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Hi All,

Just trying to get a feel for other podiatrists’ opinions regarding footcare clinics run by division one nurses.

I currently work for a rural health service in Victoria, and my colleagues and I are under pressure to introduce nurse led footcare clinics to ease our waiting lists (up to 4 months for a return appointment at one site). Podiatrists would set up these clinics; people would be referred to the clinic by podiatrists following assessment for diabetes/neuropathy/any pathology. The treatment would be carried out by division one nurses who would not necessarily have any extra footcare training apart from an in-service provided by podiatry staff. And to make us all cringe – without any supervision.

We are very nervous about setting up such a system, and are unsure of the medicolegal implications of such an arrangement – it seems all responsibility lies with podiatry.

I have read previous threads regarding therapy assistants, but they are all discussing the use of supervised clinics with some level of qualification.

I look forward to hearing your opinions,
Thanks in anticipation,
Erin

Erin, goodaye, ACT Health has conducted Foot Care Clinics for at least 5 years. Pts have been assessed by podiatrists (though at one stage diabetes educators were also) as "low risk - unable to care". Pts must have "simple nails"! 'The enrolled nurses (12 mth trained) that are used, in-serviced by a podiatrist, are NOT supervised. Don't volunteer! The nurses may ask for advice, which could implicate the pod in litigation? I don't like them.
Make sure the nurses know there's no supervision by you, that you are not responsible, that that would probably be themselves or the level 2/3 nurses.
It's where the middle level management insist the "noisy wheels" go!
RESIST !!!!!!
all the best, mark

Erin,

What is the rationale for using Div 1 nurses? They will cost about as much as podiatrists, but the community Health funding will be at a lower rate.

Re Supervision. It can be provided remotely. You just need to ensure that there is a feedback mechanism, so that any new issues that develop can be addressed quickly.

There is also an issue of patient consent. They must be aware of the risks and benefits of the alternate service.

__________________
Stephen Tucker
Eastern Health
Podiatry Manager

My location

Dear All,

I am becoming concerned that we no longer want to treat the human foot.

My reason is based upon this thread and the one where Assistant grades are to have their skill base and role enhanced.

So what are we going to be left with???

Buggered if i know!

Physios Chiropractors Osteopaths all use Bio Mech as a modality.

Nurses and Wound Care Specialists do our foot ulcers.

And all types of hangers on including beauty therapists and pedicurists all want a piece of our action.

Oh well only option left is Surgery and upsetting the Surgical Fraternities.

What is wrong with us?



regards david

There are clinics here in the United States, staffed by nurses and nursing assistants. I am aware of two separate sites, through the VA (Veterans Affairs). Patients are screened and assigned a relative risk-level. A diabetic patient with no PVD, no history of ulceration, and no neuropathy is judged to be at low-risk, and can be seen on a routine basis by nursing staff. Diabetic patients with co-morbidities are seen by the Podiatrist. My understanding is that this is done because of high-volume Podiatry Clinics, and significant wait-times for patients seeking Podiatry Care. This also occurs in rural or underserved areas, where Podiatry care is difficult to find. -John

__________________

Dr. John G. Fasick
LSUHSC New Orleans
Clinical Insructor, LSU School of Medicine
jfasic@lsuhsc.edu

It's the medico-legal issues that are really grey. I talked to the ANF to find out if nurses had liability cover for footcare stuff and they would not give me a straight answer, they say a nurse is covered for whatever they are trained to do, but if they have no training in a particular area then they are not covered. The legal issue becomes what constitutes training? And does a one day course at Mayfield actually qualify you to do anything? And if it really does then why does podiatry take four years?

The pod association in Vic when asked would not give me anything other than the fact that whoever the referring podiatrist is remains liable due to the concept of vicarious liability......you can't refer to someone that you don't know has the skills and qualifications without it having consequences back to you. This is becoming a more serious issue in general medicine as people argue about having been referred to a different service and therefore no longer being the responsility of the person who refferred them off. If you don't want to be responsible don't make a referral. Just tell them to access service elsewhere.?

It's all a bit of a mess for the time being, but if you can do basic foot care after only one day then why does it take so long for the Uni based courses to get the students actually doing stuff. There appears to be a real lack of consistent over view here, and all the different interest groups all have an axe to grind, power to gain or money to make.
regards Phill Carter

Good post.
I'm f-t public, and as a podiatrist I refer "low-risk unable-to-care" category pts to foot care nursing. Enrolled nurses performing treatments supervised by Level 3 team nurse. Apparently, according to my brave and wonderful (and very attractive) chief podiatrist, I in turn am covered by my employers vicarious liability.
mark c

Thanks everyone for your advice and opinions - there is enough doubt out there for me to stay away from this issue for a while!

These arguments, as well as advice from our insurers (don't do it) have been put to the manager pushing this program. Alternatives, such as making the service GP referral only and introducing priority criteria have been put to said manager and have been refused on the spot.

The way we are dealing with this now is to refuse to refer people to these clinics, so on we struggle with our 6 month waiting list...

Thanks again everyone, it was good to know we're not alone in being against this!

We are similar to Mark C in community health in Vic with long wait lists. However, we have a couple of Mayfield trained allied health assistants that we can either refer to or the rest of the allied health staff can refer a client to for nail care. The liability is then on the referer and the organisation. Podiatry do not manage the clinic and the allied health assistants also cut fingernails. In our area, with our referring staff/treating staff, it works very well. The client load is non-pathological nails (hands and feet) however are totally unable to reach or see their for appropriate care.

I think the trick is about the appropriate set up and relationship with podiatry. Are they an extension of your service or an adjunct. What makes them different to the pedicurist down the road that doesn't sterilize their instruments, well, the fact they do, they are part of an acredited organisation with sterilization standards, competencies, training etc.

They are just treating toe nails and finger nails. Take it away from podiatry, give it some Home and community care personal care funding and off you go. They are just nails, not rocket science.

I think we have moments of feeling too precious, that we forget our role in foot health care/prevention. Or are we still defining that?

__________________
Cheers,
Cylie.... in a permanent state of confusion

All ideas worth thinking about, but the opinion of your employer in relation to what they think you are covered for or not will mean diddly squat when the lawyers start arguing and the Judge decides who is going to pay to clean up the mess. Call me paranoid or anything else you like but my life experience says that when something unexpected happens everybody and all organizations go into spin and damage control and you stand a real chance of being on your own and held out to dry. When I was an Outdoor Ed teacher I was familiar with a case where a school leaned on a teacher to take a student on trip, the student had a known condition, the parents wanted the child to go on the trip, leaned on the school, signed all sorts of useless waivers, the teacher gave in to pressure from the school took the teenager to Alice Springs, the kid died from the known condition due to being unable to access medical help quick enough when a problem arose. The parents sued everybody involved. Five years later the teacher was bankrupt from legal fees, lost their house over it. It does not always matter who is right or wrong anyway, all that matters is who is going to pay the lawyers...and when someone sues you they will be your bills....or you'll have to pay lawyers a great deal in order to get someone else to pay the first lot of bills. Make sure you have your own insurance, I know some people in public health who rely on their employers insurance.....crazy...
regards Phill Carter