A regional referral pathway for active foot disease was set up in April 2015 for 8 NHS Trusts across north east England, which sets out when patients should be referred, who they should be referred to and how they should be referred.
It has helped to ensure that all patients with diabetes requiring care for active foot disease are referred correctly and seen in a timely manner, and is consistent with the recently updated NICE guideline on diabetic foot problems (NG19), which recommends that robust protocols and clear local pathways are in place for the continued and integrated care of people across all settings. As part of the service improvement project an antibiotic protocol for foot infections was also developed and implemented at the James Cook University Hospital only.
Aims and objectives
- To establish a standardised regional referral pathway for patients with acute foot problems that would ensure that all patients with diabetes requiring care for active foot disease were referred correctly and seen in a timely manner.
- To clarify the referral route and timescale for patients with active foot disease, ensuring that staff in primary care and GP practices know when, where and how to refer patients who need specialist input
- To ensure that all patients with active foot disease are referred for appropriate treatment -
- To ensure that all patients with active foot disease are referred to the right person
- To ensure that all patients with active foot disease receive timely treatment
- To ensure that foot infections are treated with appropriate antibiotics and that local resistance patterns are taken into account
Reasons for implementing your project
The Northern Diabetes Footcare Network was established in 2011 to improve the quality of footcare services for people with diabetes across the region, in primary, community and acute settings. It facilitates partnership working and the sharing of good practice, and as part of its quality improvement work it was considered that a standardised referral pathway across the region would help to ensure that patients needing specialist treatment for foot disease received it promptly.
Some patients with acute foot problems (such as foot ulcers, infections or Charcot arthropathy) were not being referred by the GP, but instead having their wound dressed by primary care staff, who were later discovering that it had not healed.
The updated NICE guideline (NG19) recommends that all patients with active diabetic foot problems be referred within 1 working day to the multidisciplinary foot care service. Having multiple referral pathways risked confusion about how and when to access specialist input for patients with active foot disease. Often referrals would end up at the right place but had been delayed because they had been sent to the wrong place initially (for example, the podiatry team).
How did you implement the project
The Northern Diabetes Footcare Network agreed what the referral pathway should look like. The network consists of CCG and public health representatives in addition to community and secondary care health care professionals (HCPs). The referral pathway was tailored to each CCG area, with the contact details included for the relevant secondary care unit at each site. The referral pathway clarified that all patients with active foot disease should be referred to hospital within 24 hours, which is recommended in the updated NICE guideline (NG19). The designated receiver at each site is responsible for booking the patient appointment as deemed necessary e.g foot clinic or podiatry. Another aspect of the project was the agreement of a site specific antibiotic protocol for treating foot infections at James Cook University Hospital.
As part of the protocol, patterns of resistance are taken into account, meeting the recommendations in the updated NICE guideline (NG19). A programme of communication was required to ensure that all CCGs and all GP practices were aware of the referral pathway. Some initial resistance was encountered in primary care, where some thought that referring all patients with active foot disease within 24 hours would result in such an increase in referrals that the secondary care service would be overwhelmed. The advantages of the standard referral pathway were highlighted, for example for people moving around the region such as locum GPs. Many GPs appreciated the urgency of the referrals for patients with active foot disease.
The multidisciplinary teams involved in managing diabetic foot problems at South Tees Hospitals have seen a steady increase in referrals for diabetic foot ulcer since before the standard referral pathway was introduced, but have not seen a ‘spike’ in referrals that some expected since the referral pathway was put in place.
The general increase in work over time is considered to be because of the increase in numbers of people with diabetes. It is also considered to show that people are being treated earlier. As part of the evaluation of the project patients referred to the service have been asked about when they were referred and whether they had experienced any delay at all.
The use of the antibiotic protocol is now incorporated into standard practice, however, the small print used in parts of the document has meant that some people are just acting on the information highlighted in bold and not seeing the remaining information, and are thereby at risk of prescribing inappropriate antibiotics. The Northern Diabetes Footcare Network will consider revising the type of the document to ensure that the entirety of the antibiotic advice is taken on board.
Key learning points
The key learning point is that the service change should be kept as simple and straightforward as possible. The referral pathway is one side of A4 which contains all the information required by the primary care clinician: Action to take during working hours, the telephone and fax number, and the clinical assessment required in the out of hours period to determine the next steps required.