Diabetes High Risk Foot Services
Diabetes related foot complications occur mainly as a result of diabetes-related impacts on the nerves, joints and blood vessels. Most foot ulcers occur because there is reduced or absent sensation whereby patients do not feel their injuries and as a consequence delay seeking treatment, continuing to walk on their ulcerated or fractured foot. People with diabetes have more frequent and earlier progression to blockages of the arteries which affects blood flow and ability to heal. Under these conditions, minor injuries (cuts and bruises) and stress fractures can progress to ulcers, infections and amputation.
The National Evidence Based Guidelines on the Prevention, Identification and Management of Foot Complications in Diabetes Mellitus recommend that foot ulceration as a serious complication needs immediate management and is best managed by a multi-disciplinary foot care team. In NSW there are 11 standards for High Risk Foot Services (HRFSs).
Standards for High Risk Foot Services in NSW (2014)
- A multidisciplinary team approach
- Clinical leadership and coordination
- Administrative support
- Evidence-based treatment guidelines
- Continuity of care across care settings
- Prompt access for urgent cases
- Location within health facility with access to on-site services
- Appropriate equipment
- Pressure offloading and medical grade footwear
- Access to wound care products
- Recording and monitoring of clinical outcomes
What clinical processes need to change?
Foot ulceration is one of the leading causes of hospitalisation for people with diabetes, affecting more men than women. It is estimated that on average, 19.6% of people with type 2 diabetes are at risk of foot ulceration.
Combined with the fact that diabetes related foot complications account for 8% of total deaths secondary to diabetes, there is a need to address this growing burden.
People in NSW have inequitable access to HRFSs, with significant variation in amputation rates in some population groups and geographical region. Rates of diabetes related foot related amputations are much higher in Aboriginal people (53.9 per 100,000 populations) than in non-Aboriginal people (12.7 per 100,000 populations).
The ACI’s Endocrine Network 2014 Standards for HRFS in NSW (Standards) identify the need to implement a statewide approach to improving care for people with diabetes related foot complications in order to prevent unnecessary hospital admissions. How local health districts (LHDs) achieve avoided hospitalisations through the implementation of multi-disciplinary HRFS implementation should be flexible.
Implementation options to support improved access to HRFSs may include one (or more) of the following:
- Investment in additional multidisciplinary HRFS in LHDs. This would require recommendations for local teams to:
- address the podiatry workforce
- ensure adequate resourcing to provide specialist medical and surgical consultation; and key components according to the Standards, including access to equipment
- ensure access to culturally appropriate services to encourage access by Aboriginal people
- support other sites through the provision of telehealth services; or augmentation of current services supported by telehealth (particularly for highly specialised care)
- explore options to increase access to in-hospital high risk foot care prior to discharge to ensure continuity of care across inpatient and outpatient services.
- A blended approach to caring for patients that involves primary, specialist and community (MBS funded) care, which may include the enhanced role of primary health networks in partnering with LHD-based HRFS.
- Redesign of the existing HRFS workforce to address the Standards. This includes two streams.
- Redesign of the existing workforce to provide a HRFS as outlined in the Standards.
- Exploring additional roles for Aboriginal Health Workers, Aboriginal Liaison Officers, and/or care coordinators to increase engagement and access to services for Aboriginal people.
Each option may require consideration of resourcing to support the most appropriate local service.
ACI Support Model
The following will be offered to support LHDs with implementation of change.
- Statewide service mapping
- Support to conduct local gap analysis
- Implementation support for establishing a new service or expanding an existing service.
 National Evidence-Based Guideline on Prevention (2011). Identification and Management of Foot Complications in Diabetes (Part of the Guidelines on Management of Type 2 Diabetes). NHMRC: Melbourne.
 TR Quinton, PA Lazzarini, FM Boyle, AW Russell and DG Armstrong (2015). How do Australian podiatrists manage patients with diabetes? The Australian diabetic foot management survey. Journal of Foot and Ankle Research; DOI: 10.1186/s13047-015-0072-y.
 Centre for Epidemiology and Evidence. HealthStats NSW. Available at: www.healthstats.nsw.gov.au (Accessed 18.10.2016).