Mangere Community Health Trust
PODIATRY SERVICE
Annual report 2012
17 January 2012 to 31 January 2013
Compiled by Tokhy Hoang on behalf of:
Mangere Community Health Trust
P O Box 43-161
10 Waddon Place
Mangere Auckland
Phone 09 255-0602
Fax 09 255-1673
Mangere Community Health Trust Podiatry Service Annual Report
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SERVICE DEVELOPMENT
INTRODUCTION
Within Counties Manukau District Health Board (CMDHB) there is an estimate of 34,000 people in
the Manukau district diagnosed with diabetes and over 12,000 in the Mangere community alone.
Patient education and accessible care are vital aspects to reducing preventable foot complications. The
overall goal of patient education is to allow the patient to be informed and work together with the
podiatrist to implement a suitable plan that meets the patient’s health needs. The Mangere Community
Health Trust (MCHT) focuses strongly on improving patient access to care by being in the heart of
Mangere community, completely FREE of charge and in a warm welcoming environment.
The Community ‘Foot Clinic’ Podiatry Service was established in January 2012 to maintain and
improve the foot health status of patients with diabetic foot-related pathologies. The service is
accessible to patients within the Mangere catchment and enrolled with a local general
practitioner.
The aims of the service are to:
 Reduce the number of lower limb amputations within the Counties Manukau district.
 Decrease hospital admissions for foot-related complications associated with diabetes
 Identify and educating High Risk patients
 Provide a comprehensive assessment service
 Provide a free, appropriate and accessible service for Diabetic patients within Mangere
 Initiate preventive measures when necessary
 Provide podiatric management as appropriate
 Educate health professionals, patients, whanau, and members of the community in aspects
of podiatry and diabetic foot pathology.
The service is free to all diagnosed diabetic patients who meet the referral criteria and who are
not currently in a hospital-based treatment programme. The Community Podiatry Service offers
an initial assessment to all patients who meet the referral criteria. Following the initial
assessment, the service may:






Refer on to hospital care if required, for example Manukau SuperClinic Ulcer and Vascular
teams
Refer on to other health services provided within the Diabetes Hub i.e. dietitian, retinal
screening or smoking cessation.
Recall the patient weekly for a short course of treatment of an acute infection
Recall the patient for ongoing assessments based on risk levels Diabetic Foot Category
Refer the patient back to the GP/nurse along with advice on care and management.
Refer on to Orthotic Centre - due to limited funding and resources, some treatments are
outside the scope of our Community Podiatry Service. For example, there is no provision for
orthoses or specialised footwear. We currently refer patients on to the Orthotic Centre based
in Ellerslie for assistance in insoles and footwear.
All patients seen within the service have a summary of their visit sent to the initial referrer and/or
primary care provider to ensure continuity of care.
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Many of the PHO’s within the Mangere area have had Podiatry services offered in-house to
manage their Diabetic populations in the past. However, a change to the funding structure has
meant that these services are no longer available within many PHO/Primary Care settings.
Additionally, where podiatry services are still offered at PHO/Primary Care level the majority of
the Podiatry clinics operate once a month, this is a significant limitation for many patients in
Mangere.
The MCHT ‘Diabetes Foot Clinic’ has two podiatrists, Tokhy Hoang and Asia Jones. The clinic
operates five days a week and provides late night and Saturday clinics. The two podiatrists have
one shared day once a week where they are able to discuss various issues and provide clinical
support for each other. Clinics are held at two sites in Mangere; the main clinic is situated at the
Diabetes Hub, 10 Waddon Place and a satellite clinic at Te Puea Marae Medical Centre.
PATIENTS, FAMILIES AND WHANAU
Patient education is essential and is being provided on a one-to-one basis at each assessment.
With Maori and Pacific patients we encourage family/whanau members to come along as well,
provide them with information and to help reinforce the importance of foot care and
management of diabetes within the home environment.
RELATIONSHIPS AND CLINICAL NETWORKS
Diabetes is a complex condition which requires an approach that integrates efficient collaboration
and communication within the wider inter-disciplinary team. To provide equitable, seamless
effective diabetes podiatry care, we require that these various components work together with
patients and their family to ensure the care provided is appropriate for an individual's needs based
on the stage, type and status of their diabetes.
Ensuring strong linkages with other services are crucial to the quality of service delivery provided
by the service. Integration requires a team of dedicated professionals to enable the service to
work well for both patients and clinicians. There is strong day-to-day communication between the
Podiatrists and members of local diabetes care.
There is evidence that effective collaboration between the three tiers of care can reduce
hospitalisation and essentially provide better care to patients and carers alike (Diabetes UK, 2009).
Primary tier
Retinal screeners
Dieticians
Health promoters
General practitioners
Pharmacists
Diabetes nurse specialists
Other primary podiatry services within the community
Physiotherapists
Smoking cessation team
Mental health advisor
Mangere Community Health Trust Podiatry Service Annual Report
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Secondary tier
Secondary podiatry services - Manukau Superclinic, Greenlane Hospital, Middlemore
Hospital (accordingly to patient’s residence)
Orthotists
Prosthetists
Tertiary tier
Orthopaedics
Vascular specialists
Rheumatologists
Neurologists
EXTENSION OF PODIATRY SCREENING SERVICE: Nail Surgeries
Ingrown nail infections (onychocryptosis) occur when the edge of the nail grows into the skin and
pierces the flesh as it grows out. Ingrown nails can lead to serious diabetic foot complications
because it can quickly progress to a secondary infection such as osteomyelitis (infection tracking
into the bone joint causing bone destruction) which could result in an amputation. An amputation
would result in loss of mobility, placing severe restrictions on daily living activities and quality of
life. MCHT podiatry has performed two partial nail avulsion surgeries on patients suffering chronic
ingrown nails. During each procedure we used phenolisation to prevent re-growth of the nail
edges to provide long-term results (Appendix 4).
Potential costs saved so far (average per patient):
Podiatry visits $55 each consult x5 =$275
Chemical matrixectomy= $500
Total podiatry intervention $775
VS amputation and secondary care-$11,000 minimum
Other factors associated with loss of limb:
- Loss in quality of life
- Loss in income
- Shorter life expectancy
- Depression and other psychological issues
(Data is based on the guidelines from Diabetes NZ, 2005)
MANAGEMENT OF REFERRALS AND SERVICES DELIVERED
Referral Criteria
Service users may be referred by:
 General practice;
 A midwife;
 Or other providers of a diabetic service (e.g CMDHB diabetes clinic; podiatrist; nurse
specialist)
Entry Criteria
Services users will be
Mangere Community Health Trust Podiatry Service Annual Report
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


