Understanding the problem
It is critical that patients with diabetic foot ulceration have rapid access to vascular interventions – to give them the best opportunity to heal. However, the team at the Freeman Hospital became increasingly concerned as they began to witness an increase in major amputations across their population. To improve care for this group of patients, the vascular team joined forces with stakeholders, to form the Newcastle Diabetic Foot Transformation Project.
Craig Nesbitt, Vascular Consultant, who led the project said: “Our work with diabetic patients spans a huge geographical area and covers a number of disciplines – including diabetes, vascular and podiatry teams in hospitals and community settings, and from both primary and secondary care. It was therefore paramount that we gained buy in from across the service as we had to represent everyone, from the bottom up to identify our problem areas and work together to develop solutions.”
The team worked collaboratively to identify the following problems within the service:
- Inequity of access to vascular services in our network
- Complex referral pathways from primary care
- Non standardised community vascular assessment techniques
- Poor access to rapid foot assessment (in hospital) with specialist podiatry input
- A lack of a dedicated MDT
Improvements made
Everyone involved agreed that in order to have a high-quality and effective service, diabetic patients should have rapid access to specialist foot assessment in the community with a simple and fuss-free onward pathway of referral for specialist surgical input if concerns are raised.
Collaborative working across the area was essential to making this work effectively. As a result, improvements were quickly made on the communication between the community and hospital based teams caring for diabetic patients – to help identify where the problems lay and improve the speed and continuity of their care.
A virtual weekly dedicated diabetic foot MDT for the entire network also now takes place, bringing together vascular surgeons, podiatrists, diabetologists, orthopaedics, microbiology and radiology.
The first MDT clinics are set to be launched later this year bringing together diabetic physicians, specialist podiatrists and vascular surgeons reviewing patients together at their local diabetes centres.
Everyone worked together across the network to play their role in identifying improvements needed and the following was introduced:
- A rapid and standardised community vascular assessment for ALL patients with diabetic foot disease
- One simple joint pathway from primary into secondary care
- A new daily Freeman ‘Diabetic Hot Foot Clinic’ led by podiatry
- Closer working relationships between community podiatry and vascular surgery
- New higher (nationally recommended) standards of care for patients admitted with diabetic foot disease across the network
- Weekly diabetic foot MDT
What this means for patients
For patients this now means that:
- ALL new diabetic foot problems seen in community podiatry in less than 24hours
- Additional podiatry appointments have been made available across the network
- All community patients receive a perfusion assessment
- New toe pressure measuring kits are now available for the entire network
- The new standardised pathway ensures patients are referred rapidly to ‘Diabetic Hot Foot Clinic’
- Specialist (Hot-Clinic) review available in 72hrs
- Globally recommended foot perfusion assessment of ALL patients seen in the ‘Diabetic Hot Foot Clinic’
Craig Nesbitt, Vascular Consultant and Vascular Diabetic Foot Lead added: “This project has been so successful because of the improvement in communication between community podiatry, diabetes and vascular surgery. Whilst this required lots of meetings – virtual and face-to-face when possible, visiting community centres and diabetes centres to meet and spend time alongside the people delivering the service at the coalface – it was incredibly worthwhile, as we are now seeing the benefits for patients. Everyone involved has worked incredibly hard and never lost focus on doing what is needed to improve care for our patients.”
“My advice to anyone looking to start their improvement journey is to speak to others who have been through this process before. We visited several units around the country sharing ideas from a number of different systems to create the Newcastle model of care. I would also advise others to think outside the box and to consider all ideas – no matter how big or small – and to include everyone in making those improvements together.”
The vascular team utilised Newcastle Improvement’s quality improvement tools to test out a range of ideas, and adapt them along the way, with data to back up what they were doing and why. Their approach introduced a number of effective solutions that are affecting real change and improvement for these vulnerable patients
Jo McCallum, Senior PM in Newcastle Improvement said: “We work in complex systems and this improvement demonstrates how we can unpick and understand each component (with a clear focus on primary prevention) – this is a fantastic achievement for the teams involved and is life changing for patients.”