INTEGRATED DIABETIC FOOT CARE A USER'S GUIDE
Contents
1. Able to apply the principles of evidence based medicine to their practice taking a critical approach to accessing and applying new information Undertakes an examination and assessment to form a diagnosis Takes and or reviews medical and medication histories Assesses the patient s understanding and reinforce the benefits of good glycaemic control self care and monitoring to prevent complications including the provision of lifestyle advice i e smoking cessation taking exercise healthy diet Able to accurately discuss diabetes management with the patient based on available information Able to request and interpret relevant tests in the management of diabetes Behaviours as for Level B and Communicates clearly with the patient about diabetes care while recognising that the patient may find the diagnosis or ongoing management of diabetes stressful Seeks out and develops their own professional networks for support reflection and learning Establishes multiprofessional links with clinicians in their specialism e Contributes to health improvement by working with relevant local agencies e g social services patient support networks 1 4 Level D Specialist podiatrist Knowledge as for Level C and Comprehensive knowledge of the aetiology of diabetes and the impact of disease progression Comprehensive understanding of pharmacological and non pharmacological approaches to the ma2. 18 PODIATRY COMPETENCY FRAMEWORK FOR INTEGRATED DIABETIC FOOT CARE A USER S GUIDE COMPETENCY STATEMENTS 8 WOUND CARE comnTINUED To provide effective care for people with active diabetic foot ulceration podiatrists and assistants should be able to demonstrate the following competencies 8 4 Level D Specialist podiatrist As for Level C and Generic A broad understanding of the wound healing process and its potential complications A broad understanding of the psychological impact of active diabetic foot disease on the patient Debridement Able to carry out basic sharp debridement of simple and complex wounds within the scope of their practice Appropriately recognises the need and refers the patient for advanced debridement A broad knowledge of debridement techniques other than sharp debridement Critically analyses wound care interventions to develop evidence based individualised care plans Carries out advanced wound management techniques with appropriate support and supervision Infection control Recognises the signs and symptoms of local wound infection and manages them effectively Recognises when to refer the patient for infection control by appropriately skilled colleagues Undertakes comprehensive microbiological sampling e g wound swabbing bone sampling tissue biopsy and reporting Ensures the results of microbiological investigations are seen and int
3. Demonstrates a working knowledge of basic infection control procedures e g hand hygiene and techniques for minimising cross infection Pressure relief Encourages the patient and or carer to comply with instructions on the use of pressure relieving devices for the treatment of active ulceration Dressings Carries out dressing changes as instructed and within the scope of their practice Encourages the patient and or carer to comply with recommended dressing regimens As for Level A As for Level B and Generic A working knowledge of diabetic wound management related local and national guidance Able to recognise and classify active foot ulceration including identification of vascular insufficiency neurological deficit significant foot deformity trauma increased pressures and extent and degree of infection A basic understanding of the wound healing process and the potential complications of or delays to that process A basic understanding of the psychological impact of active diabetic foot disease on the patient Able to confirm that the patient and or carer understands the purpose and nature of a proposed care plan Debridement Understands the principles of debridement and wound bed management Able to carry out wound management techniques e g basic sharp debridement wound irrigation Refers appropriately for advanced wound management Infection control
4. Develops and implements strategies to ensure the best use of local resources and technologies in diabetic foot care N This competency can be mapped to the following Mapping to KSF core dimensions C1 Communication C2 Personal and People Development C4 Service Improvement G2 Development and Innovation Map to Skills for Health competencies NOS indicators AC3 CJHF27 DANOS GEN55 GEN63 LLUK L1 LLUK L4 LLUK L17 M amp L B1 M amp L B4 M amp L B5 M amp L B6 M amp L B8 M amp L D1 M amp L D2 M amp L D7 M amp L F2 PODIATRY COMPETENCY FRAMEWORK FOR INTEGRATED DIABETIC FOOT CARE A USER S GUIDE 25 REFERENCES Boulton AJ Vileikyte L Ragnarson Tennvall G Apelqvist J 2005 The global burden of diabetic foot disease Lancet 366 9498 1719 24 Bowen G Barton H Haggen G et al 2008 The impact of a diabetic foot protection team DEPT on outcome for patients with diabetic vascular disease B J Surg 95 Suppl 1 4 5 Canavan RJ Unwin NC Kelly WF Connolly VM 2008 Diabetes and nondiabetes related lower extremity amputation incidence before and after the introduction of better organized diabetes foot care continuous longitudinal monitoring using a standard method Diabetes Care 31 459 63 DH 2009 Jonising Radiation Medical Exposure Regulations DH London Available at http bit ly mqkZ9u accessed 20 05 12 DH 2011 Operational Guidance to the NHS on Extending Patient Choice of Provider DH Lond
5. UK and NHS Diabetes 2011 Therefore skill mixing dictated by the risk based needs of the population with diabetes may enable an increase in capacity To gain a better understanding of the hierarchy of foot care needs of people with diabetes and the competencies to which they correspondingly require access Figure 1 is a helpful aid Patients at low risk of diabetic foot disease People at low risk of diabetic foot disease have no evidence of peripheral sensory and or arterial impairment They comprise approximately 70 of adults with diabetes Leese et al 2011 Leese et al 2011 estimate that this group have a 1 in 500 chance of foot ulceration per year that is 99 6 of this group will be ulcer free after 2 years With a low risk of ulceration this group do not require routine podiatry care However they do require annual screening and foot care education Furthermore they should have access to a diabetic foot care service within one working day should their foot rapidly deteriorate Several groups SIGN 2010 Diabetes UK 2012b recommend that the first healthcare professional to see the patient with diabetes in any given calendar year should provide foot screening if they are competent to do so The competencies required to provide care for this group are detailed in Levels A C of this framework Utilising non podiatrists who are competent to undertake routine Figure 1 A representation of the adult populatio
6. A E 17 SN otad Care or oi 3 18 C 3233 133313 1 1 11131 1 1 1111 11 1 111 21 10 Chatcotmetitoatthro pathy ssr 1 3 11 7 1 22 RS 331 11 1 23 12 Reseaichand aU T 3533 337 11 1 11 1311 0 24 3 3 3 1 E 25 1 0 77070 71 11111 1 1 1 1 0 26 PODIATRY COMPETENCY FRAMEWORK FOR INTEGRATED DIABETIC FOOT CARE A USER S GUIDE 3 DEFINITIONS AND ABBREVIATIONS British National Formulary Department of Health Foot in Diabetes UK Foot protection team defined by Diabetes UK 2011 Glycated haemoglobin Knowledge and Skills Framework administered by the Department of Health www dh gov uk Multidisciplinary diabetic foot care team defined by Diabetes UK 2011 National Health Service National Institute for Health and Clinical Excellence National Occupational Standards administered by Skills for Health www skillsforhealth org uk Scottish Diabetes Foot Action Group Scottish Intercollegiate Guidelines Network Training Research and Integrated Education for Podiatrists in Diabetes across the UK World Health Organization 4 PODIATRY COMPETENCY FRAMEWORK FOR INTEGRATED DIABETIC FOOT CARE A USER S GUIDE BNE DH FDUK FPT HRA KSF MDT NHS NICE NOS SDFAG SIGN TRIEPodD UK WHO FOR
7. S GUIDE NOTES PODIATRY COMPETENCY FRAMEWORK FOR INTEGRATED DIABETIC FOOT CARE A USER S GUIDE 2m Podiatry Competency Framework For Integrated Diabetic Foot Care A User s Guide 2012 TRIEPodD UK Published by SB Communications Group 1 03 Enterprise House 1 2 Hatfields London SE1 9PG T 0 207 627 1510 E tdfj sbcommunicationsgroup com W www diabetesonthenet com TRIEPodD UK yt
8. and Negotiates treatment plans including where appropriate non pharmacological therapies that both patient and prescriber are satisfied with Understands national drug budgetary constraints and can discuss them with colleagues and patients Takes a leading role in supporting and advising other prescribers and colleagues Leads collaborative working and networking with higher educational institutions and other agents to meet the needs of the population with diabetes N This competency can be mapped to the following KSF core dimensions C1 Communication C2 Personal and People Development C3 Health Safety and Security C4 Service Improvement C5 Quality HWB6 Assessment and Treatment Planning HWB7 Interventions and Treatments NOS indicators CHS74 CHS83 CHS105 CHS106 CHS109 DANOSAA1 EUSC19 GEN22 GEN63 HSC23 HSC43 HSC241 M amp l D1 M amp L E1 M7L E2 14 PODIATRY COMPETENCY FRAMEWORK FOR INTEGRATED DIABETIC FOOT CARE A USER S GUIDE 5 RADIOLOGY To provide effective care for people with diabetes podiatrists should be able to demonstrate radiological knowledge and COMPETENCY STATEMENTS associated clinical skills in the following competencies 5 1 Level A Healthcare technician 5 2 Level B Podiatry assistant practitioner 5 3 Level C Qualified podiatrist 5 4 Level D Specialist podiatrist 5 5 Level E Advanced podiatrist or practitioner 5 6 Level F Consultant podiatrist or
