the interdisciplinary approach: how to set up a diabetic...
TRANSCRIPT
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The interdisciplinary approach: how to set up a
diabetic foot clinic? Dr. Kristien Van Acker
President elect Diabetic Foot Programme IDF/ IWGDF
Diabetologist in Reet/Chimay Consultant Tropical Institute- Bridges programme
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Kristien’s Context ! 1 st multidisciplinary DFC in Belgium in
Antwerp 1989 ! National implementation
National implementation1993_2001
!! Active member of IWGDF ! Diabetic Familie member of
Thé
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Diabetic Foot Family ! EURODIALE
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Who are those Greece Family members – Google?
Nicolas Tentolouris & Christos Manes
and others like for example Kiriaki Kalligianni
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Nicolas Tentolouris &
Christos Manes
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Nicolas Tentolouris
Nicolas Katsilambros & Ivo De Leeuw
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Nicolas Tentolouris
Nicolas Katsilambros & Ivo De Leeuw
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Christos Manes
Manchester Royal Infirmerie- Andrew Boulton- Aretsides Veves
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Christos Manes
Manchester Royal Infirmerie- Andrew Boulton- Aristides Veves
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Content of our discussion ! How to start? ! Some advices of other national/international
partners ! Understanding the setting-importance of
interdisciplinarity ! Hospital administrators/policy makers ! Quality control ! In a network- context:
! Regional- national –international
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Book chapters
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Content of our discussion ! How to start? ! Some advices of other national/
international partners ! Understanding the setting-importance of
interdisciplinarity ! Hospital administrators/policy makers ! Quality control ! In a network- context:
! Regional- national -international
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You are convinced for a reason…
! You want to improve world? ! You want to reduce amputation rate ? ! You want to reduce hospitalization stay? ! You want to reduce costs?
OR…. ! You director of hospital told you!
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Understanding your own motivation….will play a key role in your Diabetic FOOT history/”memoire”
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! Lack of money ! Lack of personnel – podiatrists ! Lack of room ! Lack of equipment ! Lack of time
Some one is convincing you, however, not to start for the following reasons …
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Balancing…
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Content of our discussion ! How to start?
! Some advices of other national/international partners
! Understanding the setting-importance of interdisciplinarity
! Hospital administrators/policy makers
! Quality control ! In a network- context:
! Regional- national -international
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But how to start? ! Try to find some co-founders ; Never
alone ! ! Try to learn from other examples: step
by step.
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But how to start? ! Try to find some co-founders ; Never alone ! ! Try to learn from other examples: step by step.
! Try from the beginning to integrate it in an holistic approach ! Interdisciplinary approach: patient oriented ! Integrated in the hospital vision/philosophy ! With a good referal and contra referal
pattern (networking)
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Step by step philosophy: minimal – intermediate – maximal
! Facilities ! Material ! Personnel
! �TIME TO ACT�, 2005
Establishing Diabetic Foot Clinics
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2005
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How to establish a diabetic foot clinic?
Diabetologist
Patient
Nurse
Max Spraul, Noordwijkerhout, 1991
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How to establish a diabetic foot clinic?
Patient
Max Spraul, Noordwijkerhout, 1991
Diabetologist Nurse
Orthopaedic surgeon
Vascular surgeon General surgeon
X-ray specialist
Angiologist
Microbiologist
Podiatrist
Communication!
