cORONAVIRUS

Managing

foot disease

in the COVID crisis

cORONA

VIRUS

Managing

foot disease

in the COVID crisis

the global challenges

One thing that's certain is the global COVID-19 situation will demand more and more hospital bed capacity to manage. What we also know is diabetic foot disease is a leading cause of hospital bed occupancy, and that health care professionals working in teams adhering to evidence-based DFD guideline recommendations can significantly reduce hospitalisation. So, it's vital now more than ever, for the global DFD community to potentially help the COVID-19 situation by keeping as many DFD patients out of hospital beds as possible with effective DFD care.

But what we also know is effective evidence-based DFD care is becoming increasingly challenging for global health care professionals to provide because health systems need more physical resources to manage COVID, with less physical resources then available to manage DFD. And health care professionals are telling us they need advice from DFD experts for practical tips on how to provide evidence-based DFD care in an increasingly changing landscape.

To help tackle this, DFA has joined forces with IWGDF to keep health care professionals informed with handy global COVID-19 information specifically related to DFD, and also provide national resources for our local health care professionals.

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The COVID-19 crisis will demand more hospital bed capacity to manage

DFA_patientsicon_white_web

Diabetic foot disease is a leading cause of hospital bed occupancy

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Evidence-based care can significantly reduce DFD hospitalisation

Australian Clinical Guide for using telehealth

For people with diabetes-related foot disease during the COVID-19 pandemic

The following is a guide to help Australian clinicians who are considering using telehealth as an alternative service type to augment the care of their patients with DFD during the COVID-19 pandemic. The guide is designed to support clinicians to consider key DFD elements to determine the suitability, preparation, consultation and documentation needed to help ensure an effective telehealth consultation.

Australian Clinical Guide for using telehealth

For people with diabetes-related foot disease during the COVID-19 pandemic

The following is a guide to help Australian clinicians who are considering using telehealth as an alternative service type to augment the care of their patients with DFD during the COVID-19 pandemic. The guide is designed to support clinicians to consider key DFD elements to determine the suitability, preparation, consultation and documentation needed to help ensure an effective telehealth consultation.

KEY POINTS TO CONSIDER BEFORE THE CONSULTATION

Triage white

DETERMINE THE SUITABILITY FOR A TELEHEALTH CONSULTATION FOR YOUR PATIENT/CLIENT

• Confirm the limb &/or life threatening status and if it is appropriate to be cared for with telehealth
• Willingness to provide informed verbal or written consent to be cared for via telehealth
• Access to appropriate hardware/software required to undertake a telehealth consultation

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DETERMINE IF YOU HAVE/OR CAN OBTAIN THE BELOW HISTORY FROM YOUR PATIENT/CLIENT

• General medical history, including medication and diabetes history
• DFD treatment history, including any applicable blood or microbiological results, wound dressings, antibiotics, offloading and other services used
• Recent DFD classification information, including the site, ischaemia, neuropathy, infection, size and depth status

midway

CONTACT YOUR PATIENT/CLIENT TO DETERMINE IF YOU CAN OBTAIN THE FOLLOWING IMAGES

• Close up of the entire ulcer 
• Midway shot with 4-6cm of healthy skin surrounding the ulcer
• Distant shot capturing the entire foot                                             
• Opposite midway shot capturing the opposite side of the foot 
• All images taken with good lighting or with flash to minimise any shadows

Recent chronological series of the images (preferred but not required) 

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If answered yes to ALL the above then the patient may be suitable for a telehealth consultation

DURING THE VIDEO CONSULTATION

AGREED RULES

SET AGREED TELEHEALTH RULES WITH YOUR PATIENT/CLIENT

• Complete introduction to telehealth consultation and seek verbal/written consent for using telehealth
• Check all personal details provided and confirm images provided for the consultation by the patient/consumer are correct
• Discuss ‘at-home’ assistance available for the consultation and troubleshoot how best to view the feet via telehealth

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DISCUSS GENERAL AND PSYCHOLOGICAL HEALTH WITH YOUR PATIENT/CLIENT

• Discuss how your patient/client is coping and what support and assistance is available at home
• Discuss any fears/concerns for both foot-related and mental health
• Use the time to develop a rapport as your patient/client may feel more comfortable conversing in their own environment