9. and is able to provide them with appropriate literature on the condition Undertakes and encourages honest clear communication with patients and or their carer Aware of services designed to assist the patient and or carer in the self management of their diabetes As for Level A As for Level B and A critical understanding of the importance and effects of patient education and self management Awareness of the impact of culture and social context on how the patient feels about health related behaviours and about changing them Recognises and corrects misinformation the patient may hold about their condition and the effects of this misinformation on self care behaviours and their consequences Understands and uses a range of tools and techniques in the assessment and evaluation of the patient s health status concerns personal context and priorities Provides access to relevant information in a suitable format to the patient and or carer to support their understanding and self care An understanding of the need for detailed personal action plans to achieve and maintain health related goals for patients at increased risk of diabetic foot complications As for Level C but with an increased understanding and A working knowledge of how to develop detailed personal action plans to achieve and maintain health related goals for patients at increased risk of diabetic foot complications An awareness o
10. be able to demonstrate the following competencies in research and audit 12 1 Level A Healthcare Not applicable technician 12 2 Level B Podiatry assistant Not applicable practitioner 12 3 Level C Qualified podiatrist Understands the importance of adopting evidence based practices in the clinical setting Critically appraises methods of clinical evaluation Undertakes literature searches to answer clinical questions A knowledge of current research in diabetic foot disease Uses research and audit tools to improve their clinical practice and patient outcomes 12 4 Level D Specialist podiatrist As for Level C but with an increased understanding and Able to facilitate the integration of evidence based practices in the clinical setting A good knowledge of current research in diabetic foot disease 12 5 Level E Advanced podiatrist As for Level D and or practitioner Critically appraises the validity of information and disseminates the findings to colleagues as appropriate Actively contributes to research in diabetic foot disease A thorough knowledge of research and audit methods Participates in the design and implementation of research and audit activities e Implements research and audit tools to improve clinical practice and patient outcomes Supports colleagues using research and audit tools in the clinical setting Highly skilled in undertaking literature searches to answer c
11. diabetic foot care The over arching goal of the framework is to ensure that people with diabetes have their feet cared for based on their level of risk by healthcare professionals with appropriate skill sets regardless of where in the UK they live We hope the framework will be widely adopted Acknowledgements The development of the framework has been funded by SDFAG and TRIEPodD UK thanks the group for their continued belief in the framework Skills for Health sponsored the early stages of the development of the framework and we thank them for their support The Society of Chiropodists and Podiatrists and FDUK have provided invaluable support in the development of the user s guide We would also like to extend our thanks to the following organisations for their interest in the framework NHS Education Scotland the Scottish Diabetes Group QIS Orthotists Practice Development Group and Diabetes UK I would like to personally thank the members of TRIEPodD UK listed below for their support and for their commitment to seeing the framework through to fruition I would also like to thank those involved at various stages of the development review and promotion of the framework Stuart Baird Jody Binning Ivan Bristow Scott Cawley Margaret Doyle Wilfred Foxe John McCall and David Wylie I would also like to thank the industry sponsors listed on page 2 of this document who along with The Diabetic Foot Journal team at SB Communications Group ma
12. each dimension and the opportunity for the clinician or manager to benchmark existing skills or services against them For example if the podiatrist is a supplementary prescriber the competency would be Level E F However if the podiatrist is not a prescriber it would be acceptable to be Level D or below It is for the clinician and managers to decide what competencies they require based on individual professional and service needs It is not compulsory that higher level clinicians have the highest skill levels in all dimensions Q Is the framework applicable throughout the UK A Yes The framework is not region specific it provides guidance and clarity on the competencies required to provide a comprehensive diabetes foot service It is compatible with both NICE 2004 2011 and SIGN 2010 clinical guidance It can also be used by commissioners to define the competencies that they require groups or individuals tendering to deliver diabetic foot care services under any qualified provider initiatives to be able to demonstrate 0 Is the framework part of professional registration requirements A No Clinicians are not required to prove competency as defined by the framework in order to practice in the UK the standards of proficiency to practice are defined by the Health Professions Council However the framework is relevant to those providing any level of diabetic foot care and the authors hope it will be voluntarily adop
13. ulcer prevention footwear interventions N This competency can be mapped to the following KSF core dimensions C1 Communication C4 Service Improvement C5 Quality HWB1 Promotion of Health and Wellbeing HWB6 Assessment and Treatment Planning HWB7 Interventions and Treatments HWB9 Equipment and Devices to Meet Health and Wellbeing Needs NOS indicators CHS5 CHS40 CHS140 Diab DF02 Diab HA3 Diab HA4 Diab GEN22 HA4 HSC23 HSC43 M amp L B5 M amp L D2 PE3 PE4 PEO PE7 DES PODIATRY COMPETENCY FRAMEWORK FOR INTEGRATED DIABETIC FOOT CARE A USER S GUIDE Dil COMPETENCY STATEMENTS 10 CHARCOT NEUROARTHROPATHY To pani effective care for people with diabetes and Charcot neuroarthropathy CN podiatrists and assistants should be able to 10 1 Level A Healthcare technician 10 2 Level B Podiatry assistant practitioner 10 3 Level C Qualified podiatrist 10 4 Level D Specialist podiatrist 10 5 Level E Advanced podiatrist or practitioner 10 6 Level F Consultant podiatrist or practitioner emonstrate the following competencies A knowledge of local guidance on the management of diabetes and the potential risk of diabetic foot disease Recognise when there is a need for referral of a patient with a history of foot ulceration Uses local referral pathways appropriately Follows instruction from colleagues to ensure CN care plans are carried out within the scope of their practice A
14. 1 Level A Healthcare technician e Able to refer the patient to a colleague when skin abnormality is observed 3 2 Level B Podiatry assistant As for Level A practitioner 3 3 Level C Qualified podiatrist As for Level B and Uses the appropriate referral pathway for the investigation of suspected dermopathologies including microscopy and culture biopsies and allergy testing 3 4 Level D Specialist podiatrist As for Level C and Recognise the dermopathologies common to diabetes Makes urgent appropriate referrals to exclude malignancy Where appropriate undertakes clinical management of dermopathologies based on an agreed care plan 3 5 Level E Advanced podiatrist or As for Level D and practitioner In depth understanding of investigations for dermopathologies including microscopy and culture biopsies and allergy testing Able to diagnose and develop care plans for dermatological infections with effective antibiotic and anti mycotic regimens with reference to local and or national microbial stewardship policies 3 6 Level F Consultant podiatrist As for Level E and or practitioner Establishes clear referral pathways for dermatological intervention and treatment of the diabetic lower limb N This competency can be mapped to the following KSF core dimensions HWB6 Assessment and Treatment Planning HWB7 Interventions and Treatments NOS indicators AL2 CHS4 CHS40 CHS41 CHS46 CHS88 CHS99 Diab HA1
15. Able to recognise the clinical signs and symptoms of wound infection and refers quickly and appropriately for infection control Carries out basic microbiological sampling e g wound swabbing and ensures results are interpreted by an appropriately skilled colleague Pressure relief An up to date knowledge of biomechanical pressure relieving strategies for wound healing Uses basic pressure relieving devices within the scope of their practice Refers the patient for assessment for and supply of specialist pressure relieving devices for wound healing appropriately Works collaboratively with colleagues including orthotists to optimise patient compliance with pressure relieving devices for wound healing Dressings A broad knowledge of available dressing products their modes of action and appropriate use Aware of their local wound management formulary group and related groups N This competency can be mapped to the following KSF core dimensions C1 Communication C4 Service Improvement HWB1 Promotion of Health and Wellbeing HWB6 Assessment and Treatment Planning HWB7 Interventions and Treatments HWB9 Equipment and Devices to Meet Health and Wellbeing Needs NOS indicators CHS5 CHS7 CHS12 CHS14 CHS40 CHS61 CHS70 CHS99 CHS118 CHS177 CHS179 CHS185 CHS222 CMD5 Diab DF02 Diab DF03 Diab HA3 Diab HA4 Diab TTO1 Diab TT02 GEN22 GEN62 GEN63 HSC23 HSC43 M amp L B1 M amp L B8 PCS18
