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why 6 monthly "complete" neurovascular assessments for "high risk" pts? in clinics i have worked in, all diabetic pts have a 12-monthly "complete" neurovascular assessment, the function obviously is to 'catch' the "low risk" pts if and when they achieve "high risk" status, so a regular treatment regime can be instigated. At each treatment session, a visual inspection of feet and footwear is part thereof. A pt cannot get any 'worse' than a 'high risk' classification, so what's the point of doubling "complete" assessments, surely a 12/12 interval is sufficient? yours truly, the ignorant one

This is a question I pose to the students (...to make them think ). If you look at the policy documents they either say 6 or 12 months. We have the:
International working group guidelines (12 months)
American Diabetes Association Guidelines (12 months)
APodC/ADS Guidelines (6 months)

But you right, why do a complete re-assessment on someone who is already in that high risk category???? - they need different interventions to an assessment that the policy guidelines says should be done.

__________________
Craig Payne
Department of Podiatry
La Trobe University
Melbourne, Australia
http://www.latrobe.edu.au/podiatry
__________________________________________________ ___________________________________
God put me on this earth to accomplish a certain number of things - right now I am so far behind, I will never die.
The views expressed above are those of the author and not that of La Trobe University
This is where I am, where are you?

God help us if we had to assess every 6/12. We're struggling to cope with the annual assessments and review appointments...(I work in Community Health)

I agree you can't get any worse than high risk - although there are different levels within high risk - treatment plans need to be specific to each person's issues!

Dear All,

Why do we do an assessment?

What is the purpose of doing these checks?

I thought the purpose was to monitor change.

Then when we have evidenced change in status what then?

Surely it is to feed back to the various interested parties eg:

GP. Diabetic Clinic , Diabetic Unit at Acute Hospital, Practice Nurse, etc etc.

Then appropriate action can be taken to reduce the risk of damage to the foot.

So if foot neuropathy deteriorates then the pt has to be educated to the risks of footwear and hosiery causing damage which may not be felt etc etc.

We are supposed to know why we do something and also know what to do with the information and also what action to take.

Here in the UK the new NICE guidelines 10 for diabetes type 11 management have been published. My PCT in partnership with the GP practices and Practice nurses are running education sessions for the practice nurses in the assessment of the diabetic foot for this.

There are 4 categories of risk under these guidelines:

1: Low risk no neuropathy or vascular disease and no pathology of foot.

2: Increased Risk either neuropathy or vascular disease and no pathology of foot.

3: High risk neuropathy and vascular disease with pathology of foot.

4: Ulceration and or history of ulceration of the foot.

The Practice Nurses will be doing the annual assessment for level 1.

The Practic Nurses will be doing the 6-12 month assessments for level 2.

The Podiatry Dept will be doing the 3-6 month assessments and provide any treatment necessary for level 3.

The Podiatry Dept will be doing the 3 month assessments and provide any treatment necessary for level 4. In addition where ulceartion the Podiatry dept will provide wound care in partnership with Practice Nurse, Hospital Diabetic clinic, GP etc etc.

So as you can see quite a dramatic change.

The Nurses will be looking after 1 and 2 while we will be looking after 3 and 4.

Of note we will not be providing simple social nail care for level 1 and 2 but will be providing an education session to help people and encourage people to provide this for themselves.

In the past diabetics were told basically to not touch their feet.

Utter nonsense many of them are well able to provide basic care for their own feet and should be encouraged to do so.
Also they will be examining their feet when they are doing the basic care. Whereas before they did not look at their feet for the 3 months between nail cutting appts. This basic negligence by pts has leads to unnecessary problems.

So pt education and empowerment will hopefully lead to a new sense of reponsibility for pts for their OWN FEET thereby leading to fewer complications.

regards David

hi david, the only differences in protocol between the one you have described and that of say, ACT Health (Australia), seem to be that here the podiatrist does the 12/12 complete assessment for level 1's, level 2 is considered "high risk" and thus a 2-3 monthly tx regime by the podiatrist is initiated / continued, and apart from a different tx regime level 3 is treated the same as level 2. If you mean a complete assessment, 6 monthly for level 2's and 3 monthly for level 3's, again what's the point? a 12/12 assessment is surely sufficient for pts who are tx by a pod 2/3 monthly. An earlier reassessment / care plan only indicated for pts with onset / exacerbation of pathologies noted at the tx sessions. all the best.

