1362576103 initiatives & innovations mumbai 06

Initiatives & InnovationsInitiatives & Innovations
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Diabetic Foot Care inDiabetic Foot Care in
Non-Urban AreasNon-Urban Areas
Dr. Kalkunte R. SureshDr. Kalkunte R. Suresh
Dr. A.S. Vinaya PhDDr. A.S. Vinaya PhD
Ms. UshaMs. Usha
Diabetic Foot Care CenterDiabetic Foot Care Center
JIVAS - BangaloreJIVAS - Bangalore

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Diabetic Foot Care in Non-Urban AreasDiabetic Foot Care in Non-Urban Areas
 ProjectProject “LEAP”“LEAP” ((LLimbimb EEvaluation & education forvaluation & education for
AAmputationmputation PPrevention), funded by SBMTrevention), funded by SBMT
(Society for Biomedical Technology)(Society for Biomedical Technology)
 A project to evaluate efficacy of preventive footA 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 July964 patients recruited from July 2004 to July
20062006
 Complete data analysis pending–a) ruralComplete data analysis pending–a) rural
population showed acceptable compliance withpopulation showed acceptable compliance with
footwear b) Significant decrease in amputationfootwear b) Significant decrease in amputation
and recurrent ulcers. c) Several important lessonsand recurrent ulcers. c) Several important lessons
learned in treating rural population d) “Sociallearned in treating rural population d) “Social
Impact” of modern gadgets e) Methods to reduceImpact” 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 areasseveral initiatives in rural areas

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 Project PADASAMRAKSHANEProject PADASAMRAKSHANE
 ““Training of health care workers andTraining of health care workers and
providing diabetic foot care in non-providing diabetic foot care in non-
urban/rural regions in the State ofurban/rural regions in the State of
Karnataka”Karnataka”
 The three pronged project is sponsored byThe three pronged project is sponsored by
World Diabetic Foundation (WDF), DenmarkWorld Diabetic Foundation (WDF), Denmark..

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 THE THREE ARMS OF THE PROJECT:THE THREE ARMS OF THE PROJECT:
 Training healthcare workers: One-month course will beTraining healthcare workers: One-month course will be
offered to paramedical worker, which will involve bothoffered to paramedical worker, which will involve both
didactic teaching and hands-on experience. We aim to traindidactic teaching and hands-on experience. We aim to train
nurses, ANM’s (Auxiliary Nurse Midwife), multipurposenurses, ANM’s (Auxiliary Nurse Midwife), multipurpose
health workershealth workers
 Establish 10 “diabetic foot care Centers” with help fromEstablish 10 “diabetic foot care Centers” with help from
their medical community.their medical community.
 A Mobile Foot Clinic will help us provide care in otherA Mobile Foot Clinic will help us provide care in other
under-served areas around Bangalore and continueunder-served areas around Bangalore and continue
educating health care workers and public. It can also beeducating health care workers and public. It can also be
used to conduct “diabetic foot screening camps”.used to conduct “diabetic foot screening camps”.

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 The First arm of this projectThe First arm of this project is to train health careis to train health care
personnel from across India in diabetic foot carepersonnel from across India in diabetic foot care andand
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, HCPUse basic equipments like monofilament, sensitometer, HCP
device, hand held Doppler etc.device, hand held Doppler etc.
 Obtain exposure to advanced instrumentations like footObtain exposure to advanced instrumentations like foot
mapping devicesmapping devices
 Gain basic knowledge about biomechanics, customizedGain basic knowledge about biomechanics, customized
diabetic footwear and orthotic devices.diabetic footwear and orthotic devices.
 Witness surgical procedures in patients with diabetic footWitness surgical procedures in patients with diabetic foot
problems.problems.

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 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 footmultipurpose health workers etc. who have shown interest in diabetic foot
care, who already have at least 2 years of work experience in a hospital orcare, 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 wouldout 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 givenThey 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 clinicsto 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 alreadyRecommended by a hospital or medical practitioner who is already
providing diabetic foot care or interested in setting up a diabetic foot clinicproviding 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 toAbout 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 freeA fee of Rs.1000 is charged; they are given a stipend of Rs.1000, with free
boarding & lodgingboarding & lodging

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 Training materials & Method:Training materials & Method:
 Clinical training through direct patient contactClinical training through direct patient contact
 All trainees will be given course materialAll trainees will be given course material
written/compiled by this department &/or existingwritten/compiled by this department &/or existing
books about diabetic foot care.books about diabetic foot care.
 Patient information booklets in English andPatient 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. FlipPatient 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.

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 Training of health care workers:Training of health care workers:
 Two candidates trained every month starting from JuneTwo candidates trained every month starting from June
2006 for 11 months i.e. train 44 diabetic foot care workers2006 for 11 months i.e. train 44 diabetic foot care workers
over 2 years. In the first year train 10 candidates from theover 2 years. In the first year train 10 candidates from the
State of Karnataka and this would translate into 10 diabeticState of Karnataka and this would translate into 10 diabetic
foot care centers across the state. Other trainees could befoot 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 allwork, along with a short refresher course, workshop for all
the previously trained candidates. Invite experts from Indiathe previously trained candidates. Invite experts from India
and from outsideand from outside (? Bob Frykberg)(? Bob Frykberg)to conduct courses. Theto conduct courses. The
doctors involved in foot care centers along with trained footdoctors 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.

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 The second arm of the projectThe second arm of the project is to establish 10is 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 careAssure that individual and family counseling about foot care
reaches local public through their own, neighborhood healthreaches 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/medicalTo create awareness among other health care workers/medical
community and public, and to impart education about footcommunity and public, and to impart education about foot
problem, with ultimate aim of preventing amputation.problem, with ultimate aim of preventing amputation.