16. Diabetes Care 27 1774 82 McCardle J 2008 Diabetes and podiatry in the 21 Century Is specialism the way forward The Diabetic Foot Journal 11 129 40 NHS Modernisation Agency 2005 Good Care Planning for People With Long Term Conditions Updated Version NHS London Available at http bit ly KBALZf accessed 20 05 12 NICE 2004 Type 2 Diabetes Prevention and Management of Foot Problems CG 10 NICE London Available at www nice org uk CG10 accessed 20 05 12 NICE 2011 Diabetic Foot Problems Inpatient Management of Diabetic Foot Problems CG 119 NICE London Available at www nice org uk cg119 accessed 20 05 12 Pound N Chipchase S Treece K et al 2005 Ulcer free survival following management of foot ulcers in diabetes Diabet Med 22 1306 9 Schofield CJ Yu N Jain AS Leese GP 2009 Decreasing amputation rates in patients with diabetes a population based study Diabet Med 26 773 7 SIGN 2010 Management of diabetes A National Clinical Guideline CG 116 SIGN Edinburgh Available at http bit ly Kc3t6j accessed 20 05 12 TRIEPodD UK 2012 Competency Framework for the Prevention Treatment and Management of Diabetic Foot Disease TRIEPodD UK Edinburgh Available at http bit ly JIXAC9 accessed 20 05 12 Vileikyte L 2001 Diabetic foot ulcers a quality of life issue Diabetes Metab Res Rev 17 246 9 26 PODIATRY COMPETENCY FRAMEWORK FOR INTEGRATED DIABETIC FOOT CARE A USER
17. EWORD he Podiatry Integrated Career and Competency Framework for Diabetes Foot Care TRIEPodD UK 2012 was T developed in response to the need to identify and standardise clinical competencies in diabetic foot care from clinical practice through to research and leadership It is the first podiatry clinical competency framework underpinned by theoretical components The framework is the product of collaboration between a number of individuals professional bodies and organisations with an interest in diabetic foot care To increase the accessibility of the framework TRIEPodD UK have developed the document you are reading now which is a user s guide to the framework TRIEPodD UK recognise that podiatrists and podiatry assistants are key healthcare professionals in the delivery monitoring and design of diabetic foot care services and are increasingly leading these services in the UK This framework is an important tool that will facilitate benchmarking of existing skill sets and guidance for the professional development of podiatrists who are keen to become specialists and service leaders within diabetic foot care As it spans all levels of practice from healthcare technicians to consultant practitioners managers and services providers can use the framework to assess the scope and competency of their workforce Many of the competencies are transferable and the framework can be adapted and used by other healthcare professionals involved in
18. June 2012 TRIEPodD UK PODIATRY COMPETENCY FRAMEWORK FOR INTEGRATED DIABETIC FOOT CARE A USER S GUIDE The Diabetic Foot Journal P Skills for Health NPS Podiatrists o 8 a S T L vI g i Mi Z 5 3 L SPONSORS The following companies provided unrestricted educational grants to support the publication and distribution of this document GOLD SPONSOR Jia ec Solutions for the multidisciplinary diabetic foot clinic SILVER SPONSORS Se MOLNLYCKE HEALTH CARE Coloplast ConvaTec H oe 2 2 2 0 SANOFI 2 PODIATRY COMPETENCY FRAMEWORK FOR INTEGRATED DIABETIC FOOT CARE A USER S GUIDE CONTENTS Definitions 2 2 2 2 2 2 2 23 313 1 1 1111 1 4 5 3 3 120 5 2 8 6 A competency framework for diabetic Poor Gane 3 aerate cartier 6 Who is the framework 2 2 2 2 3 3 11 1 15 iaire 6 5 7 aa RE 3 3 3313 1 8 aeaaaee sa isdie 9 Competency statements 10 Vy eT 10 tT 12 2 Dermatolog R 005 13 4 Pharmacotherapy sissies ese oe ni 0 14 Dis AIO OG R 15 3 31 nin 16 TSIM TT E A
19. PODIATRY COMPETENCY FRAMEWORK FOR INTEGRATED DIABETIC FOOT CARE A USER S GUIDE 13 COMPETENCY STATEMENTS 4 PHARMACOTHERAPY To provide effective care for people with diabetes podiatrists should be able to demonstrate pharmaceutical knowledge and associated clinical skills in the following petencies 4 1 Level A Healthcare technician 4 2 Level B Podiatry assistant practitioner 4 3 Level C Qualified podiatrist 4 4 Level D Specialist podiatrist 4 5 Level E Advanced podiatrist or practitioner 4 6 Level F Consultant podiatrist or practitioner Not applicable Not applicable Aware of the modes of action and effects of relevant medicines including pharmacokinetics and pharmacodynamics Aware of the potential for unwanted effects e g allergic rations drug interactions precautions contraindications etc Maintains an up to date knowledge of relevant products including formulations doses and costs in the BNF drug tariff Aware of the potential misuses of relevant medicines Demonstrates an awareness of no treatment non drug and drug treatment options including preventative measures and referrals for non drug interventions As for Level C and Aware that patient specific factors e g age renal impairment impact the pharmacokinetics and pharmacodynamics of relevant medicines and that regimens may need to be adjusted based on these factors Works within local proto
20. able to demonstrate the following competencies in COMPETENCY STATEMENTS leadership and service development 13 1 Level A Healthcare technician 13 2 Level B Podiatry assistant practitioner 13 3 Level C Qualified podiatrist 13 4 Level D Specialist podiatrist 13 5 Level E Advanced podiatrist or practitioner 13 6 Level F Consultant podiatrist or practitioner Not applicable Not applicable Shows clinical leadership within their workplace Aware of local diabetes service protocols and works within them Participates in peer review of their own clinical practice As for Level C but with an increased understanding and Participates in peer review of colleagues clinical practice As for Level D and Shows clinical leadership within their local diabetic foot services Offers appropriate education and advice to podiatry and other colleagues in relation to clinical and service practices in diabetic foot care Plans and initiates collaborative training programmes for service improvement and delivery Leads the review of their own and their colleagues clinical practice Creates opportunities for colleagues to undertake self directed and supported learning Contributes to the coordination of services for the care of the diabetic foot across organisational and professional boundaries Challenges local services to improve care of and outcomes for people with diabetic foot di
21. acute CN Monitors the effectiveness of pressure relieving strategies for the management of CN e g total contact casting and makes changes or refers for further assessment appropriately Uses clinical reasoning and reflection on their practice to ensure the safe management of acute CN especially in the use casts As for Level E and Leads the design and implementation of care plans for the management of acute CN in collaboration with colleagues e g consultant physicians plaster technicians orthotists Plans and implements complex pressure relieving strategies for the management of CN Applies bespoke pressure relieving devices including total contact casts for the management of CN Monitors the effectiveness of CN care plans and makes changes where appropriate through the progressive stages of CN Understands and refers for radiological and non radiological assessments of CN Communicates to the patient and or carer the long and short term implications of a diagnosis of CN Recognises the challenges faced by the patient with acute and resolved CN and provides them and or carer with appropriate support Leads the design of long term care plans for the patient following the resolution of acute CN Contributes to the development of local and national guidance on the management of diabetes related CN Works with stakeholders in the development of local referral pathways for the manage
22. appropriate level of clinical support for requestors of radiological investigations to undertake this aspect of their role safely and effectively Proactively identifies the need for clinical or service innovations to radiological investigations of the lower limb for people with diabetes and takes a leading role designing and implementing these innovations N This competency can be mapped to the following KSF core dimensions C1 Communication C2 Personal and People Development C4 Service Improvement C5 Quality HWB1Promotion of Health and Wellbeing HWB6 Assessment and Treatment Planning HWB7 Interventions and Treatments HWB8 Biomedical Investigation and Intervention NOS indicators CHS38 CHS83 CHS99 CHS109 GEN22 GEN59 GEN63 HSC23 HSC43 HSC241 M amp L D1 PODIATRY COMPETENCY FRAMEWORK FOR INTEGRATED DIABETIC FOOT CARE A USER S GUIDE 15 COMPETENCY STATEMENTS 6 PAINFUL DIABETIC PERIPHERAL NEUROPATHY To provide effective care for people with painful diabetic peripheral neuropathy PDPN podiatrists should be able to demonstrate the following competencies 6 1 Level A Healthcare technician 6 2 Level B Podiatry assistant practitioner 6 3 Level C Qualified podiatrist 6 4 Level D Specialist podiatrist 6 5 Level E Advanced podiatrist or practitioner 6 6 Level F Consultant podiatrist or practitioner Not applicable Not applicable A basic knowledge of the 1 Causes of PDPN 2 Signs a