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Understanding the pre-per- and post- ulcer phase
Ulcer
Pre ulcer Ulcer Post-ulcer
P
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Understanding the pre-per- and post- ulcer phase
Amputation
Pre ulcer Ulcer Post-ulcer
P
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Understanding the pre-per- and post- ulcer phase
Pre ulcer Ulcer Post-ulcer
New Ulcer
P
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Intermediate- maximal model
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Aim
Minimal Intermediate Maximal
Prevention and basic curative care
Prevention and curative care for all types of out- patients
More advanced assessment and diagnosis
Prevention and specialized curative care for complex cases
To teach other centres
To develop innovative care strategies
Vilma Urbancic & KVA
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Patients
Minimal Intermediate Maximal
Own population From the regional catchment area of the hospital with possibly
some referrals from outside the region
National, regional or even international referral centre
Vilma Urbancic & KVA
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Staff Minimal Intermediate Maximal Doctor Podiatrist and /
or nurse
Diabetologist or GP Podiatrist and / or
nurse Surgeon Orthotist
Diabetologist Surgeon (orthopaedic, vascular,
general, plastic) Podiatrists Physiotherapist Microbiologist Dermatologist Psychiatrist Nurses Educators Casting technician Orthotist Administrative, reception and
secretarial staff Vilma Urbancic & KVA
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Equipment Minimal Intermediate Maximal
Scalpel handles Scalpel blades Nail nippers Nail files 10g monofilaments 128 Hz tuning fork Dressings Bandages Antiseptic instrument-
cleaning equipment
10g monofilaments 128 Hz tuning fork Biothesiometer Doppler Operating theatre Full sets of podiatry
instruments
As for intermediate centre plus: Transcutaneous oxymetry,
angiography, angioplasty, arterial bypass
fully equipped operating theatre, duplex scan, Intensive care unit, beds, CT scans, ultrasound, laser Doppler, pedobarogram, patient and operator's chairs, computerized record systems, fully equipped teaching facilities, fully equipped orthotics service, grinder
Vilma Urbancic & KVA
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Setting
Minimal Intermediate Maximal
GP's office Health centre Small regional
hospital
Hospital Usually a large teaching or university hospital
Vilma Urbancic & KVA
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Facilitating elements Minimal Intermediate Maximal Close
collaboration with a referral centre
Motivated coordinator to inspire team
Exchange of experiences with other centres
Staff meetings to discuss diabetic foot pts
Active collaboration with other depts within the hospital
Active collaboration with extra-mural facilities (GPs, nursing homes... )
Organize regional, national or international meetings
Allow providers to visit to improve knowledge and practical skills
Active collaboration with other reference centres
Active participation in the development of guidelines
Vilma Urbancic & KVA
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Content of our discussion ! How to start? ! Some advices of other national/international partners
! Understanding the setting-importance of interdisciplinarity
! Hospital administrators/policy makers
! Quality control ! In a network- context:
! Regional- national -international
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Karel Bakker slide
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Patient-experiences, beliefs - no knowledge - social and economical influences - denial - strong negative feelings (anger, guilt, anxiety, depression,...)
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Interdisciplinary team: ! Integrate separate discipline
approaches into a single consultation.
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Interdisciplinary team: ! Integrate separate discipline approaches into a single consultation.
! That is, the patient-history taking, the team, together with the patient, conducts assessment, diagnosis, intervention and short- and long-term management goals at the one time.
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Practical “golden rules “ for teambuilding:
! 5 Golden RULES ?
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Practical “golden rules “ for teambuilding:
! Activity or project management has 4
characteristics: ! 1/ definite duration, 2/ logic relationship with other
activities in the project, 3/ resource consumption (information, energy, know how, time financial resources) and 4/ associated cost
! Define roles and boundaries: ! everyone needs clarity on their own role and to be clear about
what other team members do.
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Practical “golden rules “ for teambuilding:
! Be aware of power dynamics:
! are certain members competing for control? Do some have more status than others?
! Taking decisions: ! How, who and when is important. Team members must
learn to value each other’s contributions, look at how the group communicates.
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Practical “golden rules “ for teambuilding:
! Be aware “ different professionals have different views”
! Don’t underestimate the value of listening to
service users (patients)
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Most frequent barriers to team success:
! Often small details are the biggest barriers to team
success, so pay attention to possible or current problems within your team.
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Most frequent barriers to team success:
! Often small details are the biggest barriers to team success, so pay attention to possible or current problems within your team.
