CLINICAL PROCEDURE FOR ANNUAL DIABETIC FOOT SCREENING FOR COMMUNITY PODIATRY Issue History

Issue Version

1

Purpose of Issue/Description of Change To ensure standardisation of annual foot screening for diabetic patients undertaken by podiatrists in accordance with NICE Guidance CG10

Planned Review Date

2016

Named Responsible Officer:-

Approved by

Date

Podiatry Service Lead

Quality, Patient Experience and Risk Group

June 2013

Target Audience

Section:- xxx CPxxx

All Podiatrists

UNLESS THIS VERSION HAS BEEN TAKEN DIRECTLY FROM TRUST WEB SITE THERE IS NO ASSURANCE THIS IS THE CORRECT VERSION

CONTROL RECORD Title Purpose

Author Equality Assessment Subject Experts Document Librarian Groups consulted with :Infection Control Approved Date approved by Quality, Patient Experience and Risk Group Method of distribution Archived Access

Clinical Procedure for Annual Diabetic Foot Screening for Community Podiatry To ensure standardisation of annual foot screening for diabetic patients undertaken by podiatrists in accordance with NICE Guidance CG10 Service Lead Integrated into procedure Yes No Podiatry Service Lead , Carl Royston QGS CPPG April 2013 5th June 2013

Email Date Via QGS

VERSION CONTROL RECORD Version Number Author 1 Podiatry

Intranet :- Staff Zone Location:- Datix Library

Status N

Changes / Comments Standards for annual diabetic foot screening within the Podiatry Service

Status – New / Revised / Trust Change

CLINICAL PROCEDURE FOR ANNUAL DIABETIC FOOT SCREENING FOR COMMUNITY PODIATRY 2/11

CLINICAL PROCEDURE FOR ANNUAL DIABETIC FOOT SCREENING FOR COMMUNITY PODIATRY INTRODUCTION The purpose of the Clinical Procedure for Annual Diabetic Foot Screening is to standardise the methodology and reporting mechanisms for all Wirral Community NHS Trust Podiatry staff. TARGET GROUP This procedure will only be undertaken by Community Podiatrists and supervised podiatry students on placement. TRAINING All staff in the Trust are required to comply with mandatory training as specified in the Trusts Mandatory Training Matrix. Clinical Staff are also required to comply with service specific mandatory training as specified within their service training matrix. RELATED POLICIES Please refer to relevant Trust policies and procedures INDICATIONS  Diabetic Patients who are registered with a Wirral GP who have not received foot screening within the last 12 months  Diabetic Patients who have been referred from General Practice via a referral form  Diabetic patients who have been recalled by Wirral Community NHS Podiatry Services CONTRAINDICATIONS  Patients who have not yet reached their 18th birthday, as they remain under care of Consultant Paediatrician  Patients who have open wound sites following recent foot surgery  Patients who have inaccessible areas due to plaster casting  Patients who do not consent to Annual Foot Screening CONSENT Valid consent must be given voluntarily by an appropriately informed person prior to any procedure or intervention. No one can give consent on behalf of another adult who is deemed to lack capacity regardless of whether the impairment is temporary or permanent. However such patients can be treated if it is deemed to be within their best interest. This must be recorded within the patient’s health records with a clear rationale stated at all times. Refer to Trust Patient Information and Consent Policy for further information and guidance or the Clinical Protocol for Assessing Mental Capacity and Best Interests. CLINICAL PROCEDURE FOR ANNUAL DIABETIC FOOT SCREENING FOR COMMUNITY PODIATRY 3/11

EQUIPMENT    

10g monofilament Calibrated tuning fork (or other approved vibrational device) Single use disposable non-sterile gloves Single use disposable apron Wirral Diabetes Podiatry Foot Screening Form

