Saving the NHS money by preventing pressure ulcers
For decades now pressure sores have been recognised as a serious yet preventable world-wide problem. Here we are in 2017 and we still are not doing enough to prevent these even though we know who is at risk and we know what factors elevate the risk.
Diabetic foot ulcers are a significant proportion of the total and actually we know quite a bit about the trends. England and Wales carried out a National Diabetes Foot Care Audit between 2014 and 2016 and recently published the results.
The clinical lead for the audit commented - "This report highlights inconsistences in the services available to people with foot disease in diabetes. There is also wide variation in the time which elapses before people with new foot disease are assessed by a specialist service. We know that those who wait the longest have worse healing."
Basically the care structures recommended by NICE are generally not in place. This is not a failure due to lack of medical knowledge; this is about management, organisation and resourcing. The audit included data on 11,073 patients for 13,034 new ulcer episodes at 173 specialist foot care services. A few other points stand outin this audit:-
- One third of people still had ulcers and almost one in twenty had died 24 weeks after assessment
- People with less severe ulcers were almost twice as likely to be alive and ulcer free at 12 weeks
The reality of the situation is that these patients are vulnerable and prevention is sometimes a matter of life and death.
In Scotland, the Diabetic Foot Action Group has been working hard to both raise the quality of care and consistency across Scotland. As we described in our last article on CPR for the Diabetic Foot, a Scottish system audit identified potential savings of £15 million per year if even 75% of diabetic foot ulcers could be prevented.
There is an important fact to state. This saving relates only to diabetes patients who develop foot ulcers whilst hospital in-patients. What is really needed is to expand the CPR concept to foot ulcers in general.
We know that the following Risk Factors pertain when it comes to developing pressure ulcers
- Impaired nutritional status
- Surpressed consciousness
This means that the following hospital populations are at high risk - not just those with diabetes. Elderly with femoral fractures, spinal cord injured, critical care patients, stroke patients, burns patients, renal patients etc
For the diabetic patient, the basic care pathway for foot/heel prevention decides on the most suitable prevention device based on three branches from the decision tree
- Is the patient in bed only? - the patient has no ulcer but is at risk and needs prevention
- Is the patient in bed only? - the patient has an ulcer which must be healed
- Is the patient ambulant? - the patient needs protection.
As we discussed previously a PRAFO Ankle Foot Orthosis can deal with any of these three situations but is ideal when the patient is ambulant for some of the time and either needs protection for prevention or for healing to occur.
When we consider conditions other than diabetes, other factors affect the decision tree. For example, high tone around the foot and ankle can rapidly lead to plantar flexion deformities which will delay ambulation and delay rehabilitation. Using a PRAFO with these kinds of patients is particularly important as the metal upright has the ability to resit the contracture development whilst maintaining foot and ankle protection.
Back in 1986 we were introducing the PRAFO ankle foot orthoses to the UK market and already there was acceptance of the importance of prevention. Acceptance but little evidence of action in response to the situation. In the Nursing Times of 1987, pressure sores were being described as "An expensive epidemic" which was likely to worsen due to the demographic trends. It is taking a long time to sort out these problems but it has never been more urgent.
The Scottish Foot Action Group (SFAG) pointed to the costs that they can quantify of taking action to prevent diabetic foot ulcers. They showed that it would have cost approximately £22,600 to provide appropriate pressure relief to 226 patients and this would have saved the NHS an estimated £180,000.
What about the costs that can't be so easily quantified or at least anticipated? The SFAG point to the potential for litigation when it all goes wrong.
For example, an article entitled "Daughter of woman who developed fatal pressure sores receives compensation" describes a legal claim against Durham County Council that was settled following the death of an 81-year-old woman in March 2012.
The CPR for feet concept needs to be broadened to include all foot ulcers - not just diabetic.