1362576103 initiatives & innovations mumbai 06

Initiatives & Innovations Initiatives & Innovations for for

Diabetic Foot Care in Diabetic Foot Care in Non-Urban AreasNon-Urban Areas

Dr. Kalkunte R. SureshDr. Kalkunte R. SureshDr. A.S. Vinaya PhDDr. A.S. Vinaya PhD

Ms. UshaMs. Usha

Diabetic Foot Care CenterDiabetic Foot Care CenterJIVAS - BangaloreJIVAS - Bangalore


Diabetic Foot Care in Non-Urban AreasDiabetic Foot Care in Non-Urban Areas Project Project “LEAP”“LEAP” ( (LLimb imb EEvaluation & education for valuation & education for

AAmputation mputation PPrevention), funded by SBMT (Society revention), funded by SBMT (Society for Biomedical Technology) for Biomedical Technology)

A project to evaluate efficacy of preventive foot A project to evaluate efficacy of preventive foot care in both urban & rural diabeticscare in both urban & rural diabetics

964 patients recruited from July 2004 to July 2006964 patients recruited from July 2004 to July 2006 Complete data analysis pending–a) rural Complete data analysis pending–a) rural

population showed acceptable compliance with population showed acceptable compliance with footwear b) Significant decrease in amputation footwear b) Significant decrease in amputation and recurrent ulcers. c) Several important lessons and recurrent ulcers. c) Several important lessons learned in treating rural population d) “Social learned in treating rural population d) “Social Impact” of modern gadgets e) Methods to reduce Impact” of modern gadgets e) Methods to reduce “drop puts” from treatment f) Has spawned off “drop puts” from treatment f) Has spawned off several initiatives in rural areas several initiatives in rural areas


Diabetic Foot Care in Non-Urban AreasDiabetic Foot Care in Non-Urban Areas

Project PADASAMRAKSHANEProject PADASAMRAKSHANE

““Training of health care workers and Training of health care workers and providing diabetic foot care in providing diabetic foot care in

non-urban/rural regions in the State of non-urban/rural regions in the State of Karnataka”Karnataka”

The three pronged project is sponsored by The three pronged project is sponsored by World Diabetic Foundation (WDF), DenmarkWorld Diabetic Foundation (WDF), Denmark..



THE THREE ARMS OF THE PROJECT:THE THREE ARMS OF THE PROJECT:

Training healthcare workers: One-month course will be Training healthcare workers: One-month course will be offered to paramedical worker, which will involve both offered to paramedical worker, which will involve both didactic teaching and hands-on experience. We aim to train didactic teaching and hands-on experience. We aim to train nurses, ANM’s (Auxiliary Nurse Midwife), multipurpose nurses, ANM’s (Auxiliary Nurse Midwife), multipurpose health workershealth workers

Establish 10 “diabetic foot care Centers” with help from Establish 10 “diabetic foot care Centers” with help from their medical community. their medical community.

A Mobile Foot Clinic will help us provide care in other under-A Mobile Foot Clinic will help us provide care in other under-served areas around Bangalore and continue educating served areas around Bangalore and continue educating health care workers and public. It can also be used to health care workers and public. It can also be used to conduct “diabetic foot screening camps”.conduct “diabetic foot screening camps”.



The First arm of this project The First arm of this project is to train health care is to train health care personnel from across India in diabetic foot carepersonnel from across India in diabetic foot care and and by the end of the training they would be able to:by the end of the training they would be able to:

Evaluate and recognize diabetic foot problemEvaluate and recognize diabetic foot problem Offer both preventive counseling and careOffer both preventive counseling and care Perform required minor podiatric proceduresPerform required minor podiatric procedures Use basic equipments like monofilament, sensitometer, Use basic equipments like monofilament, sensitometer,

HCP device, hand held Doppler etc.HCP device, hand held Doppler etc. Obtain exposure to advanced instrumentations like foot Obtain exposure to advanced instrumentations like foot

mapping devicesmapping devices Gain basic knowledge about biomechanics, customized Gain basic knowledge about biomechanics, customized

diabetic footwear and orthotic devices.diabetic footwear and orthotic devices. Witness surgical procedures in patients with diabetic foot Witness surgical procedures in patients with diabetic foot

problems.problems.


Diabetic Foot Care in Non-Urban AreasDiabetic Foot Care in Non-Urban Areas Selection of candidates for training – Selection of candidates for training –

They are chosen from nurses, ANM’s (Auxiliary Nurse Midwife), They are chosen from nurses, ANM’s (Auxiliary Nurse Midwife), multipurpose health workers etc. who have shown interest in diabetic foot multipurpose health workers etc. who have shown interest in diabetic foot care, who already have at least 2 years of work experience in a hospital or care, who already have at least 2 years of work experience in a hospital or out patient/clinic setting, not necessarily in diabetic care, though it would out patient/clinic setting, not necessarily in diabetic care, though it would be preferred.be preferred.