! Some of the biggest barriers include unclear goals,
unhealthy communication, playing it 'safe', individual goals and poor leadership
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Example:
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onze ploeg HFR ! * Artsen:
! K Van acker/ D. Lambrechts/ M. Van Kerckhoven ! Drs Tondu en Thiessens
! * Paramedici: ! Ilse Heyvaert, Chloé, Matthieu Quidouse: podologen ! Sandra, Elodie: wondzorgverpleegkundigen ! Lieve en Monique: gipsverpleegkundigen
! * Schoentechnieker ! Marius Bajart
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Casus of Cathy ! * 44 y ! * since 18 Yr DM type 1 ! * HBA1c 10,4% ( 90 mmol/mol)
! * 14 months ago: ! Osteomyelitis ray 5 + Charcot L
! * 14 aug 2012 acute H sepsis intens care
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Cathy, 14 aug
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Time is Tissue
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But how to start? ! Try to find some co-founders ; Never
alone !
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Debridement?
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21 augustus:
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! Angiosomen concept
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! Case report
!
arcus plantaris preop arcus plantaris postop
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Pre – ulcus phase
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Pre – ulcus phase
EDUCATION !!!
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Post – ulcus phase
Podologie opvolging ter preventieve controle 1x/maand
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Content of our discussion ! How to start? ! Some advices of other national/international
partners ! Understanding the setting-importance of
interdisciplinarity ! Hospital administrators/policy makers ! Quality control ! In a network- context:
! Regional- national –international
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Policy makers
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!Ulcer Characteristics in Europe: The Eurodiale Project
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Distribution of costs (%) for all patients included in costing analysis
(N=821)
39
95
10
2
12
5
7
66
Hospitalisation (hotelcost)Amputations
Re-vascularisation
Other interventions andsurgeryDiagnostic proceduresand investigationsAntibiotics
Off-loading/orthopaedicappliancesTopical treatment
Consultations/outpatientvisitsIndirect costs
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Diabetic Foot Clinic? Let’s talk business!
After the evidence gap: How to close the management gap?
Dirk Ramaekers, Med Director ZNA
Hospital administrators
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J&J Diabetes Centre Paris, Cordis workshops
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.
team University of Antwerp 2003
COSTS for your hospital ?
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COSTS for your hospital ?
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Ipswich Diabetic Foot Unit Main Treatment Room
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hospital wards one day hospital
operating theatres
outpatient clinic ancillary department LAB ETC X-ray
pharmacy
hospital wards
one day hospital
outpatient clinic
operating theatres
ancillary department icu
medical department
paramedical departments
supporting departments
nursing department
Pa1
Pa2
Pa3
PRA
PRB
X
X X X X X
X
X
X
X X
X
X X X
CLINICAL PATHWAY = PRIMARY PRODUCT
Match costs & revenues
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3 steps for a business plan 1. Research
• current and future number of patïents? number of referrals? (gatekeeping ?)
• care process? consequences? • patients� preferences • competitors� strengths and weaknesses • best practices • required human resources (!) • ongoing costs of operation • costs of launching the business and possible financing sources
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3 steps for a business plan
1. Calculation • projected financials of the business using a financial model
appropriate for health care • estimate the time horizon for profit • taxes, loan interest, fiscal deduction • use an automated spreadsheet
2. Writing • distinguish strategic from operational objectives • use a template • executive summary • never think outside the box!
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3 steps for a business plan 1. Research
• current and future number of patïents? number of referrals? (gatekeeping ?) • care process? consequences? • patients� preferences • competitors� strengths and weaknesses • best practices • required human resources (!) • ongoing costs of operation • costs of launching the business and possible financing sources
2. Calculation • projected financials of the business using a financial model appropriate for health care • estimate the time horizon for profit • taxes, loan interest, fiscal deduction • use an automated spreadsheet
3. Writing • distinguish strategic from operational objectives • use a template • executive summary • never think outside the box!