CLEANING EQUIPMENT  10g monofilaments should not be used to conduct more than 10 tests per session. They must be 'rested' for 24 hours following 10 uses to recover from plastic deformation.  10g monofilaments should be cleaned with a Clinell Wipe between patients.  10g monofilaments should be replaced if the tips are visibly deformed or buckled.  Calibrated tuning forks should be cleaned with a Clinell Wipe prior to use and after use. Diagnostic and Screening Standards to Promote and Maintain Patient Safety

a. How the Screening/Diagnostic procedure is requested b. How the clinician treating the patient is informed of the results (including timescales)

c. How the patient is informed of the results (including timescales) d. Taking action on the result of diagnostic /screening tests (including timescales) : documentation of the result  interpretation of the result  how patient is followed up or referred following a screening Which staff are authorised to request this test?

Description of how each step in the process is undertaken The screening is either organised internally to the podiatry service or by referral from the GP or Practice Nurse Health outcome determined by assessing podiatrist and patient informed of results at time of assessment. GP Practice gets copy of outcomes within two working weeks Patient advised of outcome on completion of assessment the same day

Additional comments:Referral form must be completed

The assessing clinician records the results during the assessment

Podiatrist records assessment directly in health records

As per Risk Categorisation & Outcomes as listed within this procedure Recorded on the Wirral Diabetes Register Screening Form Categorisation according to NICE Guidelines CG10

Recorded in the patient’s electronic record

As per Clinical Protocol for Community Podiatry Patients with Type II Diabetes Podiatrists in the service authorise and conduct the annual review

GP and Practice Nurse can request the screening

CLINICAL PROCEDURE FOR ANNUAL DIABETIC FOOT SCREENING FOR COMMUNITY PODIATRY 4/11

PROCEDURE PRIOR TO COMMENCEMENT OF SCREENING ACTION

RATIONALE

Verbally confirm the identity of the patient by asking for their full name and date of birth. If client unable to confirm, check identity with family/carer & record this on the screening form Introduce yourself as a staff member and any colleagues involved at the contact Wear identity badge which includes name status and designation

To avoid mistaken identity

Ensure verbal consent for the presence of any other third party is obtained Explain procedure to patient including risks and benefits and gain valid consent. Advise the patient that the data will be electronically stored Ascertain the current GP Practice with which the patient is registered & record this on the screening form Decontaminate hands prior to procedure. Put on a disposable apron. Single use non-sterile gloves should be worn if the patient presents with open wounds or areas of skin which are not intact.

Students for example, as the client has the choice to refuse To ensure client understands procedure and relevant risks To comply with Data Protection Act

To promote mutual respect and put client at their ease For patients to know who they are seeing and to promote mutual respect

To ensure accurate reporting and recall

Reduce the risk of transfer of transient organisms on the healthcare workers hands to the patient

COMPLETION OF THE CLINICAL HISTORY SECTION ACTION

RATIONALE

Above Ankle Amputation: Visually check for amputation sites above the malleoli

A positive result indicates the patient is categorised as 'High Risk'

Record the presence or absence of amputation on the screening form

To ensure data is accurately recorded and reported

Toe Amputation: Visually check for digital amputation sites

A positive result indicates the patient is categorised as 'High Risk'

Record the presence or absence of amputation on the screening form

To ensure data is accurately recorded and reported

Claudication: Ask the patient to report if they

A positive result indicates the patient is

CLINICAL PROCEDURE FOR ANNUAL DIABETIC FOOT SCREENING FOR COMMUNITY PODIATRY 5/11

experience cramp like calf pain induced by walking & relieved by rest

categorised as 'At (increased) Risk'

Record the presence or absence of claudication on To ensure data is accurately recorded the screening form and reported Arterial Surgery: Check for any history of lower limb arterial surgery. Include bypass surgery, angioplasty and revascularisation procedures

A positive result indicates the patient is categorised as 'High Risk'

Record the presence or absence of arterial surgery To ensure data is accurately recorded on the screening form and reported Neuropathic Pain: Ask the patient to report if they experience neuropathic limb pain

A positive result indicates the patient is categorised as 'At (increased) Risk'

