There is a large variation of clinical outcomes across regional NSW for High Risk Foot Service (HRFS) patients and there is evidence that a specialist outpatient service can improve outcomes. Decreasing the risk of lower extremity amputations, hospital admissions and the associated loss of productivity, morbidity and mortality can reduce associated hospital expenditures by up to 85%1.

The Agency for Clinical Innovation (ACI) Endocrine Network has identified the importance of standardising services across the State to reduce the variation in outcomes and ensure appropriate access for patients with diabetes related foot complications. Recognising that resources vary based on what is locally available the Lismore Base Hospital (LBH) High Risk Foot Service (HRFS) has developed a multidisciplinary HRFS in the Richmond Valley to provide a level of care beyond that provided by traditional podiatry.

The area has some of the highest rates of hospitalisation in the State for diabetic foot disease, a number of which are found to be avoidable2. This is at least partially due to Lismore Base Hospital being the tertiary referral service for both the Richmond and Clarence Valleys. Irrespective of the reason for the high rates of admission, there is a recognised need for an outpatient HRFS and escalation pathway, and for follow up for these at risk patients.

In recognising that lower limb complications contribute to unnecessary hospital admissions and amputations, the State based Leading Better Value Care (LBVC) initiative has demonstrated specialist outpatient HRFS can improve medical outcomes. The spectrum of diabetic foot disease complications includes ulceration, deformity, ischemia, infection (including osteomyelitis), and Charcot’s neuroarthropathy. There is a large body of evidence to support the fact that the majority of foot ulcers in people with diabetes can heal under the guidance of a  multidisciplinary team, with only a few requiring a lesser (below the ankle, often digital) amputation. 

The demographics of the Richmond Valley is that of an aging population and the North Coast Primary Health Network (NCPHN) has identified that the availability of podiatry services in the Lismore area is below those recommended nationally. Additionally, there are large pockets of disadvantage, a lower than average level of education and many other socioeconomic determinants of health that contribute to poorer outcomes for this population and these have contributed to a higher than State average rate of diabetes diagnosis, complications and hospital admissions.

The podiatrist for the High Risk Foot Service commenced in Lismore in February 2019, and was initially involved in a planning role, modelling the service on the National Association for Diabetes Centres [NADC] and ACI Guidelines and Key recommendations for High Risk Foot Services3. Since its inception, the HRFS has been able to meet a majority of the key recommendations and standards. The service operates in line with best practice guidelines and national and international models of care. The clinical lead podiatrist manages the clinical load, oversees the broad spectrum of care and endeavours to action referrals within one day of receipt. Prioritisation criteria determine the allocation of urgent appointments.

Recommendations from both the NADC and the ACI include structured multidisciplinary clinics held both in the morning and afternoon to ensure patient access, and access to medical oversight and escalation with specialist involvement in the clinic at least once every two weeks. The HRFS has effectively been able to meet this recommendation as it is located on site at Lismore Base Hospital, where it holds its four specialist clinics each month.

The HRFS has access to the vascular teams including consultants Dr Dominic Simring, Dr Anthony Leslie and Dr Deepak Williams and their teams for escalation as required. 

Input can also be sought from other specialties when appropriate. These include but are not limited to Infectious Diseases (Dr Sarah Coghlan), Renal and  Endocrinology/General Medicine. These services are accessed, typically by phone as required but when physical review is required this is coordinated through the Lismore Base Hospital Emergency Department. 

For those requiring corrective surgery or an orthopaedic opinion, an outpatient clinic is run once a month by Dr Richard Freihaut and the LBH orthopaedics team provide specialist input outside of the clinic’s hours. 

The allied health MDT clinics are once a week in the morning and once a month in the afternoon.

There has been overwhelming positive feedback from those involved in assisting the service. Prior to the commencement of the LBH HRFS there was a clear gap for patients in the Richmond Valley. The service now meets almost all the criteria set out in the national NADC HRFS standards. This is an excellent outcome given the difficulties in sourcing administrative support and gaining access to foot pressure offloading equipment, specifically a lab for orthotic manufacture and plantar pressure analysis system. 

In summary, the dedicated work of a motivated HRFS team with a mutual understanding of the importance of multidisciplinary, patient centered care, has given patients and clinicians involved in the service positive experiences and improved outcomes. 

References:

  1. The Australian Commission on Safety and Quality in Health Care
  2. North Coast Primary Health Network [NCPHN], Needs Analysis 2018
  3. ACI Guidelines and Key recommendations for High Risk Foot Services
  4. Agency for Clinical Innovation, High Risk Foot Services 2018

Image by Bondegezou -crop / CC BY-SA https://commons.wikimedia.org/wiki/File:Two_ischaemic_ulcers_on_the_foot_of_an_individual_with_type_2_diabetes.jpg