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 Impact of the project (arm 1 & 2)Impact of the project (arm 1 & 2)
 Within 100 kms from Bangalore there are 15 million peopleWithin 100 kms from Bangalore there are 15 million people
and this would translate (at 3.5%) in to another 500,000and this would translate (at 3.5%) in to another 500,000
diabetics! There are no well-equipped foot care centers fordiabetics! There are no well-equipped foot care centers for
this large population.this large population.
 A very large segment of non-urban/rural diabetics areA very large segment of non-urban/rural diabetics are
manual workers belonging to lower economic strata andmanual 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, rehabilitationWith poor prosthetic support for an amputee, rehabilitation
remains a mirage for many of these patients.remains a mirage for many of these patients.
 Hence, these well-equipped, supervised diabetic foot careHence, these well-equipped, supervised diabetic foot care
centers will help in preventive and early care of footcenters will help in preventive and early care of foot
problems and would have major impact in preventingproblems and would have major impact in preventing
amputation.amputation.

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 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 chartseducation 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* Additional salary for trained (at JIVAS) personnel
Rs.1000/month x 2yrs (trained at JIVAS)Rs.1000/month x 2yrs (trained at JIVAS)
 ** Furniture (including podiatry chair)Furniture (including podiatry chair)
 Maintenance and infrastructure to be provided by the localMaintenance and infrastructure to be provided by the local
facilityfacility
 FOUR OF THESE CLINICS WILL BE SET UP BY DECEMBER 2006 ANDFOUR OF THESE CLINICS WILL BE SET UP BY DECEMBER 2006 AND
THE REST BY JUNE 2006.THE REST BY JUNE 2006.

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 The Third arm of the project and possiblyThe Third arm of the project and possibly
the first of its kind in the world – Mobilethe first of its kind in the world – Mobile
Foot Clinic:Foot Clinic:
 It is equipped to provide both preventive careIt is equipped to provide both preventive care
and education/counselingand education/counseling
 It would reach out to under-served areas withinIt would reach out to under-served areas within
100 kilometers (about 2 hours driving distance)100 kilometers (about 2 hours driving distance)
of Bangalore.of Bangalore.
 It will be used to visit newly established footIt will be used to visit newly established foot
clinics, to continue interacting with the trainedclinics, to continue interacting with the trained
health care workers.health care workers.
 The mobile clinic would help in conductingThe 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.

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 The Mobile Clinic will visit centers within 100 km distance fromThe 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)which would translate to about a half a million (500,000)
diabetics.diabetics.
 We would visit 10 such “out reach” centers twice every month andWe would visit 10 such “out reach” centers twice every month and
from past experience, we would be seeing about 30 diabeticfrom 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 dietaryWe 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 - throughWe will seek assistance from local medical fraternity - through
Indian Medical Association, Medical colleges, diabetes clubs andIndian 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 otherWe will also coordinate with other existing mobile clinics in other
specialties (mobile eye clinic, mobile cardiac clinic etc) to conductspecialties (mobile eye clinic, mobile cardiac clinic etc) to conduct
“camps”.“camps”.

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 1.1. A bus completely customized for theA 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 couchAn 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

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 6.6. A computerized foot scanner forA computerized foot scanner for
abnormal pressure and biomechanicalabnormal 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

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 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 toA laptop and desk top computers, with internal connectivity to
all the equipmentsall the equipments
 A specially designed software for data acquisition and retrievalA specially designed software for data acquisition and retrieval
 10.10. For comfort of the staff of the clinic, who will travelFor 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 travelComfortable seating during travel

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 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 performA secretary, who will also be trained to perform
computerized foot scanning.computerized foot scanning.
 Two drivers, who will be trained in basic footTwo 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.

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 ““Diabetic & Foot Care Counselors – training andDiabetic & 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 posesDelivering health care in rural areas poses
significant challenges. These difficulties multiply many foldssignificant 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 ofWe 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 ofmostly due to our own lack of understanding of the need of
rural population.rural population.

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 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 fieldWe have chosen two areas within 100 kms of Bangalore to train the field
workers, as a “Pilot Project”. Extending these services to other areas willworkers, 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 recruitedThe 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 facedMany 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 12thThey 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 andMany 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 paidTheir income has to be supplemented; the new recruits will need paid
reasonable salaries.reasonable salaries.

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 They will need to under go intensive training organizedThey will need to under go intensive training organized
by JIVAS staff.by JIVAS staff.
 They have easy access to local population, since theyThey 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 fromWe need to identify at least 2 or 3 senior members from
this group, who will act as supervisors and they will needthis group, who will act as supervisors and they will need
more advanced training.more advanced training.
 All trainees will learn to use glucometer, counsel theAll trainees will learn to use glucometer, counsel the
patients about foot care and other aspects of diabetespatients about foot care and other aspects of diabetes
and generally able to address the problems and solutionsand generally able to address the problems and solutions
outlined above.outlined above.
 All trainees will need CME programs to update their skillsAll trainees will need CME programs to update their skills
on a periodic basis.on a periodic basis.

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 I marvel thatI marvel that
society would paysociety would pay
a surgeon a largea surgeon a large
sum of money tosum of money to
remove a person'sremove a person's
leg—but nothing toleg—but nothing to
save it.save it.
 George BernardGeorge Bernard
ShawShaw
These projects are not utopian
dreams; they are realities!! - JFK

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1362576103 initiatives & innovations mumbai 06