Keeping the lights on: Maintaining a multidisciplinary diabetic foot service in the face of COVID-19

By Sarah Johnson-Lynn and Paul Mackenney
University Hospital of North Tees, Stockton-upon-Tees

Published 17 April 2020

The current situation with respect to COVID-19 is creating additional pressures for a number of groups with existing health conditions and in orthopaedics, one of the most vulnerable groups we care for are those living with diabetic foot disease. The following article outlines the challenges we have experienced and our response to them within the context of our relatively new regional multidisciplinary diabetic foot service.

There is no doubt that diabetic foot disease is a significant public health problem, costing the NHS almost £1 billion pounds annually¹, a major impact on individual patients’ quality of life² and the most common reason for non-traumatic lower limb amputations³. NHS England have made it clear that diabetic foot care remains a priority, including face-to-face assessment of ulcers in MDT clinics⁴.

There have, however, been significant challenges associated with maintaining our multidisciplinary service. Many of these challenges are being felt throughout orthopaedics, such as reduced operating capacity and loss of inpatient beds but we have encountered other issues due to the way that our service intersects with others. Our medical colleagues in diabetology are under intense pressure – continuing to support the foot service and providing telephone clinics for their diabetes and endocrine patients, whilst also being redeployed with all their acute medicine colleagues to treat COVID-positive patients in emergency admissions areas, inevitably leading to COVID-19-related staff sickness. We have been endeavouring to support their role by extending our involvement in the high-risk podiatry and MDT clinics to ensure the presence of an individual with prescribing and admitting rights.

The diabetes ward has been closed due to nursing staff redeployment to care for COVID-19 patients, potentially fragmenting the extensive wound care knowledge these nurses have. This has been addressed with input from the diabetic specialist podiatrists and a small team of nurses from the diabetes ward supporting nursing staff on other wards.

Our specialist podiatry colleagues are under increased pressure with a higher patient load, as their community colleagues have been redeployed to district nursing roles, causing increased demands on both hospital outpatient appointments and domiciliary visits.

One of the less obvious areas impacting on our service is local hospital transport policy, which initially instituted a blanket ban on any patients other than for dialysis and cancer care. This has been partially resolved by negotiation on a case by case basis to allow our most vulnerable patients to be brought to hospital for dressings and outpatient IV antibiotics to try to prevent admissions. The diabetic specialist podiatry team have also increased their domiciliary visits to try to compensate for this.

Regionally, vascular surgery has seen significant impacts on their inpatient capacity, but with good, established links with our vascular hub we have managed to obtain angioplasties for our most urgent patients with agreements for them to return to a bed on our site as soon as feasible.

In order to maintain urgent surgical treatment where necessary, while minimising impact to the wider health service, we have made use of regional blocks where possible, reducing aerosol-generating procedures for our anaesthetic colleagues and maximising operating time by reducing the time needed to recover patients in theatre. This is will also maximise our use of local private sector resources, which can be challenging to access for our patients, as they are only able to accommodate ASA 1 and 2 patients, who have had a negative test for COVID-19, precluding most of our multiply comorbid group of patients.

It remains important not to lose focus on patients with foot attack (pus under pressure in the foot secondary to diabetic foot disease), which is a truly limb- (and occasionally life-threatening) problem⁵. This requires decompression and debridement as an emergency and we continue to advocate for these patients accessing surgical treatment in a timely fashion, on emergency lists, to reduce the unintended adverse outcomes in this vulnerable patient group.

References

1. Diabetic foot care in England: an economic study - Marion Kerr, Insight Health Economics, 2017
2. MS Sekhar, RR Thomas, MK Unnikrishnan, K Vijayanarayana, GS Rodrigues. Impact of diabetic foot ulcer on health-related quality of life: A cross-sectional study. Semin Vasc Surg. 2015;28(3-4):165-71. 
3. EJ Boyko, AD Seelig, JH Ahroni. Limb- and Person-Level Risk Factors for Lower-Limb Amputation in the Prospective Seattle Diabetic Foot Study. Diabetes Care. 2018;41(4):891-8.
4. NHS London Clinical Networks (2020). Clinical strategy for service management of diabetic foot units during the COVID-19 pandemic. Available at: https://www.england.nhs.uk/london/wp-content/uploads/sites/8/2020/04/5.-Covid-19-Clinical-Strategy-for-MDFTs-Crib-Sheet-02042020.pdf.
5. PR Vas, M Edmonds, V Kavarthapu, H Rashid, R Ahluwalia, C Pankhurst, N Papanas. The Diabetic Foot Attack: "Tis Too Late to Retreat!". Int J Low Extrem Wounds. 2018;17(1):7-13.