Objectives

• Capacity building of human and technical resources for diabetic foot care services in the state and semi-government health care sectors in Colombo by establishing a pioneer cohort of ‘Medical Officers-Diabetic Foot’ in Sri Lanka – To develop a locally relevant training module on knowledge, attitudes and skills required for health professionals – To train trainers in all regions with adoption of national guidelines with in service training of staff
• To improve the quality of diabetes foot care for residents living in the Colombo Municipal Council area through a partnership between the tertiary care and the existing diabetes oriented Primary Health Care services – To train Primary Health Care practitioners in quality diabetes foot ulcer care – To develop the infrastructure in Primary Health Care services of the Western Provincial Health Directorate for provision of such care
• To establish foot wear provision service – To train on the development of appropriate foot wear and encourage local production – To monitor the development of footwear – To encourage monitoring of foot care at district level
• To Prevent foot ulceration by empowering the public through activities that encourage community and family participation in a defined Suburban area of Colombo – Capacity building of health workers and Health Promoters in identified settings to implement programmes to prevent foot ulceration. – Empower communities in different settings that encourages positive behaviour (foot care and use of foot wear) – Identify those at risk and provide preventive care at grass root level

Justification

The problems of diabetic feet are ill addressed with focus on secondary prevention in the general care of diabetes in Sri Lanka. This has been to an extent been addressed through the development of a cohort of nurse educators, but feedback obtained from throughout the country revealed the requirement for in service training of medical officers managing outpatient diabetics in the state hospitals and also the dire need for community empowerment through primary care. Much evidence is available of the unacceptable outcomes of this complication in terms of disability, prolonged hospital stay and relative mismanagement / neglect of chronic wounds of diabetics in the state sector hospitals. A point prevalence study at the National Hospital of Sri Lanka (2006) revealed that 40% of hospital admissions of diabetics were due to foot complications that required in ward care for an average of 42 days per patient. Therefore, the DPTF identified the need for an island wide intervention and a focal training point for provision of technical support, particularly in the form of low cost foot wear (that has never been addressed in a coordinated fashion) and the need for focussed health education in terms of daily care of the diabetic towards prevention and in managing the problem diabetic foot.

Project areas

Nationally in the teaching, base and distinct hospitals throughout the country (secondary and tertiary care) and in the six established NIROGI clinics in the Colombo district (primary care) and selected family practices (private sector)

Beneficiaries

• Diabetic patients seeking care from state hospitals throughout the island and the diabetic clinics (established in the first component of the project) in the Primary Health Care in Colombo and suburbs (6 in number) that would amount to about 2/3 of diabetics in Sri Lanka
• Diabetic patients at risk of foot ulceration and amputation particularly from the lower socio-economic groups in the Metropolitan city of Colombo
• Patients attending state care tertiary hospital that had a wide coverage in all 26 districts. These hospitals have adequate human resource in the form of specialists and medical officers; who require capacity building and technical support through this application in order to provide focussed foot care for diabetics throughout the country.

Expected outcomes

• Capacity building of human and technical resources for diabetic foot care services in the state and semi-government health care sectors in Colombo – To improve the competency of the medical officers of state and selected private hospitals / clinics to ensure their ability for the provision of quality diabetes foot care – To provide technical support to develop appropriate footwear in state hospitals with Ragama RH and NHSL as focal points for training and service delivery for the poor and needy
• To uplift the infrastructure of the outpatient clinics of the six NIROGI clinics and the NHSL foot care service focal point to provide quality diabetes care and for diabetes prevention
• To build effective bridges between preventive and curative health services in relation to diabetes care
• To improve diabetes foot care in approximately 3000 patients in Colombo along with health education and participation of their immediate family members on prevention of diabetic foot ulceration and amputation

Methods adopted

• Capacity building in diabetes foot care by establishing a pioneer cohort of ‘Medical Officers in Diabetic Foot Care (MO-DFC)’ initially for the state health sector to be expanded to selected private Primary Health Care services through the College of General Practitioners of Sri Lanka – Develop a locally relevant training module – A group of experts in relevant fields (endocrinology, vascular surgery, primary care physician, medical education, curriculum development and public health) were identified for the development of training module. Through a series of consultative meetings, a locally relevant training module was developed on knowledge, attitudes and skills required for healthcare professionals. It incorporated the WDF step by step module for prevention of foot complications.