Patients with diabetes; and
Be registered with a GP within Mangere
Reside in the Mangere
Referral Data
A total of 1961 patients were referred to the service from commencement for the 12 months from
January 2012 to January 2013. For the six months from July to December 2012, 1090 patients had
been referred into the service compared to 743 for the previous 6 months. From the large number
of referrals 1382 patients attended appointments. Referral sources either come from the
following.
Referrer
GP
Midwife
Internal (Eye screening/ Dietician)
CMDHB Diabetic Nurses
Manukau SuperClinic
Total
311
1
1111
52
30
The number of referrals from GPs, nurses, and the Manukau Super clinic was relatively low within
the first half of the year; however there has been a steady increase as the service became
established.
Attendance rates
With the high number of referrals, attendance is an issue. This needs to be addressed over the
next year.
Attendance
579
Screened
DNA/ No contact
1382
Sites
Currently, the Mangere ‘Foot clinic’ is based:
 Mangere Health Centre and,
 Te Puea Marae
The location of both clinical sites are easily accessible to patients in Mangere with strong
emphasises placed on providing services to both Maori and Pacific provider clients.
Initial Assessment
Appointments are made for all referred patients within one week of receiving the referral. A
Podiatrist assesses each patient referred. Assessments generally take about 30-minutes depending
Mangere Community Health Trust Podiatry Service Annual Report
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of the health of the foot at presentation. Consultations involve a complete vascular, neurological,
musculoskeletal, and dermatological examination and risk assessment of the patient. From the
initial assessment a realistic and agreeable treatment plan is implemented for the patient and
whanau. The outcome of the assessment will determine how often the patient will be recalled.
This is based on the ‘Diabetic Foot Categorisation tool 20101’ (Appendix 1). The referrer receives a
letter of podiatry assessment results which includes risk categorisation, treatment plan and
recommendation date for review.
Encounter by Type
Ethnicity Breakdown of Patients Seen 17 Jan 2012 to 31 Jan 2013
There is a higher incidence of diabetes in the Maori and Pacific population within Counties
Manukau, as is the lower of this population for free diabetes annual reviews and the relatively
poorer health status of this population group.
25% of screened patients were Maori, 30% Samoan, 13% Cook Island, 17% Tongan, and 14% a
mixed Pacific.
Ethnicity
NZ European
NZ Maori
Samoan
Cook Island
Tongan
Other PI
Indian
Asian
Other
185
334
419
174
234
198
89
23
65
23
Ethnicity Breakdown
89
65 185
NZ European
334
NZ Maori
Pacific Islanders
Indian
1025
Asian
Other
10% of the patients with known diabetes in CMDHB are Maori and 15% are Pacific. 19% of
podiatry service users are Maori and 60% are Pacific. This indicates the service is responsive to the
needs of Maori and Pacific peoples.
Foot Classification
The “Ankle Brachial Index” (ABI) is part of the Diabetic Foot screening Tool (shown in Appendix 2)
and is used to assist in the classification of the patient’s risk of peripheral vascular disease. The ABI
is the ratio of the blood pressure in the lower legs to the blood pressure in the arms. Compared to
Mangere Community Health Trust Podiatry Service Annual Report
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the arm, lower blood pressure in the leg is an indication of blocked arteries (peripheral arterial
disease - PAD). The ABI is calculated by dividing the systolic blood pressure at the ankle by the
systolic blood pressures in the arm.
800
734
700
600
500
400
300
207
200
50
100
21
13
0
Low Risk (0)
Quarterly Break down
ABI
Low Risk (0)
At Risk (1)
At Risk (2)
High Risk (3)
Active Complication (4)
At Risk (1)
Jan
24
1
0
0
0
At Risk (2)
Feb
68
13
7
0
1
ABI
Low Risk (0)
At Risk (1)
At Risk (2)
High Risk (3)
Active Complication (4)
Apr
87
17
3
1
0
May
62
19
2
0
1
ABI
Low Risk (0)
At Risk (1)
At Risk (2)
High Risk (3)
Active Complication (4)
July
57
17
6
2
0
August
85
19
7
4
1
High Risk (3)
Mar
68
8
11
0
2
Total
160
22
18
0
3
June
67
16
5
3
2
Total
216
52
10
4
3
September
58
30
2
1
2
Mangere Community Health Trust Podiatry Service Annual Report
Active
complication (4)
Total
200
66
15
7
6
7
ABI
Low Risk (0)
At Risk (1)
At Risk (2)
High Risk (3)
Active Complication (4)
Oct
64
26
3
1
6
Nov
49
24
2
0
1
Dec
45
17
2
1
2
Total
158
67
7
2
9
The above statistics have showed that majority of patients that are able to be screened using the
Ankle Brachial Index are category 0 and 1, this provides an opportunity for patient education that
aims to promote self-care and maintain good foot health.
Patients that have been identified as category 2 and 3 have experienced changes to circulation
