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Model of careIn addressing the prevention and treatment strategies for a dia-betes multidisciplinary foot care team to develop and implement,communication and collaboration are two essential requirementsfor the care of the diabetic foot.

Using this approach the Portsmouth ‘diabetic foot referralpathway’ and the diabetic Baseline Foot Assessment Tool success-fully won the ‘Innovation through collaboration award’ pub-lished in The Diabetic Foot1. The referral pathway was developedfollowing the development of the Multidisciplinary DiabeticFoot Service Team in 1999. This process involved regular meet-ings with health care professionals from within primary and spe-cialist care settings.

The aim of the referral pathway was to ensure that active footdisease was optimally managed and that access for vascular assess-ment was quick.

The Baseline Diabetic Foot Assessment Tool (BFA)1 is used bya wide range of health professionals to identify the risk of diabeticfoot complications. This tool has recently been audited in anattempt to validate its effectiveness2. This audit demonstrated thedifficulties in collecting data in a district that has no diabetes reg-ister. The results show that 98% of ‘at risk’ patients (identified byBFA) were either referred for further assessment to the AdvancedPodiatrist or had a podiatric care plan already in place. 70% of ourpatients were scored as low risk and, of these, 0.18% developedfoot ulceration within the audit period. The audit concluded thatthe BFA tool is a good predictor of ulceration risk.

Advantages of model of careThe Baseline Foot Assessment Tool● BFA has enabled all patients within the Portsmouth district to

be effectively screened for developing potential foot problems.● Those who score over 25 are deemed at high risk and then are

referred to the Advanced Podiatrist for ongoing assessment andfollow-up.

● It is a simple and easy to use tool, which can be used by allhealth care professionals provided they have a 10 gm monofila-ment for assessing sensation.

The diabetic foot referral pathway● A tool to assist the primary care team in speedy referral and

providing management options in the care of the diabetic foot.● Clear guidelines for referral into community podiatry clinics or

specialist care clinics, e.g. Diabetes Foot Clinic, vascular clinics,or admission procedure depending on patient need.

● Multiprofessional development compassing ownership andagreement of treatment options.

● Addressed the inappropriate use of DSN time and highlightedthe need for facilitation and co-ordination of patient dischargerequirements, which led to the development of the ‘DiabetesSpecialist Podiatry Assistant’ (main role to assess, educate andco-ordinate patient referral to specialist team e.g. DSN for gly-caemic control, orthotic dept (see Box 1).

● Ensures patients’ needs regarding follow-up requirements aremet, e.g. orthotic involvement, community advanced podiatrycare and DSN input addressing glycaemic control.

● Ongoing multidisciplinary team meetings have developed local‘Joint diabetic wound care guidelines’, ‘Antibiotic guidelines forthe infected diabetic foot’ and formalised ‘Discharge guidelinesfor the care of the diabetic foot’. Awaiting final stages of valida-tion and acceptance from the ‘Clinical Audit Standards andEffectiveness Team’ and LDSAG.

● Generated interest within those specialities not originally con-nected to the multidisciplinary team and hence team expansion– involving orthopaedic surgeons and elderly care physicians inthe team. This enhanced its communication to other areaswithin specialist and community care.

Development of diabetic foot service sincethe introduction of a multidisciplinary

diabetic foot referral pathwayEmma Holland, Deborah Land, Sarah McIntosh, Darryl Meeking

Emma Holland, Senior Diabetes Specialist Nurse; Deborah Land,Senior Podiatry Manager; Sarah McIntosh, Diabetes SpecialistPodiatry Assistant; Darryl Meeking, Consultant in Diabetes andEndocrinology; Diabetes Centre, Queen Alexandra Hospital,Cosham, Portsmouth, Hampshire PO3 6LY, UK

Correspondence to: Emma Holland, Senior Diabetes SpecialistNurse, Diabetes Centre, Queen Alexandra Hospital, Cosham,Portsmouth, Hampshire PO3 6LY

1. Maintain and update ‘at risk’ patient register.2. Initial assessment self-care/social status – identify

barriers to self-care.3. Patient education about footcare/wear, warning signs

and when to seek help.4. Identification of problems with glycaemic control –

refer to DSN as necessary5. Liaise with ward staff/named team about patients’

requirements/management issues and record inpatients’ medical notes as well as diabetes centrepatient notes.

6. Provide education about the diabetic foot on aninformal and formal basis with the DSN.

7. Meet with DSN for liaison with patient case studies.8. Refer to advanced podiatry team for follow-up.9. Liaise with the multidisciplinary diabetic foot service

team as appropriate.

Box 1. Diabetes Specialist Podiatry Assistant – main team role

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Development of diabetic foot service

Difficulties encounteredStaff changesAlthough it has only been 14 months since the launch of the path-way the ‘contact list’ on the back of the pathway is already out ofdate and in need of revision and updating due to staff changeswithin podiatry clinics.

Staff changes in the acute ward setting have also had an impactsince education about and communication of the referral pathwayneeds to be highlighted continuously to ensure it is utilised effec-tively. During the last 12 months the acute services TissueViability Nurse had changed as well as the staff in our PatientAccess Unit. The main barrier is the time resource needed fororganising and performing sessions to update health care profes-sionals within our district.