White feet pain

VIEW FEET AND ASK YOUR PATIENT/CLIENT THE FOLLOWING

• To remove shoes and socks and position feet so you can see the ulcer
• To remove dressing so you can see both the dressing, the dressing in contact with the ulcer, and the ulcer
• Ask about any recent changes to the ulcer, including redness, swelling, pain, discharge, leakage, odour, difficulty with dressing changes, and offloading devices
• Show you how dressings are applied and self-care routine for the feet and ulcer: then provide tips if/where applicable
• Demonstrate walking using prescribed offloading device: then provide tips if/where applicable

NEXT STEPS

ADVICE

• Discuss the next steps to care for the ulcer/DFD before the next consultation, including dressing changes, offloading, and who/when to contact if the foot status changes
• Offer further resources/links that can help with ulcer prevention or healing
• Check your patient/client understand or have a level of understanding and ask to repeat these next steps in their own words

REBOOKING

• Ask your patient/client if they would be happy to undertake a telehealth consult in the future
• Determine if the next consultation is appropriate for telehealth or face-to-face
• Rebook your patient/client for the next consultation via face-to-face or telehealth

DOCUMENT

• Document all the above steps in the your patient/client medical  record as you normally would and include images supplied
• Highlight that the consultation was undertaken via telehealth and that information and technology was used

NOTE: This information should not be seen as medical advice and we do not assume liability or responsibility for damages or injury to any person or property arising from any use of any information, idea or construction in this guide.

Australian Clinical Triage Guide

For people with diabetes-related foot disease during the COVID-19 pandemic

The following clinical guide is to help Australian clinicians who are triaging and caring for people with DFD during the escalating COVID-19 situation. This guide is designed to support iHRFS and DFD clinicians, as well as primary care providers and community podiatry, on suggested acceptable alternative processes of care provision. They include considerations for service type and frequency according to factors such as the patient’s limb and/or life threatening status, local staffing and resource availability, as well as for minimising risk of COVID-19 infection.

cRITICAL
FOOT DISEASE CONDITION(S) MAINTAIN USUAL TRIAGE PLAN BEST PRACTICE CLINICAL CARE IN NON COVID-19 CRISIS COVID-19 POTENTIAL IMPACT ON CLINICAL CARE*
  • Foot ulcer with systemic
    (severe) infection
  • Acute limb-threatening ischaemia

 

Refer immediately to
Emergency Department
including for urgent
surgical review

 

  • Hospital inpatient care

 

 

 

  • Hospital inpatient care

 

 

 

 

hIGHLY sERIOUS
serious
stable
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aTELEHEALTH 

Options may include telephone, store-and-forward clinical or radiological images, videocall and other remote monitoring methods (e.g. foot temperature monitoring, step activity monitoring etc.). Telehealth can potentially be funded by Medicare, please refer to Medicare Telehealth items11

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bHOME VISITS

Clinician visits the patient’s home to perform treatment. This can potentially be funded by under Medicare, please refer to
Medicare Chronic Disease Management
items12

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iHRFS

Inter-disciplinary High Risk Foot Service (or equivalent multiple disciplines that include at a minimum a doctor, nurse and podiatrist with direct access to a surgeon, all of whom are experienced in diabetes-related foot disease care).

VERSION 1.0: 07.04.2020 LEGEND: Adapted from Rogers et al 2020. *COVID-19 potential impact in terms of local COVID transmission and/or impacts on local staffing and resource availability may differ across jurisdictions. 

Australian Clinical Triage Guide

For people with diabetes-related foot disease during the COVID-19 pandemic

The following clinical guide is to help Australian clinicians who are triaging and caring for people with DFD during the escalating COVID-19 situation . This guide is designed to support iHRFS and DFD clinicians, as well as primary care providers and community podiatry, on suggested acceptable alternative processes of care provision. They include considerations for service type and frequency according to factors such as the patient’s limb and/or life threatening status, local staffing and resource availability, as well as for minimising risk of COVID-19 infection.

cRITICAL
hIGHLY sERIOUS
serious
stable

What's happening

Around Australia?

That's a very good question & one posted on our Facebook page. How has your department/ team adapted? What are your current challenges? Click on the links below to read how some on our high risk foot services around Australia are facing the COVID-19 challenges & restrictions.

What's happening

Around Australia?

That's a very good question & one posted on our Facebook page. How has your department/ team adapted? What are your current challenges? Click on the links below to read how some on our high risk foot services around Australia are facing the COVID-19 challenges & restrictions.

Perth High Risk Foot Service

What do you consider are the 3 (or more) greatest challenges facing DFD clinicians/IHRFS during this COVID pandemic?