They can be from any part of India, but first year preference will be given They can be from any part of India, but first year preference will be given to those from the State, so that we help them establish diabetic foot clinics to those from the State, so that we help them establish diabetic foot clinics across the State of Karnataka.across the State of Karnataka.

Recommended by a hospital or medical practitioner who is already Recommended by a hospital or medical practitioner who is already providing diabetic foot care or interested in setting up a diabetic foot clinic providing diabetic foot care or interested in setting up a diabetic foot clinic or from other facilities where the training will be put to use.or from other facilities where the training will be put to use.

About 2 candidates will be chosen to train in a given month (22 per year to About 2 candidates will be chosen to train in a given month (22 per year to be trained over 11 months). be trained over 11 months).

A fee of Rs.1000 is charged; they are given a stipend of Rs.1000, with free A fee of Rs.1000 is charged; they are given a stipend of Rs.1000, with free boarding & lodgingboarding & lodging



Training materials & Method:Training materials & Method:

Clinical training through direct patient contactClinical training through direct patient contact All trainees will be given course material All trainees will be given course material

written/compiled by this department &/or existing written/compiled by this department &/or existing books about diabetic foot care.books about diabetic foot care.

Patient information booklets in English and Patient information booklets in English and regional language to be provided to the trainees.regional language to be provided to the trainees.

Patient education/counseling material -. E.g. Flip Patient education/counseling material -. E.g. Flip charts, videoscharts, videos

A set of podiatry instruments after trainingA set of podiatry instruments after training Method of training – Syllabus provided. Method of training – Syllabus provided.



Training of health care workers:Training of health care workers: Two candidates trained every month starting from June Two candidates trained every month starting from June

2006 for 11 months i.e. train 44 diabetic foot care workers 2006 for 11 months i.e. train 44 diabetic foot care workers over 2 years. In the first year train 10 candidates from the over 2 years. In the first year train 10 candidates from the State of Karnataka and this would translate into 10 diabetic State of Karnataka and this would translate into 10 diabetic foot care centers across the state. Other trainees could be foot care centers across the state. Other trainees could be from any part of India.from any part of India.

JuneJune conduct evaluation and appraisal of candidates’ conduct evaluation and appraisal of candidates’ work, along with a short refresher course, workshop for all work, along with a short refresher course, workshop for all the previously trained candidates. Invite experts from India the previously trained candidates. Invite experts from India and from outside and from outside (? Bob Frykberg)(? Bob Frykberg)to conduct courses. The to conduct courses. The doctors involved in foot care centers along with trained foot doctors involved in foot care centers along with trained foot care workers will also be asked to take part.care workers will also be asked to take part.



The second arm of the projectThe second arm of the project is to establish 10 is to establish 10 “diabetic foot care centers”, along with local medical “diabetic foot care centers”, along with local medical communities, in non-urban/rural areas of Karnataka.communities, in non-urban/rural areas of Karnataka.

Other important objectives are:Other important objectives are:

• Assure that individual and family counseling about foot care Assure that individual and family counseling about foot care reaches local public through their own, neighborhood health reaches local public through their own, neighborhood health care centre, by trained professional, in their local language.care centre, by trained professional, in their local language.

• To create awareness among other health care workers/medical To create awareness among other health care workers/medical community and public, and to impart education about foot community and public, and to impart education about foot problem, with ultimate aim of preventing amputation.problem, with ultimate aim of preventing amputation.


Diabetic Foot Care in Non-Urban AreasDiabetic Foot Care in Non-Urban Areas Impact of the project (arm 1 & 2)Impact of the project (arm 1 & 2)

Within 100 kms from Bangalore there are 15 million people Within 100 kms from Bangalore there are 15 million people and this would translate (at 3.5%) in to another 500,000 and this would translate (at 3.5%) in to another 500,000 diabetics! There are no well-equipped foot care centers for diabetics! There are no well-equipped foot care centers for this large population.this large population.

A very large segment of non-urban/rural diabetics are A very large segment of non-urban/rural diabetics are manual workers belonging to lower economic strata and manual workers belonging to lower economic strata and are single breadwinners for the entire family.are single breadwinners for the entire family.

With poor prosthetic support for an amputee, With poor prosthetic support for an amputee, rehabilitation remains a mirage for many of these patients. rehabilitation remains a mirage for many of these patients.

Hence, these well-equipped, supervised diabetic foot care Hence, these well-equipped, supervised diabetic foot care centers will help in preventive and early care of foot centers will help in preventive and early care of foot problems and would have major impact in preventing problems and would have major impact in preventing amputation. amputation.