Record the presence or absence of neuropathic pain on the screening form

To ensure data is accurately recorded and reported

Current Ulceration: Visually check for any current episode of foot ulceration

A positive result indicates the patient is categorised as 'High Risk'

Record the presence or absence of current foot ulceration on the screening form

To ensure data is accurately recorded and reported

Previous Ulceration: Check for any history of previous foot ulceration

A positive result indicates the patient is categorised as 'High Risk'

Record the presence or absence of previous foot ulceration on the screening form

To ensure data is accurately recorded and reported

Charcot Foot: Check for hypertrophic changes presenting as irregular deformation leading to joint instability

A positive result indicates the patient is categorised as 'High Risk'

Record the presence or absence of Charcot arthropathy on the screening form

To ensure data is accurately recorded and reported

COMPLETION OF THE CLINICAL EXAMINATION ACTION

RATIONALE

Palpate the dorsalis pedis and posterior tibial pulses To assess the arterial supply to both feet. on both feet Failure to detect any pulse indicates the patient should be identified as 'At (increased) Risk' Record the presence or absence of palpable pulses To ensure data is accurately recorded on the screening form and reported Test each of the 10 sites indicated on the screening To identify any presenting neuropathy form with a 10g monofilament following the manufacturers guidance

CLINICAL PROCEDURE FOR ANNUAL DIABETIC FOOT SCREENING FOR COMMUNITY PODIATRY 6/11

Record the positive or negative response for each site on the screening form

To ensure data is accurately recorded and reported

Sum the results for all columns in the Scoring box on the screening form

If 2 or more sites on either foot exhibit neuropathy the patient should be categorised as 'At (increased) Risk'

With a calibrated tuning fork (or approved vibration generation device) test the apicies of both first toes and medial malleoli for vibration perception

To identify any presenting neuropathy

Record the positive or negative response for each site on the screening form

If any site exhibits an absence of vibration perception the patient should be categorised as 'At (increased) Risk'

Decontaminate hands

Reduce the risk of transfer of transient organisms on the healthcare workers hands to the patient

COMPLETION OF THE CLINICAL COMMENTS Any free text comments recorded in the clinical comments section will have no effect on the categorisation of the patient's risk category Any information entered will be retained in the patient's record but will not be reported Any further investigation undertaken following the standard screening requirements (such as the use of Doppler ultrasound vascular assessment) may be recorded in the clinical comments box but should also be repeated in the Subjective, Objective, Assessment and Plan (SOAP) consultation or Assessment section of the patient record Any presenting clinical features or reported history which may have affected the outcome of the screening (such as oedema) may also be recorded here CURRENT FOOT CARE ARRANGEMENTS The current foot care arrangements in place reported by the patient should be recorded in this section EDUCATION LEAFLETS AND INDIVIDUAL CARE PLANS On completion of the screening form each patient should be given the educational leaflet produced by the Podiatry Service according to their final Patient Risk Category Any patient presenting for screening who is new to the service, or any current patient who has been diagnosed with diabetes following their last contact with the service should be issued with an Individual Care Plan. CLINICAL PROCEDURE FOR ANNUAL DIABETIC FOOT SCREENING FOR COMMUNITY PODIATRY 7/11

RISK CATEGORISATION AND OUTCOMES In accordance with the agreed pathways for practice staff all 'Low Risk’ patients will continue to be managed by their G.P for screening. Patients categorised as 'At (increased) Risk' or 'High Risk' will be recalled by Community Podiatry for future annual screenings Patients categorised as 'At Risk' who do not receive ongoing Community Podiatry treatment will be instructed to self-refer within 3-6 months for interim assessment Patients categorised at 'High Risk' will receive follow-up appointments rebooked by Community Podiatry in line with Clinical Protocol for Community Podiatry Patients with Type II Diabetes. EMERGENCY REFERRALS INTO SECONDARY CARE If any patient presents with a new ulceration or has a static, non-responsive or deteriorating area of ulceration, swelling or discolouration (may indicate deep infection), critical ischaemia or suspected Charcot Foot arrange an urgent appointment with the Diabetic Team at Arrowe Park Hospital (APH) / Clatterbridge Hospital immediately as detailed below. Before any referral to Wirral University Teaching Hospital (WUTH) Diabetic Team can be made, the patient must be under the care of a Diabetic Consultant at APH or Clatterbridge Hospitals. It is the responsibility of the referring clinician to ensure that any patients they refer to WUTH are registered with a consultant. This can be confirmed by phoning the relevant Diabetic Clinics on the numbers shown below. If the patients Diabetes is managed by WUTH then ring for an appointment as follows; 