23. blishes the cause of previous ulceration in order to develop and implement an appropriate ulcer prevention care plan Recognises the need for specialist footwear and prescribes it appropriately Develops footwear and orthotic ulcer prevention care plans in collaboration with an orthotist Monitors the effectiveness of foot pressure relieving devices and recognises when modification or replacement of such devices is required and ensures the necessary changes are undertaken appropriately A knowledge of the technologies used in the assessment of foot pressure and gait analysis A working knowledge of the materials used in the manufacture of foot orthoses for the prevention of recurrence of ulceration As for Level E and Provides and evaluates specialist education for the patient and or carer on the prevention of foot reulceration Able to measure patients feet for the fitting of stock footwear according to British standards Contributes to and when appropriate leads national strategies for prevention of diabetic foot reulceration Leads the implementation and integration of specialist diabetic footwear services Proactively identifies the need for clinical or service innovations to prevent diabetic foot reulceration and takes a leading role in designing and implementing these innovations Creates an environment that encourages collaboration among colleagues to optimise patient compliance with
24. clinical practice and collaborates with higher educational institutions and other educational providers to achieve this Ensures there is local capacity to facilitate support and mentor colleagues seeking to develop their clinical practice e g advanced debridement total contact cast fabrication etc Debridement Leads in the evaluation of novel wound care products Provides clinical leadership in advanced wound debridement techniques Leads in the establishment of working relationships with surgical staff responsible for surgical debridement Provides expert opinion on debridement products techniques and indications in local and national expert groups Infection control e Leads in conjunction with appropriate stakeholders the development and implementation of local antibiotic use guidance Collaborates with higher educational institutions and other educational providers on meeting the diabetic foot related educational needs of podiatrists and associated colleagues Leads in establishing relationships with surgical staff for infection control and vascular reconstruction Leads in liaising with local infection control microbiology and multidisciplinary teams to minimise patient risk associated with infection Pressure relief Demonstrates the ability to apply bespoke pressure relieving devices to optimise wound healing such as total contact and slipper casts Demonstrates the ability
25. cols for prescribing requests and uses as appropriate Understands local drug budgetary constraints As for Level D and Able to request and interpret renal and liver function tests Establishes monitors and make changes to medication regimens within the scope of the care plan and in light of the therapeutic objectives Gives clear information to the outpatient and or carer about their medication s including how when to take administer the medications where to obtain them and possible side effects Aware of common medication errors and medication error prevention strategies Aware of and accepts legal and ethical responsibility for prescribing within the context of the care plan Plays a role in developing local protocols for prescribing requests Understands current legislation on prescribing practice at local and national levels Stores prescription pads safely and is aware of what to do if they are stolen or lost Uses tools to improve prescribing practice e g review of prescribing data feedback from patients Reports prescribing errors and near misses and reviews practice to prevent recurrence Understands local drug budgetary constraints and can discuss them with colleagues and patients Provides support and advice to other prescribers when appropriate Establishes appropriate support from colleagues to train and practice as an independent prescribers As for Level E
26. de the publication and distribution of this document possible Joanne McCardle Project Lead TRIEPodD UK TRIEPodD UK Members Joanne McCardle Advanced Acute Diabetes Podiatrist Edinburgh Paul Chadwick Principal Podiatrist Salford Graham Leese Consultant Physician Dundee Alistair McInnes Senior Lecturer Brighton Duncan Stang Diabetes Foot Co ordinator Scotland Louise Stuart Consultant Podiatrist Manchester TRIEPodD UK Matthew Young Consultant Physician Edinburgh PODIATRY COMPETENCY FRAMEWORK FOR INTEGRATED DIABETIC FOOT CARE A USER S GUIDE 5 COMPETENCY STATEMENTS IN CONTEXT oot disease is a devastating but potentially avoidable complication of diabetes and as a result every 30 seconds a lower limb is lost due to diabetes related amputation somewhere in the world Boulton et al 2005 In the UK diabetic foot complications are the largest single reason for hospital admissions among people with diabetes Boulton et al 2005 and the financial implications are correspondingly huge Diabetes UK 2011 estimates that foot complications account for 20 of the total NHS spend on diabetes care Diabetes UK 2011 some 639 62 million per year in England alone Kerr 2012 The indirect intangible costs to the person with diabetic foot disease are also high with many unable to work and experiencing a poorer quality of life than those without foot dis
27. e podiatry practice A Yes Private practitioners are often essential in providing core podiatry care for people with diabetes and they can use the framework to identify their competencies in this area However some of levels of care described in the framework are only safe to undertake within a supported clinical team and would be unsuitable for clinicians in any sector to undertake while working in isolation 0 1 4 not a podiatrist can I use the document A While the framework focuses on the skill sets of podiatrists and podiatry assistants clinicians who are members of other professional groups and provide aspects of diabetic foot care will find some sections of the framework useful The authors would welcome the adoption of the framework by other healthcare professionals Oo PODIATRY COMPETENCY FRAMEWORK FOR INTEGRATED DIABETIC FOOT CARE A USER S GUIDE 9 COMPETENCY STATEMENTS 1 GENERIC To provide effective care for people with diabetes podiatrists and assistants should be able to demonstrate the following competencies 1 1 Level A Healthcare technician Knowledge A general knowledge of the nature of diabetes including its signs and symptoms Recognises the limits of own knowledge about diabetes Aware of national guidance for the diagnosis and management of diabetes e g NICE SIGN etc Skills Applies information to clinical context within agreed boundaries and protocol
28. ease Vileikyte 2001 A competency framework for diabetic foot care As the UK population with diabetes continues to grow so too will the demand for foot care Diabetes UK 2012a estimates that there are around 2 5 million people with diabetes in England and by 2025 that number is expected to reach 5 million Meeting the foot care needs of this growing group is likely to require the redesign of current services and an increase in the size of the workforce delivering foot care McCardle 2008 Currently in the UK clinicians providing diabetic foot care from basic screening through to advanced wound management have attained their professional skills in a range of ways there is no standardised route by which the theoretical and clinical skills needed to provide safe and effective diabetic foot care are obtained Stuart and McInnes 2011 This inconsistency highlights the need for a structured approach to detailing professional competencies in the delivery of diabetic foot care In answer to this need a group of clinicians who are actively involved in diabetic foot care came together to develop the Podiatry Career and Competency Framework for Integrated Diabetic Foot Care TRIEPodD UK 2012 This comprehensive document began the process of establishing standards of professional competence in delivering diabetic foot care at all levels To make the framework more accessible a user s guide the document that you are read
29. ening and assessment as for Level D and Provides expert opinion on screening and assessment programmes Where possible participates in the development of local evidence based screening programmes Facilitates colleagues learning of screening and assessment techniques to support service needs Screening and assessment as for Level E and Works with stakeholders to develop and implement local screening programmes Proactively identifies the need for clinical or service innovations to effectively screen the feet of people with diabetes and takes a leading role designing and implementing these innovations Leads collaborative working and networking with higher educational institutions and other agents to meet the needs of the population with diabetes N This competency can be mapped to the following KSF core dimensions C1 Communication C2 Personal and People Development C4 Service Improvement C5 Quality HWB6 Assessment and Treatment Planning HWB7 Interventions and Treatments NOS indicators CHS99 Diab HA3 Diab HA4 Diab TT01 GEN14 GEN20 GEN22 M amp L B1 M amp L B5 M amp L B6 M amp L D2 12 PODIATRY COMPETENCY FRAMEWORK FOR INTEGRATED DIABETIC FOOT CARE A USER S GUIDE COMPETENCY STATEMENTS 3 DERMATOLOGY To provide effective care for people with diabetes and dermopathologies of the lower limb podiatrists and assistants should be able to demonstrate the following competencies 3