Overall, the 3 biggest challenges we seem to be facing are:

  • Service challenges: Providing ongoing evidence-based HRFSs as we have in the past for our DFD patients with the impact of the various shut-downs of physical services accessible to our patients such as access to timely Vascular surgery intervention and non urgent amputations. limited casting,  patients in self-isolation/quarantine, nursing home lockdowns, reduction of community podiatry services and some GP’s.
  • Implementing the new physical distancing (or social distancing) rules in the clinic in adhering to 4 squared metres per person with particular regard to protecting our very small and specialised workforce from becoming sick or all of us being quarantined at the same time.
  • Relying on patients, carers, photos, or health professionals inexperienced in DFD  to make clinical decisions from afar. If we can see/feel the wound and foot in real life - debride, probe etc we would possibly reach a different conclusion and treatment plan. Our patients are very unreliable about reporting how they’re going. Photos are a guide but not ideal.  As my colleague said – there is a reason we like to see these patients in person every few weeks. Subtle changes are often missed (and sometimes very obvious ones!) and patients don’t always report to us when things aren’t going well.
  • The perception in the community that everything is closed and we’re not seeing any outpatients. Actually as per DFA triage guideline we are still seeing new patients and acute issues and advise people come to ED when clinically indicated or Community services / GP’s refer to the hospital outpatient Foot clinic as they normally would.
What are the 3 (or more) biggest changes you have made to your IHRFSs service processes to more effectively manage your IHRFS patients during the COVID situation?

Service changes:

  • We’re extending patients to their maximum possible review, this is usually determined by frequency of / need for debridement.
  • We monitor by phone / photos (and VC if possible) and check in every 1-4 weeks depending on the patients situation and when the risk of them not coming in is higher than the risk of them coming then we arrange to see them in person. (reactive not proactive service)
  • We’re asking patients, Nurses, Community podiatrists and GP’s  to call us ASAP if their patient’s situation changes and email in any photos to help explain
  • Existing patients already have our HRFS emergency phone line number and email and we’re encouraging them to contact us if there are issues. This is monitored 8am-4pm work days, plus via the answer machine (connects to email in box) and can be forwarded to a mobile if we are not on site.  
  • We’re communicating to the GP’s / community nurses what our plan is for their patients management and making sure they know if we have seen their patient in person or if they are being monitored remotely we need to rely on them letting us know if things are deteriorating.
  • If there is a new acute issue (or a new patient) we still arrange to see the patient as an urgent outpatient ASAP and involve the multi-disciplinary HRFS team members as required.
  • Promoting our HRFS to existing local referrers / private podiatrists / GP’s and asking them to contact us for advice if they have a patient who doesn’t wish to come to the hospital and we’ll support them to provide the best practice in community.
  • Investigating arrangements for admissions of short day cases (up to 4hrs) for minor procedures that can be done in an outpatients procedure room rather than theatre if it would prevent admission or more surgery in a few months time. For example, tenotomy instead of an amputation, more extensive debridement, or toe amp where conservative management is not possible or not stable enough and no PAD concern. 
  • If patients are almost healed we are discharging them to community care + letter to GP a little earlier than we normally would.

Infection control changes

  • All patients are screened coming into the hospital – they all have to come in one entrance. There is a Separate entrance / exit for staff
  • We wear our own clothes to and from the hospital, change into / out of uniform at work. We have clean / dirty bag for transporting.
  • We wipe down our footwear with antibacterial wipes each night and move from dirty bag to clean bag.
  • Several times a day high use items like door handles, keyboard, mouse, phone are wiped down.
  • We designate 1 reserve room in outpatients for any patients with possible symptoms to be seen in. The room has been decluttered and only necessary items taken in. PPE available at the door and has special cleaning regime.

Physical distancing changes:

  • Offices / clinics / meeting rooms have “maximum” number of people advised on posters on the doors.
  • Maximum of 3 people in a clinic room at any one time. This means any relative / carer is asked to stay in waiting area (unless absolutely necessary e.g. dementia / language).  If we need another consultant and there are already 3 in the room already then someone has to go out (usually a podiatrist or relative)
  • We’re separating out our work force and minimising contact. Each day each coordinating podiatrist has one of 3 roles with different responsibilities and a different “base” location. For example:
      • The podiatrist doing the phone / VC reviews can do this from home. 
      • The podiatrist seeing urgent inpatients / ED is also manning the HRFS emergency phone line, triaging and is based in an office.
      • The podiatrist seeing the patients in person is in the outpatients clinic room.
  • Each podiatrist has one day a week working from home and once direct patient contact (i.e. phone/VC reviews) is done they use this time for admin / letters and project/service development work.
  • One podiatrist doesn’t attend the HRFS in person – they stay in a different area and are the “runner” e.g. get extra dressings / walkers etc from the store room and drop off to us. The consultants give input by phone / VC as much as possible.
  • We’re staggering our start / finish times and lunch breaks. And we communicate during the day by phone, email, whats app group and VC for meetings.
  • Shared office spaces have had some computers removed and put in other rooms (e.g. meeting rooms) to separate out staff to required social distancing levels.
  • Student placements have been cancelled.
What are the 3 (or more) biggest changes you have made to your individual clinical practices to more effectively manage your DFD patients during the COVID situation?

