DEPARTMENT OF PODIATRY
PDSA Cycle to improve pathways
of care for patients discharged
from Victoria Hospital vascular
ward and who require podiatry
foot management upon discharge
Angela Green
Podiatry Principal
October 2013
INDEX
1. PLAN - AIM
2. DO - CHANGE/TEST
IMPLEMENTATION
3. STUDY – DATA ANALYSIS
4. ACT – DEVELOP CHANGE
5. REFERENCES
SIGN 89 (2006) reminds us that ‘Peripheral arterial disease, and its most common
manifestation,
intermittent
claudication,
are associated with considerable
morbidity and mortality’ also ‘Patients with claudication can have a significantly
reduced quality of life due to their restricted mobility’. Surely the support and risk
reduction that can be achieved by regular foot and lower limb screening, Podiatry
management, advice and initiation of other risk reducing measures such as
footwear cannot be overlooked and impact underestimated. Yet there are still
occasions when people with foot problems and peripheral arterial disease are not
seen by a Podiatrist and no pathway for Podiatry support following discharge to
help reduce further foot complications and subsequent admissions.
Plan
Aim: To ensure podiatry lower limb management is in place for patients who suffer from
lower limb peripheral arterial disease and are being discharged from a vascular ward.
This was specifically targeting patients who did not have diabetes since care is usually in
place for the diabetes population.
This was achieved by:

Discussions between Podiatry and the Vascular team identified that a service
improvement was required to address the on-going foot management post
discharge of this patient group who were at an increased risk of amputation.

A member of the senior nursing team in Ward 52 Victoria Hospital devised a
brightly coloured sticker which was adhered to the front cover of the notes of all
patients with lower limb arterial disease admitted to the ward.
The sticker
prompted the question ‘Do you attend Podiatry?’ If no Podiatry was in place or
they were uncertain about whether they saw a Podiatrist, a referral was made
using the ‘Referral for Podiatry treatment’ document (appendix1) which was held
in the vascular ward.

Completed referrals were sent to the Podiatry Principal at the Diabetes Centre,
Victoria Hospital for dissemination to local clinics and data collection.

Over a 3 month period a table was completed to identify how many patients were
not being seen in Podiatry (impact on patient) and the potential caseload
increase in each locality (impact on Podiatry service)
Do
The use of the sticker prompts to identify those patients who did not have podiatry in
place or were unsure if podiatry was in place for when they were discharged was
implemented. Where podiatry referral was required the ‘Referral for Podiatry treatment’
document was completed and sent to Podiatry department, Diabetes Centre, Victoria
Hospital, Kirkcaldy for data collection. The data was gathered over a 3 month period
from 20th May 2013 to 20th September 2013
Diabetes Did
Y/N
patient
say
podiatry
was in
place
Y
No
Was
podiatry
in place
If ‘Yes’ at
what level
Yes
Kelty
Y
No
Yes
Foot
screening
only – low
risk
Diabetes
specialist
Podiatrist
3.
4.
Markinch
Carnegie
N
N
No
Unsure
No
Yes
5.
6.
7.
8.
9.
10.
11.
12.
Carnegie
Cowden
Cowden
Carnegie
Kirkcaldy
Carnegie
Adamson
Carnegie
N
N
N
N
N
N
N
N
No
Unsure
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Patient
Locality
1.
Kirkcaldy
(Fairisle)
2.
Community
Podiatry
Over the 3 month period 12 referrals were received. Of these 2 patients has diabetes
and had already seen a Podiatrist. Of the remaining 10 patients 1 reported being unsure
whether they saw a Podiatrist or not. It transpired that care was already in place for this
patient.
The remaining 9 patients were referred to their local Podiatry clinic.
6 patients resided in the Dunfermline and West Fife locality
2 patients resided in the Kirkcaldy and Levenmouth locality
1 patient resided in North East Fife locality
Study
The snapshot report confirms, as predicted, that some patients, who had a high foot risk,
had not been referred to Podiatry services before hospital admission and no Podiatry
follow-up would have been in place. It also confirmed that for patients with diabetes they
were known to Podiatry services.
The stickers and direct questioning by ward staff is an effective and simple way of
identifying those in need of input and the referral document is a direct means of referring
the patients for care once home. The new system of identifying, referring and putting
care in place for this high risk patient group has further enhanced care for patients
suffering from PAD and potentially reducing further foot complications associated with
the disease process.
Over the 3 month period, 9 patients were referred to Podiatry. If the same number of
patients were to be referred month on month then over the year there is the potential for
around 36 patients to be referred. This would have an impact on service delivery since
the input required for those patients at high risk of ulceration is time consuming and
places increasing demands on staff delivering the care. Where foot ulcerations are
present, this poses additional service pressures in terms of staffing and dressings
resources.
.
We are fortunate to have an excellent rapport in Fife between Vascular and Podiatry
services with patient care at the forefront of improvements to service delivery. This
small project with the development of the Podiatry sticker by Vascular ward staff and the
implementation of the Podiatry treatment referral form coupled with the excellent
communication both services have with each other has gone another step towards
improving patient care and outcomes. At present the Podiatry Principal attends the
multidisciplinary team meeting once per week which further enhances patient care and
streamlining of care between services. It allows the opportunity for individual cases to
be discussed and patients whom Podiatry may have concerns about highlighted to the
vascular team for their intervention as appropriate.
Unfortunately, there is currently no specialist Podiatry provision for patients attending
out-patient vascular clinics or specific to vascular wards. There is no specialist Podiatry
provision for people with PAD in community Podiatry clinics.
To enhance services,
patient outcomes and to streamline care between disciplines whilst at the same time
providing a seamless transition for the care of patients from the ward to community and
to out-patient clinics, the development of a specialist podiatry role would be
advantageous to ensure continuity of care with regard to wound and high risk foot
management.
Act