 

• Practice guidelines incorporating the national HSDP guidelines of 2007 were developed and adopted. – Training of trainers – Through regional meetings of SLMA, the training of trainers (physicians, surgeons, community physicians) from all nine provinces was carried out (9 sessions with 15 in each=135), where the developed algorithm for prevention and management of foot complications was addressed in detail. The criteria for selection of MO-DFC in each state hospital, their role and responsibilities, and methods of monitoring were discussed with the trainers and relevant administrators to ensure sustainability of this activity. – Training programmes to monitor the district level quality of care – Specific training programmes were conducted at district level for 175 MO-DFC and 26 MO-NCD to monitor the patient numbers, outcomes and quality of care at the district level (total 200 in 4 sessions). A basic toolkit was provided for trained staff to help recognise high risk foot (tendon hammer, tuning fork and monofilament). The management of affected feet was through the existing health service and trained staff. The institutions selected for enhancement were the same hospitals that had trained DENOs. – Database on diabetic foot care – A national database on diabetic foot care was developed through MO-NCD and MO-DFC on follow-up in order to determine risk factors for poor outcomes.
• Improving the quality of diabetes foot care through the health care model of primary-tertiary HC partnership initiated in the Western Province by the initial NIROGI project – In service training was conducted for all health professionals of the initial NIROGI clinics (Maligawatthe, Sedawatte, Wellampitiya, Thalangama, Piliyandala and Delkanda) with emphasis on foot care, with the establishment of foot clinics in a more comprehensive and focussed manner (monthly foot clinic with one expert/trainer from the central tertiary setting in attendance) – The quality of care and linkages with the empowerment of the community on prevention of foot complications was documented and monitored. – Several IEC material (leaflets books and DVD in trilingual format) were developed and disseminated for attendees of the foot clinics.

 

• Develop a curriculum and train students of the School of Orthotics & Prosthetics (Ragama Rehabilitation centre) on the development of footwear appropriate for high risk diabetic feet, who are expected to serve throughout the state health sector – Training of trainers in centres of excellence in India through established WDF projects (CMC Vellore, Bangalore, etc.)
• Develop a focal point for the manufacture of low cost footwear at the National Hospital of Sri Lanka Colombo (as the national centre) – Purchasing of machinery / consumables – Monitoring of development of footwear – Training other government and privates sector foot manufacturers

Impact assessment and evaluation

• Descriptive cross sectional study on Diabetes and Foot Complications carried out in teaching Hospital Kurunegala – Diabetes and Endocrinology unit by Dr G.J.C Garusinghe
• Foot screening and amputation data was collected and analysed at Panadura Base hospital and National Hospital in Sri Lanka
• 12 PNOs trained in India were reviewed.

Key achievements

• Developed a national level training module by the technical group and evaluation carried out in 10 meetings; and it was successfully distributed island wide to healthcare professionals as trainers

 

• Capacity building of 969 MOs on diabetic foot care by establishing a pioneer cohort of ‘Medical Officers-Diabetic Foot’ in Sri Lanka In collaboration with SLMA and College of surgeons of Sri Lanka
• 24 awareness sessions on preventing foot ulceration were done in Kotte and Kolonnawa MOH areas, following which 40 active community groups having skills on detecting, managing and prevention of foot ulceration were formed. Through them, 525 people were sensitized on foot ulceration.
• Successfully piloted diabetic foot clinics in 5 selected hospitals (Colombo South TH, Kurunegala TH, Jaffna TH, Anuradhapura TH and Kandy TH) to improve the quality of wound care by establishing a health care model of tertiary-primary care partnership. 3000 patients received foot screening and care.
• Training of trainers was conducted for 12 Prosthetics and Orthotics (P and O) officers and 2 experienced technicians from DSI. They were sent to receive a specific training on diabetic foot in Vellore and Bangalore in India in order to establish a core national group of trainers for our local setting.
• P and O training was conducted by the trained staff in India for 30 P and O and 26 staff nurses by conducting 2 workshops at the Ragama Rehabilitation Hospital in collaboration with the Sri Lankan Association of Prosthetics and Orthotics (SLAPO).
• 6 models were developed (DSI) IEC material for free distribution at point of sale developed. Number sold in 1st quarter reached 5000 exceeding expectation This new line of diabetic shoes was launched officially under name ‘NIROGI’ to coincide with the World Diabetes Day 2015. They are currently available in DSI Showrooms Island wide. An Educational leaflet was also developed to handover to customer with each purchase.