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New material: 10 Euro’S afschrijvingen Podologie: 20 Euro
1 patient contact in a DFC: 75-100 euro of costs for the hospital manager
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After costing all activity associated with the clinic, there was an overall saving of 114,063 Euro’s per year associated with the introduction of the MDFPC.
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All depends in whom’s pocket….
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Content of our discussion ! How to start? ! Some advices of other national/
international partners ! Understanding the setting-importance
of interdisciplinarity ! Quality control ! In a network- context:
! Regional- national -international
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81
Recognition of diabetic foot centres in Belgium
1 JULY 2005
�Third Line Curative Diabetic Footclinics� Critiria: �Experience�: 52 new diabetic foot ulcers patient (Wagner 2/Charcot) Specialised multidiciplinary team must be present at the out patient clinics during at least 48 weeks a year and at minimum a half day a week
Minimum members of the team:
Diabetologist Surgeon Podiatrist Diabetic nurse/educator Orthotist
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Standards of Quality for Specialized Diabetic Foot Clinics
according to the Criteria of the Diabetic Foot Working Group
of the German Diabetes Association (DDG)
1.1. Structural quality a) Equipment b) Documentation c) Staff
1.2. Structural- and Process quality Interdisciplinary cooperation by contract
1.3. Process quality a) Clinical pathways/standard operation procedures (SOP) b) Hygiene plans c) MRSA management plan
1.4. Audit (active und passive) 1.5. Quality of performance
Treatment results of 30 consecutive patients
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IQED-foot - Meeting Foot-clinic May 2007
Geographical spread
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84
Off-loading ( example of benchmarking) Belgian Benchmarking system
010
2030
4050
6070
8090
100
% o
f pat
ient
s
Clinics
Sample size 1600 patients
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Content of our discussion ! How to start? ! Some advices of other national/
international partners ! Understanding the setting-importance
of interdisciplinarity ! Quality control ! In a network- context:
! Regional- national -international
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20% increased risk Regular `foot protection´
60% no current abnormality Routine annual screening
15% high risk Intensive `foot protection´
5% active ulcers, infection, revascularisation, amputation
Multidisciplinary foot care team management
Robert J. Young in: Boulton, Cavanagh, Rayman (Eds.) The Foot in Diabetes, 4th Edition, Wiley & Sons, Chichester (UK), 2006
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Foot Protection Team
GP practices
In-patient service
Community Nurses
Multidisciplinary foot care team
Integrated care
Skills Knowledge Respect Co-operation Communication Awareness
Neil Baker slide
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Education for healthcare professionals
P
© Dr. Kristien Van Acker
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Organization of care Targets:
! Primary care integration ! Referral and contra referral system
Hospital Specialized interdisciplinary team
Health Centre Family health programme
P
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Organization of care
Hospital Specialized interdisciplinary team
Health Centre Family health programme
P
! Wound DF > 2 weeks
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Organization of care
P
DFWound > 2 weeks
Primary care! Diabetes clinic!Minimal model!
Intermediate model; DFC!
Reference centre,DFC!
Charcot!Complex revascularisation!
DF wound>1 month!
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93
“Step by step” - improving diabetes foot care in the developing world
Funded by the World Diabetes Foundation (WDF)
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Senegal
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February 2013
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February 2013 Mark Sankale
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Diabetic Foot Clinics: Implementation in Brazil - 1992
Brasília
Example:
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Brazilian Foot Clinic Implementation 92/04
Outpatient = 58
Foot Centre = 01
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99
Spirit of IWGDF
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! Available to order at: http://shop.idf.org
P
© Dr. Kristien Van Acker
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1996 in een cel/hotelkamer in Amsterdam
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Editorial Board IWGDF 2003
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Deligates of IWGDF 2011
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Lao Tzu, China, 6th century
„ A journey of a thousand miles begins with one step „
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K. van Acker, Belgium, 21th century
„ All world-wide known diabetic foot clinics, so called centers of excellence, were created one
step at a time “
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Thank you on behalf of our patients…..