I have just re-jigged the guidelines in my trust to reflect the NICE guidlines.

It will mean that:

Low risk (no neurovascular change) = annual review by nurse
Increased risk (non-immediately threatening neurovasc changes) = 3-6/12 by Podiatrist
High risk (immediately threatening n/v changes or px acute diabetic foot complication) = 1-3/12 by Podiatrist
Ulcerated foot = referral to multidisciplinary foot clinic within 24 hours and reviewed in that setting until 'resolution'

The point, obviously, is not the assessment, but what you do about the complications i.e. orthoses, footwear advice, referral to vascular surgeon, referral to Diabetes specialist nurse.

Theoretically, this should mean that we actually end-up with fewer short-return patients, as will we have picked-up their problems before they develop the ulcer/Charcot.

Of course this doesn't account for patients who don't turn up for ongoing assessment, who are usually the ones we need to see and so whther this will make a difference is debatable!

I don't think it's the assessment that's important, but the education and treatment provided to prevent the problems occurring???!!!!

Just my take on it!

__________________
nicpod1

nicpod1 says "I don't think it's the assessment that's important, but the education and treatment provided to prevent the problems occurring???!!!!"
davidjohnconley says "fair enough"

Agree 100%. That's what we're trying to achieve...the level of resistance is incredible though. Some days you feel like throttling the Pods that have gone before me (at least those before me where I've worked) and convinced these people that they're completely helpless with regards to foot care!

Dear All,

in response to OFITG i believe in the past many of us practiced with our heads up our arses.

Pt comes into clinic and sits down.

Both feet nails cut and filed.

Both feet pmpj cal red.


Oh yeah what did you come here for?

Oh yes the Physio dept referred you for insoles .

Never mind see you in 3 months ..
whhereupon the same event would take place for approx 20 years.

And we wonder why we are not taken seriously.

Those idiots amongst us who have endeavoured to change to modern evidence based practice to try and effect a positive outcome for our patients are faced with:

What about me nails.

I really do despair at times.

Even new grads are bullied hoodwinked into this by pts.

Today our new grad was doing the annual diab assess on a 48 year old male.

Who really did ask for his nails to be cut.

When informed that he had been doing this himself for a year this led to an acidic comment and petulent behaviour from this pt.

Who in his other life as a human being not an NHS pt runs a successful business.

It is interesting .

So we soldier on ducking and diving the irrelevant complaints about not cutting nails and avoiding the manager who has had to provide a polite response to the nonsense complaint.

Yep i had my managers response today to a recent complaint from a diabetic pt who is able to cut own nails and who has been doing so. But expected me to cut nails for her when doing annual diab review recently.

wait till they find out they will be in care pf practice nurse who will not cut nails.#

Should be fun.

regards David.

Oh to be a fly on the wall!!

so says davohorn
" a diabetic pt who is able to cut own nails and who has been doing so. But expected me to cut nails for her when doing annual diab review recently."

so says davidjohnconley
16.11 (aust east daylight saving time) 9th december, 2005
another has just left my treatment room, rushed to me as an emergency with a "lump" of recent origin. Dx pinch callus from new joggers. on Ax has beautiful numbers, his given footcare/footwear/orthoses advice & handout and is bid adieu......... the stunned mullet expression "you haven't cut my nails"....... Aaaaaaaaaaaaaaaaaaaaaaaargh

I kniw the feeling.Here in the states,my diabetic pts ask:Are you going to cut my nails?Well,I do that.But I also provide these folks with a foot exam and advice on what to do if a problem.Compliance usually is not an issue.....although I had a lay with 2 nasty ulcerations on her feet ignore her followup(she came in recently and her ulcers appear to be a lot better,thank goodness).So you do what you can.I myself see these folks every few months or more as needed.