Footcare root cause analysis guide released
A guide has been published to encourage healthcare professionals to use root cause analysis (RCA) to help reduce the number of unnecessary diabetes-related amputations.
RCA determines to what extent an amputation was avoidable or unavoidable, and whether or not it was the best possible outcome for the person with diabetes.
If avoidable, completing an RCA will help identify what changes are required to reduce the likelihood of the same event happening again.
The guidelines, which have been compiled by Diabetes UK, have been based on the South West Cardiovascular Clinical Network’s Diabetes Foot Care Resource Pack.
‘Challenging medical problem’
Dr Richard Paisey, honorary consultant and diabetes footcare Lead at South West Cardiovascular Clinical Network, said: “Using this guide should provide each area an accurate and up-to-date picture of the proportion of major amputations which were potentially avoidable by prompter intervention.
“Ultimately, using root cause analysis should highlight best practice and also facilitate follow up of missed opportunities in provision of care in each case.
In Torbay, we have been undertaking RCAs for about 10 years. Data shows we have lower amputation rates than our neighbouring providers of diabetic foot service, however this lower rate cannot be wholly attributed to undertaking RCA’s
“There may be generic problems in delivering foot care in an area which could be addressed by constructive discussion with all care providers involved. Changes required in foot care provision are often cost neutral short term and longer term will be cost saving.”
Other experts including podiatrists, members of the Northern Footcare Network and a practice nurse were also consulted to help create the guide.
The pack includes a data collection template, a primary care data collection tool and a reporting template.
For each RCA that has been undertaken, the learning has been huge in terms of recognising cand helping put in place action plans to address any necessary improvement that has been identified in terms of process and services
Dr Paisey added: “An improvement in integration of care for people with diabetes with foot problems through the RCA enhances the whole service.
“It replaces the sense of disinterest, even nihilism about this challenging medical problem, with satisfying collaboration and a sense of pride in a job well done. It justifies the skillful treatment and post-operative care where the loss of the limb has been the best option for the patient.”
The guide has been put together after Diabetes UK used Public Health England data to show that the number of amputations is continuing to increase and is now 20 a day in England.
Experts estimate that four out of five amputations could be prevented as 80 per cent are preceded by a foot ulcer, which are largely preventable.
Angie Abbott, head of Podiatry and Orthotic Services at Torbay and South Devon NHS Foundation Trust, also contributed to the guide.
Speaking from her own experience she said: “For each RCA that has been undertaken, the learning has been huge in terms of recognising and helping put in place action plans to address any necessary improvement that has been identified in terms of process and services.
“The RCA process has increased the profile of diabetic foot, and increased knowledge and awareness of the risk to diabetics of foot disease. The RCA process has been the vehicle to set up a diabetic foot improvement group to improve services and raise awareness of diabetic foot disease.
“In Torbay, we have been undertaking RCAs for about 10 years. Data shows we have lower amputation rates than our neighbouring providers of diabetic foot service, however this lower rate cannot be wholly attributed to undertaking RCA’s.
“However, RCA’s do demonstrate a culture of continued learning and allow for action plans to be put in place to address learning and improve services.”
Foot care pathway
Diabetic foot disease is the most common cause of diabetes-related hospital admission.
The risk of amputation can be reduced through provision of an integrated foot care pathway. Also, everyone with diabetes should have a quality annual foot risk assessment and, if at increased risk, referred for assessment by trained staff in community foot protection services and have quick access to multidisciplinary specialist foot care teams (MDfT). The longer the delay before being seen by the diabetic foot care team, the more likely foot ulcers will be severe.
Currently there is still considerable variation in outcomes and processes across the diabetes foot care pathway, from the number of foot checks delivered in primary care, and the quality of them, to major and minor amputation rates.
Bridget Turner, director of policy and care improvement at Diabetes UK, said: “Losing a limb is devastating for the person with diabetes and reduces life expectancy.
“It is also costly in terms of health care and social support. This guide builds on the work of others and is a really important step in aiming to avoid the current variation in the number of amputations around the country.
“Root cause analysis is a vital part of scrutinising what can go wrong and providing essential learning. It is this learning that informs the improvements needed to ensure people at risk of amputation are provided with the best possible information, education and care throughout their journey.”