportunities to prevent amputation in patients admitted via A&E, as well as instances where amputation has been promoted as the only solution to an acute foot episode, with subsequent achievement of limb salvage following involvement of the MDFT.
The main aim of this project was for patients with diabetic foot conditions to access the right care at the right time via a podiatry pathfinder, there by reducing amputations, reducing length of stay and improving patient outcomes.
How did you implement the project
A bid was submitted to the NHSE Diabetes Transformation Fund to gain funding to establish the AAFS and increase capacity for outpatient clinics and ward podiatry.
Meetings were held with interested parties including the RFH MDFT, A&E, Acute Foot Patient Group, community podiatry, partner hospitals, primary care and NCL STP. These meetings established agreed internal and external pathways and criteria for care plans by the podiatry pathfinder.
AAFS is maintaining a detailed clinical audit of all patients and their outcomes as well as the National Diabetic Foot Audit to support on-going funding of the service. It was essential to fill clinical posts prior to starting project. Attracting new staff to central London proved difficult due to high living costs. Also new staff required training in systems which caused delay.
RFH was undergoing an expansion of A&E during the setup of the AAFS and finding space within the A&E proved challenging. Also, as the first 7 day A&E dedicated podiatry service in England, there was no previous model to work from. A&E staff were initially hesitant about podiatry involvement in their cases and education of staff was paramount in gaining their understanding and utilisation of the service.
AAFS has seen;
- An increased number of referrals from A&E.
- Decreased the time from initial referral to presentation of acute diabetic foot conditions and referral to MDT if admitted.
- 93% of patients were seen in AAFS within 24 hours.
- Ensuring patients see the right person in the right place at the right time.
- Supporting GPs with direct access to AAFS.
- Integrating pathways for MDT's, partner hospital and community services.
- Delivering evidence based practice from NDFA and NG19 whilst auditing outcomes.
- Commitment to people with diabetes as outlined by the RFH Acute Foot Patient Group.
- Pathways to local hospital or community services or entering elective surgical pathways.
- Commitment to the North Central London diabetes population.
- Compliments from patient carers who feel supported by our service as it allows for same day service.
- Consultant Podiatrist was responsible for making the bid to NHSE and developing the AAFS, pathways and new team.
- The advanced wound care podiatrists have developed skills further to improve autonomous and MDT working whilst in A&E.
- AAFS audit continues to evaluate and measure the impact of our service on acute diabetic foot conditions.
- Podiatry team have developed their own online templates and audit tools.
Key learning points
We have learnt many new skills from implementing our AAFS.
Initially, our business case was strong, evidenced based, well supported by vascular and diabetes consultant colleagues and clearly outlined the reasoning for the service development. The expansion of our reach within the hospital to A&E allowed for relationships to be formed. By increasing the knowledge of podiatry and what we can achieve, we have seen referrals to our outpatient service from services that have not historically referred. Also by increasing the number of team members, this allowed for increased diversity of clinical and personal skills.
As with any new service, there have been hurdles:
• Recruitment - the success of the AAFS may help this.
• Securing the appropriate space was difficult. AAFS model may be of benefit to other organisations to develop a similar service.
• Expanding the detail of our referral pathway may have helped with confusion from the streaming nurse in A&E.
• Receiving regular feedback in a formal manner may have helped with stakeholder engagement of the A&E consultants and staff, but difficult given the time pressures on all concerned.
As the project continues to evolve, we will learn from these challenges and implement strategy to turn these into a positive.
NHSE Diabetes Transformation Funding used to establish the AAFS