We have made multiple individual clinical practice changes as well to try and address challenges and still provide good quality evidence-based care for our DFD patients, including:

Services/clinical practice changes:

    • Ensuring everyone who needs an extended course of Ab’s for diabetic foot infections have enough to complete their planned course, plus a backup script if they’ve nearly finished just in case they can’t get back in.
    • If blood tests or repeat scripts, further imagining  are required the relevant consultant calls the patient to discuss and posts the requests out / ordered digitally so that when they do physically come in we have gathered all the information required to make clinical decisions.
    • Ensuring those doing their own dressings at home have enough dressings supply and a clear personal wound care plan to follow or have community nursing arranged.
    • We are minimising the use of TCC just in case patients cant get back in. Only new acute Charcot are likely to get a TCC at the moment and we’d hope to transition to a CROW as quickly as possible.

Infection control changes:

  • We use our standard PPE for non-COVID patients (gloves + gown if required), but if we have a patient with symptoms or are COVID positive then full COVID PPE is used inc mask etc.
  • Everything used is wiped down between patients / after use – inc chair, stool, trolley and any equipment such as Doppler, dermatemp.
  • Wash hands and alcohol gel all the time.

Physical distancing changes:

    • If a patient refuses to come into the hospital to see us when we feel it is necessary - there have been a few - we advise them to see a community pod +/- GP and liaise with them regarding their treatment plan.
    • Waiting areas have had chairs removed / spaced out or notices put on alternate seats to encourage physical distancing.

Brisbane High Risk Foot Service

What do you consider are the 3 (or more) greatest challenges facing DFD clinicians/IHRFS during this COVID pandemic?

Overall, the biggest challenges we seem to be facing are:

  • Maintaining distance whilst examining high risk feet
  • Attempting to reduce clinic number whilst maintaining easy and regular access to clinic review for high risk feet
  • Attempting to reduce surgery and inpatient stay for ongoing diabetic foot infections
What are the 3 (or more) biggest changes you have made to your IHRFSs service processes to more effectively manage your IHRFS patients during the COVID situation?
  • Reduce as many other review appointments in clinic to increase flow and reduce waiting time for high risk foot patients
  • Carry out phone reviews for less critical patients
  • Social distancing for patients in waiting area and through clinic
What are the 3 (or more) biggest changes you have made to your individual clinical practices to more effectively manage your DFD patients during the COVID situation?
  • Direct communication with imaging services to enable rapid access for patients requiring pre-operative imaging
  • Increased use of local and community podiatry services to decrease attendance on site at hospital out-patients
  • Increased consultant operating and supervision when possible to reduce time in theatre and re-operations

Adelaide High Risk Foot Service

What do you consider are the 3 (or more) greatest challenges facing DFD clinicians/IHRFS during this COVID pandemic?

1.Our hospital is the COVID-designated hospital. Thus, we have had to decant our iHRFS and podiatry OPD from our hospital to another non-COVID designated hospital using the following system:

  • Red – requires ongoing care –no change to appointment frequency
  • Yellow stable –longer time between appointments
  • Green intact –delayed appointment

2. We are the centre of excellence IHRFS for many rural and remote patients. However, with the COVID-situation and limited travel we have where possible been offering telehealth options (for triage and followup).

3.To try and keep social distancing, we have had to increase the time for each of our IHRFS appointments to reduce waiting room time and ideally not have anyone waiting.

