DEMO Evidence Based Diabetic Foot Risk Screening Tool -- Level 1 Summary

1. DEMO Evidence Based Diabetic Foot Risk Screening Tool -- Level 1 Summary HNHB LHIN Wide Foot Care Working Group

2. Presented in Partnership

3. Presented byFeet First Steps To Health Diabetic Foot Care Program • Connie Comtois-Spitman- Presenter • LHIN Wide Foot Care Best Practices Working Group/ Provider Team - Producer • Lori Makarchuk-OTN / Operations

4. Diabetes Action Group Report 2008 Recommendations • All individuals diagnosed with diabetes in the HNHB LHIN receive an annual foot exam by a regulated health care professional • Health care providers within the LHIN provide evidence based foot care that is appropriate to the provider/ seek appropriate referral • No cost Diabetic foot care service be made available to those found to be at high risk

5. Goal Develop LHIN wide, Multidisciplinary community initiative for the evidence based assessment , education and treatment of basic foot care issues related to diabetes.

6. Diabetic Foot Screening Tool Users • Level 1 Point of contact// Multidisciplinary Diabetes Health Care team. • MD, NP, BSN, RN,RD, Pharm,( may be RPN, homecare under medical directive), Diabetic Educators CDE • Level 2 Specialized foot care Chiropodist/ Podiatrist/ Physician • ( in addition, BSN, RN, ENT with advanced training) • Level 3 Specialized High Risk Referral, Neurologist, Vascular Surgeon, Orthopod, Infectious Disease, Plastics, Derm etc

7. Summary60 sec Diabetic Foot Screening Tool • Vascular assessment ( Pulse, Cap refill, appearance) • Neurological assessment ( monofilament/ vibration on-off method, pain report) • Skin/ Nails ( condition/ self care/ deformity) • Footwear/ hosiery assessment ( condition/fit/ appropriateness)

8. Vascular assessment REVIEW Capillary refill time ( 3 sec or less) Presence of Pedal Pulses ( Dorsalis Pedis) Skin Temperature ( Hot/ Cold) Dependant Rubor/ Erythema/ Odema ( red, irritated, swolen )

9. Neurological Assessment for Sensory Loss Includes Monofilament testing score 10 sites ( x/10 ) *using Semmes Weinstein 10g monofilament Vibration test *using on/ off method 128 MHz tuning fork to dorsal aspect great toe proximal to nail.

10. Skin Assessment REVIEW • Identification of lesions toes, dorsum, plantar, heel, toes, between toes • Presence of corns, callus, blisters • Open areas eg • Fissures/ Ulceration • ( duration/ appearance should be documented)

11. Nail Assessment REVIEW • Thickness ( normal, crumbled, broken) • Discolored ( black, brown, yellow, reddish) • Bruised, loose or missing • Condition/ Self care manageable?

12. Footwear/ Hosiery Assessment • Look for signs of wear, including integrity of materials inside and on the sole • Fit and distortion of shoe shape • Fit of stockings indicated by indentation on legs/ toes • Appropriateness ie thermal in winter, or walking shoes for daily activity etc • Can they retain the foot?

13. 60 second Foot Screen Algorithm

14. Resource Flow Chart Self Management Goal Setting / Problem Solving High Risk Intervention Vascular, Ortho Nero, Endo Wound Care (Level 3) Education Patient Refer to Foot Care Program RN / PRN Chiropodist / Podiatrist (Level 2 ) Level 1 Foot Screen

15. Evidence Based Vascular Assessment • Capillary Refill time (1)protocol • Dorsalis Pedis Pulse (2)location and assessment 1 http://www.nlm.nih.gov/medlineplus/ency/article/003394.html 2 A. Mowlavi et al, Postgrad Med J, 2002. 78:746-747

16. Evidence Based Neurological Assessment • Validity of the Semmes Weinstein 10g monofilament examination Level 1/ Class A Evidence • Assessment using Superficial pain sensation and vibration by on-off method are both well established with Level 1/ Class A Evidence • Recommendation of minimum of Annual Screening for the patient with the Diabetic Foot, although more frequent screens may be indicated based of level of risk Feng Y. , Schlosser FJ, Sumpio BE, J Vasc Surg 2009 Sep 50(3) 675-82: Kamel N et al J Diabetes Complications 2005 Jan-Feb 19(1)47-53 OlaleyeD., Perkins BA.,Bril V Diabetes Res Clin Pract. 2001 Nov.54(2)115-28:

17. Diabetes Guidelines Reviewed Canadian Diabetes Association-Clinical Practice Guidelines or the Prevention and Management of Diabetes in Canada 2008 Registered Nurse’ Association of Ontario-Reducing Foot Complications for People with Diabetes ( Nursing Best Practice Guideline) 2007 Best Practice Recommendations for the Prevention, Diagnosis and Treatment of Diabetic Foot Ulcers: Update 2010 Canadian Association Wound Care Diabetes Care Program Nova Scotia( Best Practice Clinical Guideline Diabetic foot care LEAP ( Lower Extremity Amputation Prevention)

18. LHIN Wide Foot Care Best Practices Working Group/ Provider Team • Connie Comtois-Spitman-(Chair) NHCHC Feet First Steps to Health ( Chiropodist) • Dr. Vance Pegado- DRCC (Physician Lead ) • Bo Fusek- DRCC ( CDE) • Crystal Poyton- Quest CHC ( PHCNP) • Michelle Overholt- Grandriver CHC (PHCNP CDE) • Cathy Jager- Joseph Brant CHC ( CDE) • Elenore Wormald-Medical Group Niagara FHT( CDE)

19. Acknowledgments • North Hamilton Community Health Centre • Feet First Steps to Health Diabetic Foot Care Program Hamilton/ Niagara • Quest Community Health Centre • Diabetes Regional Coordination Centre • Ontario Telehealth Network • References are available upon request Contact: comtois-spitman@nhchc.ca/