30. erpreted by an appropriately skilled colleague Pressure relief A broad knowledge of biomechanical pressure relieving strategies for foot ulcer healing Dressings Good knowledge of available dressing products their modes of action and appropriate use 8 5 Level E Advanced podiatrist As for Level D and or practitioner Generic Advanced understanding of the wound healing process and its potential complications An advanced understanding of the psychological impact of active diabetic foot disease on the patient Able to classify active foot ulceration including advanced investigations of vascular insufficiency ankle brachial pressure index Doppler ultrasound neurological deficit foot deformity trauma increased pressures extent and degree of infection Contributes expert opinion on the development of care plans for complex diabetic foot ulceration Contributes to the development of local guidance related to diabetic wound management A working knowledge of national guidance related to diabetic wound management Contributes to the development of local referral pathways Applies high level clinical reasoning in the management of complex diabetic foot ulcers Debridement Able to carry out advanced debridement with a range of debridement tools of complex wounds within the scope of their practice Able to carry out advanced wound management techniques e g topical negative p
31. ess of specialist footwear and other orthotic devices and makes changes or refers for further assessment as appropriate As for Level E and Reviews and revises patient information relating to the prevention of diabetic foot ulceration Engages with and influence national bodies regarding strategies on providing information for preventative care Able to measure for stock footwear according to British standards N This competency can be mapped to the following KSF core dimensions C1 Communication HWB6 Assessment and Treatment Planning HWB7 Interventions and Treatments HWB9 Equipment and Devices to Meet Health and Wellbeing Needs NOS indicators CHS48 CHS76 CHS99 Diab DF02 Diab HA3 Diab HA4 GEN14 GEN22 HSC23 HSC43 M amp L D2 PODIATRY COMPETENCY FRAMEWORK FOR INTEGRATED DIABETIC FOOT CARE A USER S GUIDE T COMPETENCY STATEMENTS 8 WOUND CARE To provide effective care for people with active diabetic foot ulceration podiatrists and assistants should be able to demonstrate the following competencies 8 1 Level A Healthcare technician 8 2 Level B Podiatry assistant practitioner 8 3 Level C Qualified podiatrist Generic Understands how the complications of diabetes mean that a wound on the foot must be seen by a suitably skilled colleague as a matter of urgency Able to access local referral pathways appropriately Debridement Not applicable Infection control
32. f counselling techniques interview methods and motivational interviewing As for Level D and Understands and manages the psychological impact of diabetic foot disease in the patient An in depth understanding of the tools and techniques for assessment and evaluation of the patient s health status concerns personal context and priorities High level skills in undertaking and encouraging honest clear communication with the patient and or carer about active diabetic foot disease As for Level E and Influences the design and dissemination of relevant suitably presented patient information on the prevention and management of diabetic foot disease Leads collaborative working and networking with higher educational institutions and other agents to meet the needs of people with diabetic foot disease N This competency can be mapped to the following Mapping to KSF core dimensions C1 Communication Development HWB4 Enablement to Address Health and Wellbeing Needs HWB6 Assessment and Treatment Planning Map to Skills for Health competencies NOS indicators CHS38 CHS44 CHS45 CHS61 CHS70 CHS105 CHS177 CM D5 Diab DA4 Diab PEO1 GEN14 GEN22 GEN32 GEN62 HSC330 HT2 MH97 PE PES M amp L D2 PODIATRY COMPETENCY FRAMEWORK FOR INTEGRATED DIABETIC FOOT CARE A USER S GUIDE m3 COMPETENCY STATEMENTS 12 RESEARCH AND AUDIT To provide effective care for people with diabetes podiatrists should
33. he advanced level of diabetic foot care However during the development process the need to define the full spectrum of competencies became apparent Once compiled a UK wide consultation process was undertaken Stakeholders were invited to provide feedback on the document either via email or at a 2009 consultation day The consultation process Identified the need for a more accessible user s guide which you are reading now e Generated broad professional agreement on the appropriateness of the content but also minor changes Revealed confusion between the framework s levels and the Agenda for Change pay bandings In response to this the competency levels in the user s guide have been renamed using letters Levels A F for clarity B 1 An online training programme for medical staff nurses www diabetesframe org clinical support workers and foot care assistants is available at 8 PODIATRY COMPETENCY FRAMEWORK FOR INTEGRATED DIABETIC FOOT CARE A USER S GUIDE Frequently asked questions There are a number of recurring questions about the framework In this section the authors aim to address the most frequently asked questions about the framework Q Do I need to be proficient in all dimensions A No The dimensions include everything required to manage people with diabetes This spans basic screening through to complex care of active foot disease It provides guidance on the competencies required in
34. ing now was devised The user s guide is divided into 13 dimensions of competency pages 10 25 which are then divided into Levels A F which reflect increasing complexity of care The authors wish to stress that no single clinician need possess all of the competencies to the highest level rather these competencies should be reflected across the team or service responsible for delivering local diabetic foot care Who is the framework for Podiatrists deliver the bulk of diabetic foot care in the UK and are key members of the FPT and the MDT For these reasons the framework focuses on the podiatrist but is relevant to and can be adapted for use by all those involved in delivering diabetic foot care Likewise the benefits and uses of the framework extend to a range of stakeholders Clinicians can use the framework to Benchmark their existing competencies Identify areas in which to increase their competency Aid them in writing performance reviews e Identify a career pathway in the specialism of diabetic foot care Patients will benefit from the adoption of the framework by clinicians and services by e The assurance that they will be treated by a clinician with competencies specific to the management of the diabetic foot relative to their level of need s The emphasis the document places on patient empowerment education and wherever possible self management e The improvements in patient o
35. linical and non clinical questions Highly skilled in the presentation oral and written of research and audit results to colleagues 12 6 Level F Consultant As for Level E and podiatrist or practitioner Leads the design and implementation of research and audit activities Creates opportunities for colleagues to participate in research and audit activities Collaborates with higher educational institutions research funding bodies health boards and other stakeholders to develop innovative research and audit activities Ensures appropriate access to research resources for colleagues Highly skilled in the presentation oral and written of research and audit results at local and national levels and is influential in the implementation of findings Creates an environment that facilitates colleagues to improve their knowledge about and participation in research and audit activities N This competency can be mapped to the following Mapping to KSF core dimensions C1 Communication C2 Personal and People Development C3 Health Safety and Security C4 Service Improvement Map to Skills for Health competencies NOS indicators GEN 18 GEN23 GEN32 HI 11 HI16 HI19 HSC23 HSC43 LLUK L10 M amp L D2 R amp D8 a R amp D10 R amp D13 24 PODIATRY COMPETENCY FRAMEWORK FOR INTEGRATED DIABETIC FOOT CARE A USER S GUIDE 13 LEADERSHIP To provide effective care for people with diabetes podiatrists should be
