Summary
This project looks at the implementation and outcomes of an inpatient diabetic foot podiatry service at the Royal Glamorgan Hospital (RGH) between April 2023 and August 2024. The project is designed to improve patient care by establishing a dedicated multidisciplinary foot service (MDFS) within the inpatient setting with a focus on providing timely podiatry interventions, multidisciplinary coordination and education for healthcare professionals to ensure comprehensive management of active diabetic foot disease. The primary goal was to reduce length of hospital stay and enhance patient outcomes for diabetic patients presenting with foot ulcers, which is a significant cause of morbidity and mortality.
Innovation/Novel approach to an existing problem
Length of hospital stay (LoS) for a person with diabetic foot ulcers (DFU) is estimated to be 8.04 days longer than for someone with diabetes free from ulceration. However, only one third of patients with active foot ulceration at the time of admission have a foot examination within 24 hours (NHS Digital 2017). There was no dedicated inpatient podiatry service to facilitate and lead the co-ordinated multidisciplinary management of people admitted with an acute diabetic foot problem, including the fast track of individuals to the desired service, within 24 hours of admission. In addition, there was no support and provision to educate ward staff on foot risk screening for people with diabetes on admission to hospital and when or what to refer to the podiatry service, plus what measures to take to avoid hospital-acquired pressure ulcers. Similarly, there was no point-of-care contact for acute diabetic foot presentation at Emergency Department (ED)/Medical Same Day Emergency Care Unit (SDECU), which meant patients were at risk of being admitted unnecessarily, presenting as frequent flyers or being discharged unsafely. This project established a dedicated inpatient podiatry service to provide timely podiatry care for DFUs within one working day of admission or on presentation at ED/Medical SDECU, coordinate multidisciplinary management of DFU, plus educate staff on diabetic foot risk, assessment and management. The project is the only one in Wales to incorporate urgent and timely podiatry intervention in the emergency setting as part of a comprehensive, dedicated inpatient podiatry service.
Equality, Diversity and Variation
The provision of an inpatient podiatry team had long been on the diabetes and therapies IMTP. Limited funding meant the project was undertaken by a secondment of a band 7 podiatrist in RGH from April 2023-March 2024, extended to March 2025. A VBHC support worker was employed to assist with data collection/reporting. Previously, many patients were reviewed on an ad hoc basis and seen on the good will of the podiatry team. This remains the case for the two DGH sites that do not have a coordinator role. Following a successful bid, the project has continued at RGH and two WTE band 7 acute inpatient podiatrists are working at the other two DGH sites for a further two years. VBHC team involvement will aid with evaluation, reengage with stakeholders and share project outcomes at conferences and meetings. The two added DGH sites will follow same pathway as the pilot site. It is hoped that collaboration between the three sites will further strengthen the case for this role to be permanent.
Impact to Patient Care
This project aims to provide an integrated MDFS, with clear leadership and co-ordination, to ensure urgent specialist review (diabetes, microbiology, orthopaedic, podiatry, vascular and radiology) to improve patient outcomes, including reducing amputation risk. Further, it provides support and education for healthcare professionals to enable them to provide foot screening and risk stratification for all people with diabetes admitted to hospital, combined with a targeted approach of podiatric clinical interventions to prevent the development of new foot ulcers during the inpatient stay. Benefits include reduced LoS and avoidable admissions, faster reviews, reduced readmission following inpatient stay and reduced hospital-acquired DFUs, plus improved patient-reported experiences. Provision of an inpatient education programme on DFU empowers inpatient teams to identify, manage and promptly refer DFUs and improved coordination between inpatient teams better manages diabetic foot problems. A diabetic foot risk screening tool pilot is planned for rollout across hospital sites.
Results
The project has significantly improved the time to review DFU patients within 24 hours of admission or presentation. With the new service model (NSM), an average of 96.9% of patients are reviewed within 24 hours (previously 63%) with approximately 71% of the months achieving 100%. There has been a threefold increase in the number of patients seen by the podiatry team monthly, rising from an average of four patients per month at baseline to 12.9 patients per month under the NSM. Improved coordination between the wards and the podiatrist along with the awareness sessions have led to a rise in ward referrals to approximately 10 patients per month. The integrated MDFS has kept the rates of DFUs readmissions low. Notably, 62.5% of the months analysed reported no instances of readmission, which signifies the beneficial effects of specialised evaluations, coordinated care management, and educational initiatives for patients. The NSM recorded an average of 0.88 avoidable admissions per month. Under the baseline model (Oct 2022-March 2023), the median length of stay (LoS) for DFU patients was 73.5days. Following implementation of the project in April 2023-March 2025 , the median LoS reduced to nine days thanks to: early DFU assessment by the inpatient podiatrist within the 24 hours of admission; direct initiation of care plans and diagnostic imaging; improved collaboration between podiatry, ward staff and discharge teams; plus increased awareness and early identification of foot complications on admission. Importantly, shorter LOS has not led to readmission rates, a key measure of sustainable efficiency.
User Feedback
PREMS surveys indicate significant patient satisfaction with the MDFS. The service appears to effectively fulfil its objectives of delivering patient-centred care, characterised by transparent communication and prompt assistance. A consistent theme is greater patient involvement in decision making. Efforts to further empower patients in their healthcare choices could lead to even greater satisfaction levels and improved outcomes. Additional testimonials state the positive impact of the project on LoS for patients with diabetic foot disease, alongside better continuity of care and patient experience.