Equipments provided for each diabetic foot clinic:Equipments provided for each diabetic foot clinic:

* * Sensitometer – VPTSensitometer – VPT * Sensitometer - HCP * Sensitometer - HCP * Patient education booklets (1000) * Patient education booklets (1000) * Patient* Patient education flip charts education flip charts * Set of podiatry instruments * Set of podiatry instruments * PC with soft wear * PC with soft wear * Additional salary for trained (at JIVAS) personnel Rs.1000/month * Additional salary for trained (at JIVAS) personnel Rs.1000/month

x 2yrs (trained at JIVAS)x 2yrs (trained at JIVAS) * * Furniture (including podiatry chair)Furniture (including podiatry chair)

Maintenance and infrastructure to be provided by the local Maintenance and infrastructure to be provided by the local facilityfacility

FOUR OF THESE CLINICS WILL BE SET UP BY DECEMBER 2006 AND FOUR OF THESE CLINICS WILL BE SET UP BY DECEMBER 2006 AND THE REST BY JUNE 2006.THE REST BY JUNE 2006.



The Third arm of the project and possibly The Third arm of the project and possibly the first of its kind in the world – Mobile the first of its kind in the world – Mobile Foot Clinic: Foot Clinic:

It is equipped to provide both preventive care and It is equipped to provide both preventive care and education/counseling education/counseling

It would reach out to under-served areas within It would reach out to under-served areas within 100 kilometers (about 2 hours driving distance) of 100 kilometers (about 2 hours driving distance) of Bangalore. Bangalore.

It will be used to visit newly established foot It will be used to visit newly established foot clinics, to continue interacting with the trained clinics, to continue interacting with the trained health care workers. health care workers.

The mobile clinic would help in conducting The mobile clinic would help in conducting “camps” for mass screening for diabetic foot “camps” for mass screening for diabetic foot problems in these areas.problems in these areas.



The Mobile Clinic will visit centers within 100 km distance from The Mobile Clinic will visit centers within 100 km distance from Bangalore and would service a population of about 15 million, Bangalore and would service a population of about 15 million, which would translate to about a half a million (500,000) diabetics. which would translate to about a half a million (500,000) diabetics.

We would visit 10 such “out reach” centers twice every month and We would visit 10 such “out reach” centers twice every month and from past experience, we would be seeing about 30 diabetic from past experience, we would be seeing about 30 diabetic patients per visit. patients per visit.

We will also offer other services, apart from foot care, like dietary We will also offer other services, apart from foot care, like dietary

counseling, blood sugar monitoring.counseling, blood sugar monitoring.

We will seek assistance from local medical fraternity - through We will seek assistance from local medical fraternity - through Indian Medical Association, Medical colleges, diabetes clubs and Indian Medical Association, Medical colleges, diabetes clubs and through organizations like Rotary club etc. through organizations like Rotary club etc.

We will also coordinate with other existing mobile clinics in other We will also coordinate with other existing mobile clinics in other specialties (mobile eye clinic, mobile cardiac clinic etc) to conduct specialties (mobile eye clinic, mobile cardiac clinic etc) to conduct “camps”.“camps”.


Diabetic Foot Care in Non-Urban AreasDiabetic Foot Care in Non-Urban Areas 1.1. A bus completely customized for the A bus completely customized for the

needs for this unique clinic.needs for this unique clinic. 2.2. A podiatry chair for patient care. A podiatry chair for patient care. 3.3. An examination couch An examination couch 4.4. Equipments for neuropathy evaluation: Equipments for neuropathy evaluation: Sensitometer – VPT, with computer interfaceSensitometer – VPT, with computer interface Sensitometer – HCP, with computer interfaceSensitometer – HCP, with computer interface MonofilamentsMonofilaments 5.5. Equipments for vascular evaluation: Equipments for vascular evaluation: Hand held DopplerHand held Doppler Mini vascular laboratory for physiologic assessmentMini vascular laboratory for physiologic assessment A laptop based color duplex scanA laptop based color duplex scan



6.6. A computerized foot scanner for A computerized foot scanner for abnormal pressure and biomechanical abnormal pressure and biomechanical evaluation.evaluation.

7.7. A cobbler/footwear area with – A cobbler/footwear area with – Heat gun/oven for insole moldingHeat gun/oven for insole molding Buffing machine to help create footwearBuffing machine to help create footwear Other hand-tools for creating footwearOther hand-tools for creating footwear 8.8. For minor podiatry procedures: For minor podiatry procedures: A complete set of foot care instrumentsA complete set of foot care instruments Flash sterilizers for the instrumentsFlash sterilizers for the instruments Washing area for the instrumentsWashing area for the instruments



8.8. Patient education/counseling materials: Patient education/counseling materials: A large screen TV, DVD/VCD for screening education videosA large screen TV, DVD/VCD for screening education videos Built in sound system for counseling patient groupsBuilt in sound system for counseling patient groups Patient education booklets and flip charts.Patient education booklets and flip charts.