Continuation of communication and current patient referral processes between
services using the ward stickers on in-patient notes and the referral to Podiatry
document. A list of local Podiatry clinics was sent to the ward for use once the
pilot period had ended so that patients can be referred directly to their local
podiatry clinic upon discharge and not directed through the Podiatry department
at the Diabetes Centre first. The referral documents will be completed by the
ward staff to ensure local Podiatrists are aware of those vascular, high risk
patients being discharged and whether or not they have a foot wound. It also
provides the Podiatrist with information pertaining to any vascular interventions
which have been carried out whilst the patient was in hospital, providing a more
complete overview and patient history.

Continuation of attendance of a Podiatrist at the multidisciplinary vascular
meetings

Development in the future of a specialist Vascular Podiatry post should service
development funding become available to do so to streamline and enhance
patient care and support in the vascular team management of the vulnerable foot
References
SIGN 89 (2006), Diagnosis and management of peripheral arterial disease. Available at
www.sign.ac.uk/guidelines/fulltext/89/ (accessed 18th September 2013)
Appendix 1
SURNAME:
TITLE:
DATE OF BIRTH:
FIRST NAME:
CHI NO: (10 DIGIT NUMBER AT THE TOP LEFT OF YOUR PRESCRIPTION)
ADDRESS:
CONTACT TEL NO:
/
/
POST CODE:
MOBILE NO:
GP PRACTICE:
PRACTICE ADDRESS:
PLEASE GIVE DETAILS OF ANY PREVIOUS NHS PODIATRY TREATMENT?
YEAR:
REASON:
VENUE:
MEDICAL HISTORY: Please record any ill health problems you have or have had in the past e.g.
diabetes, stroke, arthritis etc
MEDICATION: Please list all medications/tablets you are taking including any herbal remedies
(Attach additional sheet if more space is required)
ALLERGIES:
FIRST LANGUAGE:
DO YOU REQUIRE US TO ORGANISE AN
INTERPRETER?
REASON FOR REFERRAL: PLEASE NOTE THAT NHS FIFE PODIATRY DOES NOT PROVIDE A
SIMPLE NAIL CUTTING SERVICE
HOW LONG HAVE YOU HAD THIS COMPLAINT?
PLEASE SUPPLY ANY OTHER HELPFUL INFORMATION:
REFERRED BY:
DATE:
OFFICIAL USE ONLY
DATE RECEIVED:
DATE APPOINTED:
REFERRAL
PODIATRY
PLEASE RETURN
FORMFOR
TO YOUR
LOCAL TREATMENT
PODIATRY CLINIC
DO YOU NEED PODIATRY?
A guide to self-referral to the Podiatry Service
Podiatrists assess and treat problems of the foot and lower limb.
Our service aims to promote good foot health in the population of Fife, in order to
help sustain mobility and independence and reduce pain.
The NHS Fife Podiatry Service does not provide a simple nail cutting service.
HOW DO YOU SELF REFER?
If you are a Fife resident with foot problems you can self-refer to the podiatry
service without seeing your GP or other health care professional.
Please complete the attached self-referral form in as much detail as possible and
either hand in or post it to your local podiatry clinic.
WHAT WILL HAPPEN NEXT?
A podiatrist will check your form and you will be contacted to arrange an
appointment or discuss your application.
Assessment appointments are normally offered at a clinic close to your home.
At your first appointment the podiatrist will review your medical history and
assess your foot health.
Using this information the podiatrist will determine your clinical need and put
together an agreed treatment care plan with you.
Please note our service aims to support patients to self care therefore ongoing
podiatry treatment may not always be required.