The key to reducing diabetes-related amputations is to ensure that an integrated footcare pathway is in place and there is access to a multidisciplinary foot team. Sheffield, in 2009, had all of this – yet it still had one of the highest amputation rates in the country. Root cause analysis of all amputations over a 12-month period identified that the sheer complexity of the pathway was often creating unnecessary barriers to the patient journey. A number of different initiatives, were implemented, such as a foot hotline, simplification of the foot pathway and improved training of primary care screeners. As a result, there has been almost a halving of the amputation rates in Sheffield, over a period when the national rate has remained static.
Amputation is one of the most feared complications of diabetes and has an enormous impact on patients’ lives, including loss of occupation and status, disfigurement, reduced mobility, and depression. In addition survival is bleak, with mortality rates after amputation of 50% at five years, which is worse than many cancers. A recent study has shown that there is a 10-fold variation in the incidence of major amputation as a consequence of diabetic foot disease. Sheffield had one of the highest amputation rates in the country from 2007-10: 4.4 amputations per 1000 people with diabetes, compared to a national average of 2.7. In addition, from 2008-12, there was an 80% rise in foot clinic activity (reflecting the increasing prevalence of diabetes from 4.2% of the population to 6%), without the equivalent rise in resource - and this was resulting in significant levels of both patient and staff dissatisfaction.
After a detailed root cause analysis of every amputation (minor and major) over a 12-month period, it became clear that there were issues across both primary and secondary care which were potentially contributing to our high amputation rates, with at least 20% of them potentially avoidable. No single intervention was likely to be effective so the team set out to design and implement a series of different interventions that would result in the primary objective of reducing the rate of amputations and secondary objectives of reducing delays and improving patient experience.
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