9.9. For record keeping and data acquisition: For record keeping and data acquisition: A laptop and desk top computers, with internal connectivity to A laptop and desk top computers, with internal connectivity to

all the equipmentsall the equipments A specially designed software for data acquisition and retrieval A specially designed software for data acquisition and retrieval

10.10. For comfort of the staff of the clinic, who will travel For comfort of the staff of the clinic, who will travel 20 days a month:20 days a month:

The mobile clinic, fully air-conditioned, even when parked.The mobile clinic, fully air-conditioned, even when parked. Provisions for acquaguard, microwave, mini refrigerator.Provisions for acquaguard, microwave, mini refrigerator. Comfortable seating during travel Comfortable seating during travel



Dedicated staff for Mobile Clinic:Dedicated staff for Mobile Clinic:

Two diabetic foot care specialists trained by us.Two diabetic foot care specialists trained by us. A foot care technicianA foot care technician A secretary, who will also be trained to perform A secretary, who will also be trained to perform

computerized foot scanning.computerized foot scanning. Two drivers, who will be trained in basic foot Two drivers, who will be trained in basic foot

technologies and organizing patient visitations.technologies and organizing patient visitations. Two cobblers for creating and repairing footwear.Two cobblers for creating and repairing footwear. Two ward boys to assist the staff.Two ward boys to assist the staff. One cleaner/helper to perform “house-keeping” One cleaner/helper to perform “house-keeping”

chores of the bus.chores of the bus.



““Diabetic & Foot Care Counselors – training and Diabetic & Foot Care Counselors – training and delivery of care at rural door steps”delivery of care at rural door steps” (Bare-foot doctors) (Bare-foot doctors)

Prologue:Prologue: Delivering health care in rural areas poses Delivering health care in rural areas poses significant challenges. These difficulties multiply many folds significant challenges. These difficulties multiply many folds for preventive care and counseling.for preventive care and counseling.

The ProblemsThe Problems: : We learned many lessons during the implementation of We learned many lessons during the implementation of

“Project LEAP” in the last 2 years. Though the project was “Project LEAP” in the last 2 years. Though the project was successful to a large extent, there were several lacunae, successful to a large extent, there were several lacunae, mostly due to our own lack of understanding of the need of mostly due to our own lack of understanding of the need of rural population. rural population.


Diabetic Foot Care in Non-Urban AreasDiabetic Foot Care in Non-Urban Areas The Diabetic & Foot Counselors – Recruitment and training:The Diabetic & Foot Counselors – Recruitment and training:

We have chosen two areas within 100 kms of Bangalore to train the field We have chosen two areas within 100 kms of Bangalore to train the field workers, as a “Pilot Project”. Extending these services to other areas will workers, as a “Pilot Project”. Extending these services to other areas will depend on the success of this project and availability of funding:depend on the success of this project and availability of funding:

The field workers – “Diabetic & Foot Care Counselors” – will be recruited The field workers – “Diabetic & Foot Care Counselors” – will be recruited from locally available “Volunteers”. from locally available “Volunteers”.

Many of these volunteers are diabetics and do realize the problems faced Many of these volunteers are diabetics and do realize the problems faced by the patients.by the patients.

They have more than basic education and have studied up to 10th or 12th They have more than basic education and have studied up to 10th or 12th standard.standard.

Many of them are already working as counselors for different projects and Many of them are already working as counselors for different projects and visit several villages on a regular basis.visit several villages on a regular basis.

Their income has to be supplemented; the new recruits will need paid Their income has to be supplemented; the new recruits will need paid reasonable salaries.reasonable salaries.



They will need to under go intensive training organized They will need to under go intensive training organized by JIVAS staff.by JIVAS staff.

They have easy access to local population, since they They have easy access to local population, since they belong to those areas.belong to those areas.

We need to identify at least 2 or 3 senior members from We need to identify at least 2 or 3 senior members from this group, who will act as supervisors and they will need this group, who will act as supervisors and they will need more advanced training.more advanced training.

All trainees will learn to use glucometer, counsel the All trainees will learn to use glucometer, counsel the patients about foot care and other aspects of diabetes patients about foot care and other aspects of diabetes and generally able to address the problems and solutions and generally able to address the problems and solutions outlined above.outlined above.

All trainees will need CME programs to update their skills All trainees will need CME programs to update their skills on a periodic basis.on a periodic basis.


Diabetic Foot Care in Non-Urban AreasDiabetic Foot Care in Non-Urban Areas I marvel that I marvel that

society would pay society would pay a surgeon a large a surgeon a large sum of money to sum of money to remove a person's remove a person's leg—but nothing to leg—but nothing to save it.save it.

George Bernard George Bernard ShawShawThese projects are not utopian

dreams; they are realities!! - JFK

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