 

• 12 meetings, workshops and seminars were held for footwear development.
• Purchased machinery/consumables for producing footwear.
• Production of diabetic footwear by DSI and customized at Rehabilitation hospital,Ragama
• National guideline for the diabetic foot care was piloted in 10 piloting hospitals (Anuradhapura, Ratnapura, Galle, Matara, Jaffana, Kurunagala, Kandy, Colombo south, NHSL and Colombo North).
• 10g Monofilament for foot screening was developed in house and validated.
• Equipment was purchased for the piloting hospitals such as hand held doppler, digital BP and locally produced monofilament.
• Purchased equipment to NHSL (advanced vascular Doppler to NHSL) and Ragama rehabilitation hospital (Computerized PEDOGRAPH main unit and 5 duro meters).
• Amputation registries that were not maintained previously were initiated at the NHSL and Colombo South Hospital.
• Developed a database on diabetic foot care through follow up in order to determine risk factors for poor outcomes and registered 5000
• Developed and disseminated 10,000 IEC material
• Monitoring of development of footwear at Rehabilitation hospital Ragama.
• This component led to further expansion of interested hospitals to become dedicated to managing chronic leg/foot wounds e.g. Wijaya Kumaratunge Hospital Seeduwa where since 2014 when the in house doctor attended a 4 weeks hands on training at the NHSL vascular surgical unit and has been able to thereby benefit over 25,000 patients with chronic wounds with advice on appropriate footwear since. They recently introduced a CME programme for hospital and primary care doctors in the region that has potential for sustainability.
• The College of Surgeons led Diabetic Wound care programme in 5 districts for capacity building has set the stage for an expansion and networking of a ‘diabetic foot care’ commitment at primary care level in many regions of Sri Lanka.

Lessons learnt

• The project highlights and advocates the need for P & O and a total foot care approach.
• The development of low cost custom made shoes by P&Os now employed full time by the Ministry of Health Island wide and through corporate sector is most likely to be sustainable with regular awareness sessions provided for the shoe industry to benefit the changing dynamics of care givers and consumers, and secure commitment towards sustainability not on profit basis.
• Screening of diabetic foot has become more formalised by the large effort taken through the project to make physician specialists and primary care givers aware of the importance of screening for high risk feet. The in house development of a monofilament encourages the application of a foot screening toolkit to become a regular feature in the management of diabetics in Sri Lanka.
• The total foot care approach initiated by the project where surgeons and physicians could liaise better to focus on the high risk diabetic foot despite major resource limitations. There has been a ripple effect of the foot care CMEs and capacity building for doctors and allied health staff throughout Sri Lanka. Provision of gaps in technical support improved their teams’ commitment to the cause with specific focus on diabetic foot and likely to ensure a sustained effort to prevent lower limb amputations.

Technical group

• Prof Mandika Wijeyaratne – Coordinator
• Dr Piyasena Samarakoon (Deputy Director General of Health-Medical Services I, Ministry of Health)
• Dr Ananda Gunasekera (Deputy Director General of Health-Medical Services II, Ministry of Health)
• Dr Jayasundera Bandara (Deputy Director General of Health-Education Training and Research, Ministry of Health)
• Dr Rezni Cassim and Dr Nalaka Gunawansa (Vascular Surgeon, National Hospital of Sri Lanka)
• Sri Lanka College of Endocrinologists (Drs Noel Somasundaram, Uditha Bulugahapitiya, Sajitha Siyambalapitiya, Prasad Katulanda, Manilka Sumanatilleke, Charles Anthonypillai)
• Dr Kayathri Periyasamy (Consultant Diabetologist)
• Dr Namaratne (Primary Care Physician, College of General Practitioners)
• Dr Palitha Karunapema (Deputy Director, Ragama Rehabilitation)