What are the 3 (or more) biggest changes you have made to your IHRFSs service processes to more effectively manage your IHRFS patients during the COVID situation?
  • We now use every second treatment room to maintain social distance. We use the “vacant” room for documentation and discussion between the team.
  • Where possible we have only the patient in the treatment space during the consult and ask any carers or family members to wait outside unless they are needed.
  • We have retained final year undergraduate placements to try and maintain some teaching, but generally one student per clinic only.
What are the 3 (or more) biggest changes you have made to your individual clinical practices to more effectively manage your DFD patients during the COVID situation?
  • We have ensured all staff are proficient in donning & doffing, and droplet precautions.
  • We have encouraged all staff to have the seasonal flu vaccine.
  • We have repatriated our indigenous/ rural patients where possible back to their home towns/interstate before the border closures. 

Global DFD Q&A

We’ve teamed up with IWGDF and DFoot International to launch the IWGDF COVID and DFD webpage to give practical answers from global DFD experts to help you do the best you can for your DFD patients during the pandemic.

 

 

 

 

IWGDF logo - guidelines - transparant
D-FOOT INTERNATIONAL
logo

Global DFD Q&A

with International Experts

IWGDF logo - guidelines - transparant

We’ve teamed up with IWGDF and DFoot International to launch the IWGDF COVID and DFD webpage to give practical answers from global DFD experts to help you do the best you can for your DFD patients during this pandemic.

You can ask a COVID19/DFD related question to the network of global experts about topics including Patient Advice, Telehealth, Infection, Offloading, PAD, Wound Healing Interventions and Classification. So click on the below link to access the latest information from the DFD global experts and to ask a question!

 

 

LATEST NEWS

From around

the DFD world

LATEST NEWS

From around

the DFD world

Lockdown academey

gLOBAL

D-Foot International is holding free webinars during the current period of lockdown.

Lectures from experts around the world will focus on different topics related to diabetic foot: infection, vascular disease, Charcot foot, local wound care, etc of up to 20 minutes.

After registering, you will receive a confirmation email containing information about how to the webinar.

Kings College

FROM THE UK

Diabetic Foot Clinic, King’s College Hospital: Diabetes Foot Care in the COVID-19 Pandemic

This commentary is written to help all healthcare professionals who are treating people living with diabetes and particularly those with foot problems. Whilst it is vital to protect the resources and facilities of hospitals so that they can care for the massive number of persons with COVID- 19, it is important to support people living with diabetes who have foot problems and treat as many as we can outside the hospital.

NZ triage Guide

FROM NZ

New Zealand Society for the study of Diabetes (NZSSD) have released the NZ Triage Guide.

Click HERE to view:

all feet on deck 2

fROM THE USA

All Feet On Deck—The Role of Podiatry During the COVID-19 Pandemic

All Feet On Deck—The Role of Podiatry During the COVID-19 Pandemic: Preventing hospitalizations in an overburdened healthcare system, reducing amputation and death in people with diabetes.

Lee C. Rogers,Lawrence A. Lavery,Warren S. Joseph,David G. Armstrong, (2020)

Journal of the American Podiatric Medical Association In-Press

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fROM THE UK

Clinical guide for diabetes patient management in coronavirus pandemic

The NHS have developed the "Specialty guides for patient management during the coronavirus pandemic -  Clinical guide for the management of acute diabetes patients during the coronavirus pandemic".

D-Foot Annoucement

ANNOUNCEMENT

Statement from D-Foot International concerning the global COVID-19 crisis

D-Foot International is collaborating with other associations in the world to reconcile the best response in this crisis. We are working with FIP-IFP, IWGDF Guidance and Diabetic Foot Australia to coordinate a common response globally. I encourage you as a community of experts in the diabetic foot to share your local experiences and help us spread the best options for our patients.

pathway

fROM THE UK

COVID-19 SITUATION: Lower Limb Amputation Prevention Guidance Update

This pathway guidance has been developed by a collaborative group of expert clinicians in FDUK, to support all lower-limb clinicians during the COVID-19 situation in line with current best practice. The guidance is to assist the identification and management of people with critical/limb-threatening ischaemia or infection. The aim is to focus clinical assessment and decisions on urgent triage, referrals & access to High Risk Foot Podiatry, Hospital Vascular, Diabetes Foot, Infectious Diseases or Orthopaedic/ Podiatric Surgeon Teams, for potential life and limb-saving treatments.

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AUSTRALIA

FootForward are hosting free DFD related webinars for health professionals 

During Wednesdays in April, FootForward will be presenting 20-minute lunchtime webinars. With you and your patients in mind, they have created a webinar series to help you understand and implement current international guidelines adapted to the Australian experience.

Journals

GLOBAL

Here's some global journals offering free access to information for COVID19

The following peer-reviewed  journals and news sources are offering free access to their Coronavirus sites: