Quality Assurance and Verification Division HEALTHCARE AUDIT SUMMARY REPORT Title Number Audit of compliance with the HSE Model of Care for the Diabetic Foot in high risk diabetic patients in selected acute hospitals QAV003/2015 Timeframe March July 2015 Audit Team Members Ms Mary Greene, Auditor, Quality Assurance and Verification Division (Lead) Ms Anne Keane, Auditor, Quality Assurance and Verification Division Ms Catherine Timoney, Auditor, Quality Assurance and Verification Division Approved by Dr Edwina Dunne, Assistant National Director, Quality Assurance and Verification National Audit Contact Ms Marie Tighe, Programme Manager, National Diabetes Programme/Primary Care until 20 March 2015 Ms Caroline Mc Cusker, National Lead Podiatrist from the 20 March 2015 Source of Evidence Type Request for Evidence University Hospital Waterford Louth County Hospital Sligo Regional Hospital Date Evidence returned 16 April 2015 Evidence returned 16 April 2015 Evidence returned between 24 April - 25 May 2015 Issue Date 23 July 2015 Site Visit University Hospital Waterford Louth County Hospital Sligo Regional Hospital 28 April 2015 13 May 2015 02 June 2015
Report Distribution Date: 23 July 2015 Name Mr Patrick Lynch Mr Liam Woods Dr Ronan Canavan Ms Caroline Mc Cusker Dr. Edwina Dunne Title National Director, Quality Assurance and Verification Division National Director Acute Hospitals Clinical Lead, National Diabetes Programme Podiatrist, National Audit Contact Assistant National Director, Quality Assurance and Verification Division
1. BACKGROUND / RATIONALE The National Diabetes Programme of the Health Service Executive (HSE) developed the Model of Care for the Diabetic Foot (2011). Diabetic foot disease is a common complication of diabetes and by its nature patients often have a long documented history in the healthcare record (HCR) regarding their care. The Model of Care (MOC) for the diabetic foot defines a risk categorisation method in foot care management, i.e., high risk is defined as an abnormality that predisposes a patient to foot ulceration and active foot disease is defined as the presence of an active foot ulcer. This integrated MOC is based on three categories of risk and is intended to provide a structured approach to the management of foot care needs of patients with diabetes. The National Programme Lead for Diabetes has sought assurance that the integrated model of foot care for diabetic patients in the high risk category was in use and being managed by multidisciplinary foot care services. The hospitals selected for audit were Louth County Hospital (LCH), Sligo Regional Hospital (SRH) and University Hospital Waterford (UHW). 2. AIM AND OBJECTIVES The aim of the audit was to establish the level of foot care management for high risk diabetic patients in selected acute hospitals as per the model of care for the diabetic foot based on the following objectives: To determine that diabetic patients who are categorised as high risk have scheduled annual care reviews by members of the foot protection team. To determine that diabetic patients with active foot disease are referred to the diabetic foot clinic urgently and are seen within 24 hours or at the next clinic by the multidisciplinary foot care service. To establish the process of referral for rapid access to a multidisciplinary team in a tertiary centre (vascular or orthopaedic) where required. 3. KEY FINDINGS Categorisation of risk and annual reviews: Foot assessments are carried out predominately by the podiatrist. A risk category for each patient was documented on a foot assessment tool but the audit team found that this was not always completed. Annual reviews occur however records were limited as the audit period defined was from January to March 2015. In the HCRs audited all high risk and active foot disease patients were assessed and followed up regularly. Active foot disease patients referred within 24 hours: In the model four hospital visited the majority of active foot disease patients referred were seen within 24 hours or the next working day. Active foot disease patients are managed in the model three hospital; this is not in keeping with the MOC. A limited number of patients were seen within 24 hours or the next working day. Referral to the tertiary centre from the model three hospital only occurs for vascular assessment. The model two hospital referred all patients with active foot disease to the model three and four hospital for management. Multidisciplinary Team (MDT): Foot protection teams were in operation in each hospital. The teams comprised mainly of the endocrinologist, podiatrist and diabetes nurse specialist (DNS). Meetings were held regularly often jointly with another group hospital. Formal MDT meetings in the tertiary centre occurred infrequently due to non attendance of the surgical specialities.
Rapid access and referral to the tertiary centre: Referral by the foot protection service to the tertiary centre and or other hospital specialties is informal and the audit team found that documentation of referrals was limited in the healthcare record (HCR). Communication regarding discharge of patients in the tertiary centre back to the host hospital was poor and frequently not documented. Podiatry service: The audit team was informed that all hospitals have a podiatry service. In two hospitals the podiatrists were only in place in the last twelve months. The podiatry clinic was held daily in the model four and three hospitals and weekly in the model two hospital. The podiatry and endocrinology clinics are mostly held concurrently and review all high risk and active foot disease patients in the model four and three hospitals. In the model two hospital patients were seen by the podiatrists initially in order to manage their referral to the model four or three hospital. The audit team found that communication between hospitals was informal and lacked structure. The hospital based podiatrist works closely with the community podiatrist in their area. Diabetes Nurse Specialist: The DNS screens diabetic patients and provides education on the importance of good foot care. The DNS also provides education on foot assessment to practice nurses based in GP practices. Documentation of the care provided by the DNS was noted in the HCR or electronically in the model three and two hospitals visited. In the model four hospital DNS nursing notes were kept separate from the HCR. All patient documentation must be recorded in the HCR in accordance with the HSE Standards and Recommended Practices for Healthcare Record Management V3 (2011). Database: There is a need for a national database to record activity data on the foot protection service. Two hospitals held records of referral and attendances at the podiatry service and the team found that this data varied in content and needed updating on a continual basis. Diabetic and podiatry consultations in two hospitals were predominately paper based while one hospital had an electronic IT system for all out patient attendances. There is no formal record of podiatry attendances in the model two hospital. The audit team was informed that the model three and two hospitals had a high level of DNA s to the foot protection service. 4. CONCLUSION In all three hospitals compliance with the MOC was variable. The audit team found that the model four and two hospitals were in the main compliant and can provide reasonable assurance that the MOC has been implemented. The model three hospital was partially compliant, the audit team provide partial assurance as the MOC has not been fully implemented. Key deficits found by the team were the timeliness of referral from model three and two to the model four hospital, the lack of communication between hospitals resulting in the absence of discharge information from the model four hospital. A national database for all high risk diabetic foot patients is required in order to demonstrate the activity and outcomes for patients. 5. RECOMMENDATIONS 1. A national database must be developed to accurately record standardised data on high risk and active foot disease patients which is accessible to all disciplines 2. To develop a structured approach to the communication of discharge information between hospitals for the diabetic foot patient. The audit team wish to acknowledge the co-operation and goodwill afforded to them by the management and staff at all hospitals involved.
Lead Auditor Ms Mary Greene Signature Date 23 July 2015 AND QAVD Dr. Edwina Dunne Signature Date 23 July 2015
APPENDIX A: RECOMMENDATIONS ISSUED TO THE HOSPITALS Recommendations issued to the sites in respect of Objective 1 Hospital Recommendation UHW SRH LCH 1. Ensure that all foot assessment screening tools are fully completed and a risk category is documented in the HCR. 1. Create a summary report from the Prowellness system on each high risk diabetic foot patient and include this information in the patients HCRs biannually. 1. Develop a database that accurately records the high risk and active foot disease category of patients. Recommendations issued to the sites in respect of Objective 2 Hospital Recommendation UHW SRH LCH 1. Ensure as a matter of urgency that all documentation of the care provided by the diabetic nurse specialist to the diabetic foot patients is recorded in the health care record in accordance with the HSE Standards and Recommended Practices for Healthcare Record Management V3 (2011). 1. Sligo Regional Hospital must develop a podiatry database that accurately records the high risk and active foot disease category of patient who attend the diabetic foot service within a 24 hour period or the next working day. None Recommendations issued to the sites in respect of Objective 3 Hospital Recommendation UHW SRH LCH 1. Ensure that the Model of Care for the Diabetic Foot (2011) is implemented across all departments including the Emergency Department. 2. Hold multidisciplinary foot care team meetings on a regular basis to formalise the Model of Care for the high risk diabetic foot patient across all departments. 1. Agree with UHG a clear process of documentation of care for the diabetic foot patient. 1. Agree with the BH and OLOLH a clear process of documentation of care for the diabetic foot patient.