36. ment of CN and enables their implementation Proactively identifies the need for clinical or service innovations to effectively manage CN and takes a leading role designing and implementing these innovations N This competency can be mapped to the following Mapping to KSF core dimensions C4 Service Improvement HWB6 Assessment and Treatment Planning HWB7 Interventions and Treatments Map to Skills for Health competencies NOS indicators CHS38 CHS40 CHS41 CHS47 CHS85 CHS88 CHS99 CHS173 DiabHA1 DiabHA3 DiabHA4 Diab TT01 GEN22 HA4 HSC23 HSC43 DD PODIATRY COMPETENCY FRAMEWORK FOR INTEGRATED DIABETIC FOOT CARE A USER S GUIDE COMPETENCY STATEMENTS 11 HEALTH IMPROVEMENT To provide effective health improvement and self management strategies relating to the diabetic foot podiatrists and assistants should be able to demonstrate the following competencies 11 1 Level A Healthcare technician 11 2 Level B Podiatry assistant practitioner 11 3 Level C Qualified podiatrist 11 4 Level D Specialist podiatrist 11 5 Level E Advanced podiatrist or practitioner 11 6 Level F Consultant podiatrist or practitioner Understands the importance of patient education for and self management of long term conditions A basic understanding of the psychological impact on the patient and or carer of having a long term condition Aware of the kinds of misinformation the patient may have about diabetes
37. n with diabetes their risk of diabetic foot disease and the competency framework levels related to their care Leese at al 2011 TRIEPodD UK 2012 Total adult population with diabetes Level of risk Related competency framework levels PODIATRY COMPETENCY FRAMEWORK FOR INTEGRATED DIABETIC FOOT CARE A USER S GUIDE 7 COMPETENCY STATEMENTS IN CONTEXT annual diabetic foot screening is central to freeing qualified podiatrists to deliver more clinically complex care Patients with established risk factors for diabetic foot disease People with significant peripheral sensory and or arterial impairment but who have not had an episode of active foot disease comprise approximately 20 of the adult population with diabetes Leese et al 2011 The risk of people within this group ulcerating is between 3 and 7 per year Leese et al 2011 It is recommend that this group receive regular podiatry care depending on individual needs This care should be provided in dedicated diabetic foot care sessions at community treatment centres They should have access to a diabetic foot care service within one working day should their foot rapidly deteriorate NICE 2004 2011 SIGN 2010 Diabetes UK 2012b The competencies required to provide care for this group are detailed in Levels C E of this framework Patients with a history of diabetic foot disease This group comprises those who have had at least one previous episode of acti
38. nagement of diabetes Skills as for Level C and Communicate clearly to the individual what is involved in the assessment and management of the presenting condition Generic behaviours as for Level C and Able to critically reflect on and improve their own practice 10 PODIATRY COMPETENCY FRAMEWORK FOR INTEGRATED DIABETIC FOOT CARE A USER S GUIDE COMPETENCY STATEMENTS 1 GENERIC conTINUED To provide effective care for people with diabetes podiatrists and assistants should be able to demonstrate the following competencies 1 5 Level E Advanced podiatrist Knowledge as for Level D and or practitioner In depth knowledge of the aetiology of diabetes and the impact of disease progression In depth understanding of pharmacological and non pharmacological approaches to the management of diabetes In depth knowledge of the signs and symptoms of diabetes including the WHO diagnostic criteria e In depth knowledge of normal and abnormal blood glucose ranges HbA levels and how to monitor them In depth understanding of diabetes related national guidance and NHS frameworks Skills as for Level D and Evaluates and interprets clinical information from diverse sources and makes informed judgements about its quality and the appropriateness of disseminating it to colleagues High level clinical decision making skills that are effectively translated into clinical practice Influences a
39. nd contributes to the design of patient record systems and decision support tools Employs their in depth diabetes knowledge to engage with patients about their care Provides patients and or carers with information that supports them in providing informed consent for clinical interventions Contributes to the development of evidence based clinical and cost effective diabetes care Behaviours as for Level D and Reflects on the performance of their service clinic relative to other local and national services clinics Engages in the critical review of their own and others practice and learns from them Where appropriate contributes to diabetes related national guidance and NHS frameworks Seeks out and develops professional networks for their own and colleagues support reflection and learning Establishes and or monitors the multiprofessional approaches to integrated patient care Acts as a professional mentor for junior colleagues Creates formal links with relevant local agencies e g social services patient support networks 1 6 Level F Consultant podiatrist Knowledge as for Level E or practitioner Skills as for Level E and Takes a leading role in the development of diabetes related national guidance and NHS frameworks Takes a leading role in the design of patient record systems and decision support tools Contributes to the development of evidence based cli
40. nd supplying insoles as part of the management of diabetic foot disease Monitors the effectiveness of pressure relieving devices and appropriately refers patients for further foot pressure assessment A knowledge of the technologies used in the assessment of foot pressure and gait analysis Dressi Advanced knowledge of available dressing products and their modes of action Extensive experience in the appropriate use of available dressing products Supports other colleagues in choosing appropriate dressings for patients with diabetic foot ulceration Makes dressing product choices based on consideration of clinical indications wound type patient needs and formulary and budgetary directives Provides expert opinion to their local wound management formulary group and other related wound dressing groups 8 6 Level F Consultant level As for Level E and podiatrist or practitioner Generic Contributes to the development of relevant national guidance Facilitates the development of local referral pathways and enables their implementation Works with stakeholders to develop and implement care pathways for patients with active foot disease Proactively identifies the need for clinical or service innovations to effectively manage active diabetic foot ulceration and takes a leading role designing and implementing these innovations Leads in the integration of theoretical wound management into
41. nd symptoms of PDPN 3 Typical progression of PDPN Able to recognise the common signs and symptoms of PDPN when reported by a patient and refer appropriately A basic knowledge of the evidence based treatments available for the relief of the symptoms of PDPN Provides the patient and or carer with information on PDPN in a suitable format As for Level C and Able to refer appropriately for further investigations and treatment Able to differentiate between PDPN and other painful symptoms such as ischaemic rest pain As for Level D and An in depth knowledge of the 1 Causes of PDPN 2 Signs and symptoms of PDPN 3 Typical progression of PDPN An in depth knowledge of the evidence based treatments available for the relief of the symptoms of PDPN Helps the patient and or carer to understand the actions they can take to manage the symptoms of PDPN Provides the patient and or carer with information on PDPN in a suitable format and encourages them to engage in active self management and treatment compliance Supports or contributes to specialist PDPN clinics As for Level E and Works with stakeholders to develop and implement PDPN care pathways Proactively identifies the need for clinical or service innovations to effectively manage PDPN and takes a leading role designing and implementing these innovations Leads collaborative working and networking with higher educational institutio
42. nical and cost effective diabetes care and takes a leading role in disseminating this information to colleagues Behaviours as for Level E and Influences national policy on diabetes care Proactively identifies the need for clinical and service innovations to meet the needs of people with diabetes and takes a leading role designing and implementing these innovations N This competency can be mapped to the following KSF core dimensions C1 Communication C2 Personal and People Development C5 Quality HWB6 Assessment and Treatment Planning HWB7 Interventions and Treatments NOS indicators B1 B6 CDE4 CfA410 CHS19 CHS48 CHS56 CHS76 CHS83 Diab GA1 Diab GA2 Diab HA1 Diab HA13 Diab TTO1 EUSC01 EUSC02 GEN12 GEN13 GEN14 GEN22 GEN27 GEN31 GEN39 GEN40 GEN44 GEN63 HI19 HSC41 HSC224 HSC434 LLUK M amp L B1 MH92 MH93 PE8 Pharm PHP15 PHS07 PODIATRY COMPETENCY FRAMEWORK FOR INTEGRATED DIABETIC FOOT CARE A USER S GUIDE i COMPETENCY STATEMENTS 2 SCREENING To effectively carry out diabetic foot screening and assessment podiatrists and assistants should be able to demonstrate the following competencies 2 1 Level A Healthcare technician 2 2 Level B Podiatry assistant practitioner 2 3 Level C Qualified podiatrist 2 4 Level D Specialist podiatrist 2 5 Level E Advanced podiatrist or practitioner 2 6 Level F Consultant podiatrist or practitioner Screening Clearl