and/or sensation. Therefore early detection and intervention at these stages can be highly
effective at reducing the risk of further deterioration and complications, 13% of the patients seen
in the clinic fall into this category.
Service exit:
Patients exit the service when the:
 Patient has declined the service
 Patient has missed two consecutive appointments.
 Patient has been identified as having ‘At Risk’ feet and their care is transferred on to the
Manukau SuperClinic.
When patients exit from the service they, and their primary care provider are informed by letter.
CONCLUSION/REFLECTION
The MCHT podiatry service has been running for over 12 months now and we are beginning to see some of
our recall patients screened from the previous year. Most recalled patients have said they went away with
the education given by the team and have started walking more, eating better and feel they have more
energy now. In addition to the positive verbal feedback received from patients, we have also noticed
improvements in various aspects of their diabetes management. Some patients have better feet now i.e.
improved skin integrity. Many patients have improved their HbA1c levels and are getting closer to achieving
the target range.
MCHT podiatry and the team the Diabetes HUB will continue to re-evaluate our service to ensure we
continue to provide optimal community-based podiatry care.
Mangere Community Health Trust Podiatry Service Annual Report
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Not
Achieved
KPI’s
Partial
Achieved
Reduce the number of lower limb amputations within It is difficult to measure this outcome
over such a short period; this will only
the Counties Manukau district.
become evident after a few years.
Decrease hospital admissions for
complications associated with diabetes
foot-related
Identify and educating High Risk patients
It is difficult to measure this outcome
over such a short period; this will only
become evident after a few years.
Achieved
Provide a comprehensive assessment service
Achieved
Provide a free, appropriate and accessible service for
Diabetic patients within the Mangere area
Achieved
Initiate preventive measures when necessary
Achieved
Provide podiatric management as appropriate
Achieved
Educate health professionals, patients, whanau, and
members of the community in aspects of podiatry and
diabetic foot pathology.
Mangere Community Health Trust Podiatry Service Annual Report
Achieved
9
APPENDIX 1: Case photos
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APPENDIX 2: CATEGORY OF REFERRALS
Risk
Category
0
Risk Levels
Low Risk
At Risk
At Risk
High Risk
Active
Foot
Complication
Definition
No LOPS
NO PAD
No deformity
No
neuropathy
ABI > 0.9
LOPS +/- deformity
PAD +/ LOPS
Hx of ulcer or
amputation
Active ulceration
Charcot foot
Neuropathy
ABI > 0.9
Neuropathy
ABI < 0.8
Neuropathy
PAD
Neuropathy
PAD
Absent
Pedal
pulses
with
possible
symptoms of PAD
Hx ulceration,
Charcot
joints,
or
amputation
Active
diabetic
foot complication
Same
as
category 1
Same as category
1
Consider
vascular
consultation
if
PAD
present
Multidisciplinary
team
management of
foot complication
Foot
Presentation
2
3
4
(Secondary
intervention)
Pedal pulses
palpable
No deformity
Treatment
1
Pedal
palpable
pulses
Foot
deformity
with
signs
of
pressure i.e callus/
corns.
No
Hx
ulceration,
Charcot
joints,
or
amputation
No Hx ulceration,
Charcot joints, or
amputation
Patient
education
including
advice
on
footwear.
Consider
prescription
of
accommodative
footwear
Consider
prophylactic
surgery
if
deformity is not
able to be safely
accommodated in
shoes.
Continue
education
Possible Hx
vascular
intervention
of
Foot deformity
may be present.
No Hx ulceration,
Charcot joints, or
amputation
Consider
prescriptive
accommodative
footwear
Consider vascular
consultation for
combined followup
Continue patient
education
Continue
patient
education
patient
Specialist wound
care
Consider vascular
consultation
if
PAD present
Consider surgery
for foot deformity
Suggested
Follow-up
Annual
review with
Get Checked
screening
Every 3 to 6
months
(by
specialist
podiatrist)
Every 2 to 3
months
(by
specialist
podiatrist)
Mangere Community Health Trust Podiatry Service Annual Report
Every 1 to 2
months
(by specialist
podiatrist)
Continue patient
education
As required until
resolved
11
APPENDIX 3: Wagner Classification of Diabetic Foot Ulcers

Grade 0: No ulcer in a high risk foot.

Grade 1: Superficial ulcer involving the full skin thickness but not underlying tissues.

Grade 2: Deep ulcer, penetrating down to ligaments and muscle, but no bone involvement
or abscess formation.

Grade 3: Deep ulcer with cellulitis or abscess formation, often with osteomyelitis.

Grade 4: Localized gangrene.

Grade 5: Extensive gangrene involving the whole foot
APPENDIX 4: Chemical Matrixectomy
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