demo evidence based diabetic foot risk screening tool -- level 1 summary
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DEMO Evidence Based Diabetic Foot Risk Screening Tool -- Level 1 Summary. HNHB LHIN Wide Foot Care Working Group. Presented in Partnership. Presented by Feet First Steps To Health Diabetic Foot Care Program. Connie Comtois-Spitman- Presenter - PowerPoint PPT PresentationTRANSCRIPT
DEMO Evidence Based Diabetic Foot Risk Screening Tool --
Level 1 Summary
HNHB LHIN Wide Foot Care Working Group
Presented byFeet First Steps To Health
Diabetic Foot Care Program
Connie Comtois-Spitman- Presenter LHIN Wide Foot Care Best Practices
Working Group/ Provider Team - Producer Lori Makarchuk-OTN / Operations
Diabetes Action Group Report 2008 Recommendations
All individuals diagnosed with diabetes in the HNHB LHIN receive an annual foot exam by a regulated health care professional
Health care providers within the LHIN provide evidence based foot care that is appropriate to the provider/ seek appropriate referral
No cost Diabetic foot care service be made available to those found to be at high risk
Goal
Develop LHIN wide, Multidisciplinary
community initiative for the evidence based
assessment , education and treatment of basic
foot care issues related to diabetes.
Diabetic Foot Screening Tool Users
•Level 1 Point of contact// Multidisciplinary Diabetes Health Care team. MD, NP, BSN, RN,RD, Pharm,( may be RPN, homecare under medical directive), Diabetic Educators CDE
•Level 2 Specialized foot care Chiropodist/ Podiatrist/ Physician
( in addition, BSN, RN, ENT with advanced training)
• Level 3 Specialized High Risk Referral, Neurologist, Vascular Surgeon, Orthopod, Infectious Disease, Plastics, Derm etc
Summary60 sec Diabetic Foot Screening Tool
Vascular assessment ( Pulse, Cap refill, appearance)
Neurological assessment ( monofilament/ vibration on-off method, pain report)
Skin/ Nails ( condition/ self care/ deformity) Footwear/ hosiery assessment ( condition/fit/
appropriateness)
Vascular assessment REVIEW
Capillary refill time ( 3 sec or less)
Presence of Pedal Pulses ( Dorsalis Pedis)
Skin Temperature( Hot/ Cold)
Dependant Rubor/ Erythema/ Odema ( red, irritated, swolen )
Neurological Assessment for Sensory Loss Includes
Monofilament testing score 10 sites ( x/10 )
*using Semmes Weinstein 10g monofilament
Vibration test
*using on/ off method 128 MHz tuning fork to dorsal aspect great toe proximal to nail.
Skin Assessment REVIEW
Identification of lesions toes, dorsum, plantar, heel, toes, between toes
• Presence of corns, callus, blisters
• Open areas eg Fissures/ Ulceration
( duration/ appearance should be documented)
Nail Assessment REVIEW
Thickness ( normal, crumbled, broken)
Discolored ( black, brown, yellow, reddish)
Bruised, loose or missing
Condition/ Self care manageable?
Footwear/ Hosiery Assessment
Look for signs of wear, including integrity of materials inside and on the sole
Fit and distortion of shoe shape Fit of stockings indicated by indentation on
legs/ toes Appropriateness ie thermal in winter, or
walking shoes for daily activity etc Can they retain the foot?
60 second Foot Screen Algorithm
60 Second Foot Screen for Patients with Diabetes
STOP-LOOK TOUCH ASSESS
STEP2 Touch-10 seconds
Temperature - Hot
0=foot warm
1=foot is cold
Temperature-Cold
0=foot is warm
1=foot is cold
Range of Motion
0=full range to hallux
1=hallux limitus
2=hallux rigidus
3=hallux amputation
Erythema
0= no
1= yes
Score = 0-5( Low risk) yearly screen Score = 6-11 ( Low/ Moderate) screen every 6 months Score =12 to 17 Moderate screen every 3 months Score =18 to 23 High risk screen every 1-2 months
STEP3 Assess-30 seconds Sensation-Monofilament Testing
0=10 sites detected
2= 7 to 9 sites detected 3= 0 to 6 sites detected Vibration on-off method 0=Present 2=Absent
Ask- 4 questions
Are your feet ever numb?
Do they ever tingle?
Do they ever burn?
Do they ever feel like insects are crawling on them? 0= no to all questions
2= yes to any questions
Pedal Pulses
0 = present 1 = absent
Dependant Rubor
0 = no
1= yes
STEP 1 Look-20 seconds
Skin
0=intact/healthy
1=dry, fungas,callus
2=heavy callus
3=open ulcer
or previous ulcer
Nails
0=well kept
1=unkempt/ragged
2=thick, damaged,
infected
Deformity
0=no deformity
1=mild deformity
2=major deformity
Footware
0=appropriate
1=inappropriate
2=causing trauma
Resource Flow Chart
Self Management Goal Setting / Problem Solving
Patient
Education
High Risk InterventionVascular, Ortho
Nero, Endo Wound Care
(Level 3)
Level 1 Foot ScreenRefer to Foot Care Program
RN / PRN Chiropodist / Podiatrist (Level 2 )
Evidence Based Vascular Assessment
Capillary Refill time (1)protocol Dorsalis Pedis Pulse (2)location and
assessment
1 http://www.nlm.nih.gov/medlineplus/ency/article/003394.html
2 A. Mowlavi et al, Postgrad Med J, 2002. 78:746-747
Evidence Based Neurological Assessment
Validity of the Semmes Weinstein 10g monofilament examination Level 1/ Class A Evidence
Assessment using Superficial pain sensation and vibration by on-off method are both well established with Level 1/ Class A Evidence
Recommendation of minimum of Annual Screening for the patient with the Diabetic Foot, although more frequent screens may be indicated based of level of risk
Feng Y. , Schlosser FJ, Sumpio BE, J Vasc Surg 2009 Sep 50(3) 675-82: Kamel N et al J Diabetes Complications 2005 Jan-Feb 19(1)47-53OlaleyeD., Perkins BA.,Bril V Diabetes Res Clin Pract. 2001 Nov.54(2)115-28:
Diabetes Guidelines Reviewed
Canadian Diabetes Association-Clinical Practice Guidelines or the Prevention and Management of Diabetes in Canada 2008
Registered Nurse’ Association of Ontario-Reducing Foot Complications for People with Diabetes ( Nursing Best Practice Guideline) 2007
Best Practice Recommendations for the Prevention, Diagnosis and Treatment of Diabetic Foot Ulcers: Update 2010 Canadian Association Wound Care
Diabetes Care Program Nova Scotia( Best Practice Clinical Guideline Diabetic foot care
LEAP ( Lower Extremity Amputation Prevention)
LHIN Wide Foot Care Best Practices Working Group/ Provider Team
Connie Comtois-Spitman-(Chair) NHCHC Feet First Steps to Health ( Chiropodist)
Dr. Vance Pegado- DRCC (Physician Lead ) Bo Fusek- DRCC ( CDE) Crystal Poyton- Quest CHC ( PHCNP) Michelle Overholt- Grandriver CHC (PHCNP CDE) Cathy Jager- Joseph Brant CHC ( CDE) Elenore Wormald-Medical Group Niagara
FHT( CDE)
Acknowledgments
North Hamilton Community Health Centre Feet First Steps to Health Diabetic Foot Care
Program Hamilton/ Niagara Quest Community Health Centre Diabetes Regional Coordination Centre Ontario Telehealth Network References are available upon requestContact: [email protected]/