43. ns and other agents to meet the needs of the population with diabetes N This competency can be mapped to the following KSF core dimensions C1 Communication C4 Service Improvement HWB1 Promotion of Health and Wellbeing HWB6 Assessment and Treatment Planning HWB7 Interventions and Treatments NOS indicators CHS40 CHS62 CHS99 CHS118 CHS120 CHS179 Diab TTO1 Diab TT02 DFO1 EUSC1 GEN14 GEN22 GEN62 M amp L B6 M amp L D2 16 PODIATRY COMPETENCY FRAMEWORK FOR INTEGRATED DIABETIC FOOT CARE A USER S GUIDE COMPETENCY STATEMENTS 7 ULCER PREVENTION To effectively prevent foot ulceration among people with diabetes podiatrists and assistants should be able to demonstrate the following competencies 7 1 Level A Healthcare technician 7 2 Level B Podiatry assistant practitioner 7 3 Level C Qualified podiatrist 7 4 Level D Specialist podiatrist 7 5 Level E Advanced podiatrist or practitioner 7 6 Level F Consultant podiatrist or practitioner Understands how the complications of diabetes increase the risk of foot ulceration When appropriate is able to inform the patient and or carer that they are at increased risk of foot ulceration in a manner that is respectful of the distress the patient and or carer may experience at this time Understands the necessity of urgent referral and treatment in the event of suspected ulceration As for Level A As for Level B and Able to carr
44. on Available at http bit ly oN7h4X accessed 20 05 12 DH 2012 Podiatry Any Qualified Provider Implementation Pack DH London Available at http bit ly FO9GTg accessed 20 05 12 Diabetes UK 2011 Putting Feet First National Minimum Skills Framework Diabetes UK London Diabetes UK NHS Diabetes 2011 A Survey of The Diabetes Specialist Podiatrist Workforce UK Pilot NHS Diabetes Newcastle upon Tyne Available at http bit ly L28IXB accesssed 20 05 12 Diabetes UK 2012a State of the Nation 2012 England Diabetes UK London Available at http bit ly KcgOTU accessed 20 05 12 Diabetes UK 2012b Integrated Footcare Pathway Diabetes UK London Available at http bit ly AGyqDf accessed 13 03 2012 Kerr M 2012 Foot Care for People With Diabetes The Economic Case for Change NHS Diabetes Newcastle upon Tyne Available at http bit ly xjY7FS accessed 20 05 12 Krishnan S Nash F Baker N et al 2008 Reduction in diabetic amputations over 11 years in a defined U K population benefits of multidisciplinary team work and continuous prospective audit Diabetes Care 31 99 101 Leese GP Stang D McKnight J 2011 A national strategic approach to diabetic foot disease in Scotland changing a culture British Journal of Diabetes amp Vascular Disease 11 69 73 Maciejewski ML Reiber GE Smith DG et al 2004 The effectiveness of diabetic therapeutic footwear in preventing reulceration
45. practitioner Not applicable Not applicable An understanding of the available radiological investigations and the rationale for their use An understanding of the side effects of radiological investigations and why in some circumstances a non radiological method of investigation may be more appropriate Keeps up to date with changes in clinical practice related to requesting or interpreting radiological images As for Level C and Has completed training in the Ionising Radiation Medical Exposure Regulations DH 2009 Requests radiological investigations Requests radiological investigations frequently enough to maintain competency Up to date knowledge of the actions indications contraindications interactions cautions dose and side effects of the radiological investigations ordered Works within and contributes to the development of local protocols for radiological requests e g patient group directions As for Level D and Able to interpret radiological reports Able to clearly communicate to the patient and or carer the rationale behind undertaking a radiological investigation and the potential risks and benefits of doing so Communicates the results of radiological investigations to the patient and or carer in terms they understand Provides support and advice to other radiological requesters and colleagues where appropriate As for Level E and Negotiates the
46. ressure systems Recognises the need and refers the patient for surgical debridement appropriately Supports less experienced colleagues in developing advanced debridement skills Infection control Leads colleagues in comprehensive microbiological sampling e g wound swabbing bone sampling tissue biopsy and reporting Interprets results from microbiological sampling Recognises deep infection e g foot abscess and refers for appropriately Recognises the need for inpatient treatment of diabetic foot ulceration and facilitates the process of the patients admission to hospital using local pathways Contributes in the development of local antibiotic use guidance PODIATRY COMPETENCY FRAMEWORK FOR INTEGRATED DIABETIC FOOT CARE A USER S GUIDE 19 COMPETENCY STATEMENTS 8 WOUND CARE comnTINUED To provide effective care for people with active diabetic foot ulceration podiatrists and assistants should be able to demonstrate the following competencies 8 5 Level E Advanced podiatrist Pressure relief or practitioner continued An up to date knowledge of advanced and customised pressure relieving strategies used in the management of diabetic foot disease Recognises when to use advanced pressure relieving devices e g moon boots removable walkers total contact casts A knowledge of the materials used in the manufacture of foot orthoses Skilled in fabricating modifying a
47. s Uses relevant patient record systems and decision support tools Uses up to date information and terminology to communicate with patients and colleagues Updates medical histories appropriately Undertakes protocol led clinical examinations within the scope of their practice Communicates to patients the benefits of good glycaemic control self care and monitoring to prevent diabetic complications Behaviours Refers to and seeks guidance from appropriately skilled colleagues when necessary Able to reflect on and improve their own practice with support from senior colleagues Constructively challenges inappropriate practices Utilises available professional networks for support reflection and learning Takes responsibility for their own continuing professional development 1 2 Level B Podiatry assistant Generic knowledge skills and behaviours as for Level A practitioner 1 3 Level C Qualified podiatrist Knowledge as for Level B and A general knowledge of the aetiology of diabetes and the impact of disease progression A basic understanding of pharmacological and non pharmacological approaches to the management of diabetes Familiar with diabetes related national guidance and NHS frameworks Aware of the WHO criteria for diabetes diagnosis Can recognise normal and abnormal blood glucose ranges HbA levels and how to monitor them Skills as for Level B and
48. s for Level A As for Level B and A working knowledge of local and national guidance on the diagnosis and management of CN Recognises patients at increased risk of CN Recognises the clinical signs and symptoms of acute onset CN and refers the patient to a specialist team in an appropriate and timely manner Recognises when further investigations are required for the diagnosis of CN An understanding of the rationale for biomechanical pressure relieving strategies in the management of CN Assists in the implementation of care plans for the management of CN A basic understanding of the psychological impact of active diabetic foot disease As for Level C but with an increased understanding and A knowledge and understanding of the interventions for a suspected CN Assists in the implementation of care plans for acute CN Confirms that the patient and or carer understands the purpose and nature of the proposed CN care plan Able to undertake long term care plans following the resolution of CN As for Level D and Undertakes differential diagnosis of CN distinguishing acute CN from other acute conditions e g cellulitis ankle sprain deep venous thrombosis An up to date knowledge of pharmacotherapies for the management of CN Assists in the design and implementation of the care plan for acute CN A working knowledge of pressure relieving strategies for the management of
49. sease Participates in the development of guidance protocols and recommendations related to diabetic foot care Provides expert knowledge in relation to diabetic foot services Leads projects designed to improve diabetic foot related patient and service outcomes Participates in the development of professional networks related to diabetic foot care Designs delivers and evaluates educational packages for appropriate colleagues and students on diabetic foot care and service development and delivery As for Level E and Provides clinical leadership on diabetic foot care at local national and international levels Leads diabetic foot care services across organisational and professional boundaries Leads the development of professional networks related to diabetic foot care and facilitates the participation of colleagues in these networks Develops and implements clinical guidance and protocols related to diabetic foot care at local and national levels Communicates the sometimes complex and challenging needs of providing diabetic foot care to key opinion leaders policy makers and politicians nationally and influences related policy Supports colleagues in bringing about service improvement in the care of the diabetic foot Proactively identifies the need for clinical or service innovations in diabetic foot care and takes a leading role in designing and implementing these innovations