APH – 678 5111 or bleep the Diabetes Specialist Nurses.



CBH – 334 4000 or bleep the Diabetes Specialist Nurses.

If the patients’ Diabetes is managed by their GP ask the GP/Surgery to send the referral by fax to the following numbers within the same working day. 

APH fax – 604 7486.



CBH fax – 482 7765.

Then arrange an appointment with the Diabetes Team explaining a faxed referral will be sent from the patients’ GP. Without a fax referral from the patients GP, WUTH will refer patients back to community care without treatment.

CLINICAL PROCEDURE FOR ANNUAL DIABETIC FOOT SCREENING FOR COMMUNITY PODIATRY 8/11

COMPLETED SCREENING FORMS Completed screening forms should be sent to the Podiatry Diabetes Co-ordinator at; Community Podiatry Office, Whitehouse, 3 Port Causeway, Bromborough, Wirral CH62 4NH All completed forms will be quality assured and attached to the patient's electronic record. The original forms will be forwarded to the patient's current GP WHERE TO GET ADVICE FROM Advice regarding the screening can be obtained from the Specialist Diabetes Podiatrists and the Podiatry Diabetes Co-ordinator INCIDENT REPORTING Clinical incidents or near misses must be reported via the Trust’s incident reporting system. SAFEGUARDING In any situation where staff may consider the patient to be a vulnerable adult, they need to follow the Trust Safeguarding Adult Policy and discuss with their line manager and document outcomes. REFERRALS Any referrals to health professionals, therapists or other specialist services must be followed up and all professional advice or guidance documented in the patients’ health records. EQUALITY ASSESSMENT During the development of this procedure the Trust has considered the clinical needs of each protected characteristic (age, disability, gender, gender reassignment, pregnancy and maternity, race, religion or belief, sexual orientation). There is no evidence of exclusion of these named groups. If staff become aware of any clinical exclusions that impact on the delivery of care a Trust Incident form would need to be completed and an appropriate action plan put in place.

CLINICAL PROCEDURE FOR ANNUAL DIABETIC FOOT SCREENING FOR COMMUNITY PODIATRY 9/11

APPENDIX ONE RISK ASSESSMENT FOR SCREENING/DIAGNOSTIC PROCEDURES Name of Screening/Diagnostic Procedure: CLINICAL PROCEDURE FOR ANNUAL DIABETIC FOOT SCREENING Date risk assessed: April 2013 Risk assessed by: Service Lead Likelihood that process will fail Low Medium High

Risk identified in process

Mitigation/Controls

a. Process for requesting the screening/diagnostic procedure

X

Systems failure as patient may not be recalled for the screening

Podiatry service have a system in place to ensure all patients are reviewed annually

b. Process for informing the clinician treating the patient of the result

X

Criteria

Podiatrist records the results directly into healthcare records

c. Process for informing the patient of the result d/e. Process for action if referral required after a screening test

X

Identify risks from the ‘process’ of conducting the test if relevant

X

X

GP informed by letter within 2 working weeks The patient is informed directly following the assessment Podiatry staff to follow Clinical Protocol for Community Podiatry Patients with Type II

Non-invasive assessment: No risk present

GP is also informed This protocol outlines standards for conducting reviews of high risk patients