Podiatric workloadOther difficulties which have evolved (as expected) from the dia-betic foot referral pathway is the increase in podiatry workload.This has increased to meet the demand of ‘at risk’ patients.Specialist clinics in the acute ward have increased from four to sixwith some of extended length. A specialist podiatrist can now beaccessed each weekday for advice, patient referral or informationon local access. In the community, advanced podiatrists now carepredominantly for a medium to high risk caseload. Staff move-ments and changes make equitable cover throughout the commu-nity clinics difficult. A timetable review is taking place at present.

Financial supportAs mentioned in the original article1 the referral pathway has notreceived any financial support and has been developed and main-tained after reviewing existing resources. However there has beenreluctance within primary care in covering the cost of the monofil-aments required in performing the baseline foot assessment. Thisat the moment is being re-addressed by the diabetes centre team.

ConclusionAlthough the implementation and maintenance of the referralpathway has encountered difficulties, addressing these challengeshas led to new developments and initiatives in the care of the dia-betic foot.

Additional resources have still not been forthcoming but creativemanagement underpinned by evidence base and patient demandhas initiated change. Recognition of the pivotal role within sec-ondary care for the Diabetes Specialist Podiatry Assistant is essen-tial to the development of co-ordinating the follow-up of thosepatients already at high risk of re-ulceration and amputation.

References1. Holland E, Bradbury R, Meeking D. Using a team approach to set up a diabetic foot

referral pathway. Diabet Foot 2000; 3 (3): 106–110.2. Audit of Baseline Diabetic Foot Assessment. 2000.

The forms for the BFA tool are available online ondiabetesonestop. www.diabetesonestop.com

RCN Diabetes Nursing Forum NewsThe Royal College of Nursing Forum represents nursing on a number of national groups and committees as well as within the RCN

Changes in committee membershipEileen Padmore has stepped down from the committee for healthreasons. We are very grateful for her dedicated leadership over thelast year, and for the groundwork she has completed on behalf of theforum. Also, Jane Pennington and Dorothy Cook have retired fromthe group, but we are delighted to welcome Paul Dromgoole, a DSNfrom East Yorkshire, Rebecca Nute, a DSN from Chippenham, andJackie Lucas, a nursing home manager from Bristol. I am the newlyelected chair and, for the first time, we have a deputy chair, SarahO’Brien.

Annual conference: “Roles, skills and competencies”The annual Forum conference was held at the Thistle Hotel,Liverpool, from 17-18 May. The programme was full and topicalreflecting the conference title. Kim Manley, Head of PracticeDevelopment at the RCN Institute brought the delegates up-to-datewith progress towards a UK-wide integrated career andcompetencies framework for diabetes nursing. The working group isplanning to circulate a consultation document in the autumn. SueHodgetts, Chief Executive of the Somerset, Devon and CornwallWorkforce Development Confederation, worked through the 12diabetes National Service Framework standards focussing on theroles and skills needed to meet the challenge of future diabetes care.Tim Hoy a firefighter with type 1 diabetes, relayed some personalstories and left no doubt that he understands the roles, skills andcompetencies required by people with diabetes. Barbara Stuttle,Nurse Prescribing Manager for the London and South East regions,examined the history of nurse prescribing with the key message tobe positive about the advances that have been made so far, and torespond to the government’s latest consultation document. DrGeoffrey Gill, Reader in Medicine, and Consultant Physician,

University Hospital, Aintree, presented a clear, concise and up-to-date summary of the medical treatments for diabetes. Workshops onhypertension management, insulin regimens, primary prevention ofdiabetes, and consultation skills followed, and the day ended with adebate on whether blood testing was a waste of time and resourcesfor people with type 2 diabetes.

The next conference will be held in September 2003. Exact dateand venue to be confirmed.

A request for your involvementPrescribing Consultation: Please get hold of a copy of theconsultation document entitled “Proposals for supplementaryprescribing by nurses and pharmacists….” on www.mca.gov.uk. Ifyou wish, you can respond individually to the Medicines ControlAgency, but we shall also submit a response from the RCN Forum,and will be most grateful for your comments.

Diabetes guidelines for nurses: The new committee plans to workwith the RCN Institute to develop national guidelines for nurses, andis currently brainstorming ideas. We would like advice from membersabout the focus of the RCN recommendations in the light ofguidance already published by NICE (National Institute of ClinicalExcellence) and SIGN (Scottish Intercollegiate Network). What sort ofguidelines would be most useful? Initiation of insulin treatment?Should there be separate guidelines for patients?

Please send comments on either of these topics toKaribu01@globalnet.co.uk or to the RCN Diabetes Forum,c/o Anne Elliott, 20 Cavendish Square, London W1M 0AB

Marilyn Gallichan, ChairEmail: karibu01@globalnet.co.uk

The Royal College of Nursing: The Voice of Nursing20 Cavendish Square, London, W1M 0AB. Telephone 020 7409 3333 Fax: 020 7647 3435