50. ted by these healthcare professionals The level of integration of the framework into practice should be made at the local level Q Does my level of competency within the framework impact on my Agenda for Change pay banding A There is no direct read across from the Agenda for Change pay bands and the framework levels FREQUENTLY ASKED QUESTIONS Q Iam a manager how can I use the framework A Asa manager the framework can be used to identify the needs of the service by mapping current staff competencies to the dimensions to ensure all areas of care are covered It can also be used on an individual basis and linked to the KSF to inform professional development plans Q Iam a podiatrist how can I use the framework A This document is designed to be used by clinicians to identify their current skill level It can be used for informing professional development plans and links to KSF are provided It is also a tool for planning career progression should you wish to specialise in diabetic foot care Q I am a strategic healthcare planner how can I use the framework A This document provides guidance on the staff competencies required across the spectrum of diabetic foot care It can be used to identify gaps in services and provide guidance on the competencies required at each level It can be used by commissioners or equivalent to define competent providers and services Q Can the framework be used in privat
51. to ensure foot pressure relieving devices are used appropriately As for Level A As for Level B and A basic understanding of the complications of diabetes and their increasing severity in relation to preventing foot reulceration Communicates to the patient and or carer the risk of reulceration in an appropriate manner while recognising the potentially stressful nature of the information Provides education for the patient and or carer aimed at the prevention of recurrence of ulceration Assists in implementing the care plan to prevent ulcer recurrence Maintains up to date knowledge of biomechanical pressure relieving strategies and their implementation Recognises when high street footwear is appropriate and when referral for specialist footwear is needed depending on the patient s needs A knowledge of the materials used in the manufacture of foot orthoses for the prevention of reulceration As for Level C and Increased understanding of the natural history of diabetes and its complications and how to assess its severity in relation to preventing foot ulcer recurrence Works collaboratively with orthotists and other colleagues to optimise patient compliance with footwear advice and orthotic devices As for Level D and Advanced understanding of the natural history of diabetes and its complications and how to assess its severity in relation to preventing foot ulcer recurrence Esta
52. to plan and implement complex pressure relieving strategies Employs a broad knowledge of the range of pressure relieving devices to select the most appropriate interventions for the patient A knowledge of and experience in using technologies for gait analysis and foot pressure measurements Creates an environment that supports collaborative work with orthotists and other colleagues to optimise the patient s compliance with pressure relieving devices Dressings Provides expert opinion on dressings and medical devices in local and national wound formulary and associated groups 20 PODIATRY COMPETENCY FRAMEWORK FOR INTEGRATED DIABETIC FOOT CARE A USER S GUIDE COMPETENCY STATEMENTS 9 POST ULCER CARE To provide effective care for people with a history of diabetic foot ulceration podiatrists and assistants should be able to demonstrate the following competencies 9 1 Level A Healthcare technician 9 2 Level B Podiatry assistant practitioner 9 3 Level C Qualified podiatrist 9 4 Level D Specialist podiatrist 9 5 Level E Advanced podiatrist or practitioner 9 6 Level F Consultant podiatrist or practitioner Aware that people with a history of diabetic foot ulceration are at increased risk of reulceration Recognise when there is a need for referral of a patient with a history of foot ulceration Uses local referral pathways appropriately Follows instruction from colleagues
53. utcomes that should flow from receiving care from a workforce that is demonstrably competent in the care of the diabetic foot Managers and commissioners can use the framework to Streamline services in line with NHS Modernisation Agency 2005 guidance by ensuring the right mix of staff competencies to meet the various levels of foot care needed by people with diabetes e Plan appropriate professional development activities leading to improvements in staff satisfaction retention and succession planning McCardle 2008 e Define those competencies that they require groups or individuals tendering to deliver diabetic foot care services under any qualified provider initiatives DH 2011 2012 to be able to demonstrate 6 PODIATRY COMPETENCY FRAMEWORK FOR INTEGRATED DIABETIC FOOT CARE A USER S GUIDE COMPETENCY STATEMENTS IN CONTEXT Educational and training institutions can use the framework to Ensure their curriculums include training in appropriate diabetic foot competencies specifically Level C competencies are appropriate for new podiatry graduates and they should be included in undergraduate podiatry syllabi Identify where gaps exist in the provision of continued professional development courses Workforce planning based on patient needs Reliance on the podiatry workforce alone for the management of all levels of foot care for people with diabetes has been suggested to be unsustainable Diabetes
54. ve foot disease including those who have undergone a diabetes related amputation and form 4 8 of the adult population with diabetes Leese et al 2011 This group has a 40 50 risk of reulcerating each year Maciejewski et al 2004 Pound et al 2005 The high risk of active foot disease in this group necessitates careful follow up by appropriately skilled podiatrists in the community based FPT who have robust support from and referral pathways into the MDT The competencies required to provide care for this group are detailed in Levels D E of this framework Patients with active diabetic foot disease At any one time 1 4 of adults with diabetes have active foot disease Leese et al 2011 This group requires careful management and frequent review by an MDT with the support of a network of community based FTPs and nurses who undertake care between MDT clinic visits It is widely acknowledged that the management of active diabetic foot disease by an MDT improves patient outcomes Bowen et al 2008 Canavan et al 2008 Krishnan et al 2009 Schofield et al 2009 The competencies required to provide care for this group are detailed in Levels E F of this framework Development of the framework The Podiatry Career and Competency Framework for Integrated Diabetic Foot TRIEPodD UK 2012 is the product of 5 years work by clinicians and interested organisations The initial aim was to produce a competency framework for t
55. y communicates what is involved in the screening process to the patient Carries out basic diabetic foot screening in line with national guidance and or local protocols Assigns an ulcer risk score based on the results of the screening using relevant decision making tools when available Records the screening results on the relevant patient records system s Explains the results of the screening to the patient and or carer in an appropriate manner Provides up to date verbal and written advice relevant to the risk status resulting from foot screening Aware of and appropriately uses local referral pathways As for Level A Screening as for Level B Assessment Able to carry out a basic diabetic foot assessment allocate risk status stratification and record the information on the relevant system Carries out thorough assessment of the diabetic foot including vascular insufficiency peripheral sensory neuropathy and deformity Able to make appropriate specific referrals for specialist intervention Aware of local policies regarding screening and assessment of the diabetic foot Screening as for Level C Assessment as for Level C and Carries out in depth assessments of the diabetic foot Aware of local and national guidance and policies regarding diabetic foot screening and assessment Facilitates the training of colleagues in screening according to local policies Scre
56. y out a foot ulcer risk assessment including the identification of vascular insufficiency neurological deficit significant foot deformity trauma or increased pressures Assesses whether the patient and or carer is aware that they are at increased risk of developing foot ulceration Provides the patient and or carer with up to date verbal and written advice on the prevention of foot ulceration Assesses the patient s understanding of the information on ulcer prevention provided and their ability to undertake appropriate self care behaviours Maintains an up to date knowledge of biomechanical pressure relieving strategies and devices and their role in reducing the risk of foot ulceration A basic knowledge of the materials used in the manufacture of orthoses Recognises those patients for whom high street footwear is appropriate and provides advice on making appropriate footwear choices Recognises when a patient cannot safely wear high street shoes and refers them for specialist footwear As for Level C and Communicates what is involved in foot assessment and obtains the patient s informed consent As for Level D and Provides expert advice to the patient and or carer on the benefits of ulcer prevention and self care Appropriately prescribes specialist footwear and other orthotic devices A working knowledge of the materials used in the manufacture of orthoses Monitors the effectiven
Download Pdf Manuals
Related Search