Overall, the 3 biggest challenges we seem to be facing are:

• Service challenges: Providing ongoing evidence-based HRFSs as we have in the past for our DFD patients with the impact of the various shut-downs of physical services accessible to our patients such as access to timely Vascular surgery intervention and non urgent amputations. limited casting,  patients in self-isolation/quarantine, nursing home lockdowns, reduction of community podiatry services and some GP’s.
• Implementing the new physical distancing (or social distancing) rules in the clinic in adhering to 4 squared metres per person with particular regard to protecting our very small and specialised workforce from becoming sick or all of us being quarantined at the same time.
• Relying on patients, carers, photos, or health professionals inexperienced in DFD  to make clinical decisions from afar. If we can see/feel the wound and foot in real life - debride, probe etc we would possibly reach a different conclusion and treatment plan. Our patients are very unreliable about reporting how they’re going. Photos are a guide but not ideal.  As my colleague said – there is a reason we like to see these patients in person every few weeks. Subtle changes are often missed (and sometimes very obvious ones!) and patients don’t always report to us when things aren’t going well.
• The perception in the community that everything is closed and we’re not seeing any outpatients. Actually as per DFA triage guideline we are still seeing new patients and acute issues and advise people come to ED when clinically indicated or Community services / GP’s refer to the hospital outpatient Foot clinic as they normally would.

Service changes:

• We’re extending patients to their maximum possible review, this is usually determined by frequency of / need for debridement.
• We monitor by phone / photos (and VC if possible) and check in every 1-4 weeks depending on the patients situation and when the risk of them not coming in is higher than the risk of them coming then we arrange to see them in person. (reactive not proactive service)
• We’re asking patients, Nurses, Community podiatrists and GP’s  to call us ASAP if their patient’s situation changes and email in any photos to help explain
• Existing patients already have our HRFS emergency phone line number and email and we’re encouraging them to contact us if there are issues. This is monitored 8am-4pm work days, plus via the answer machine (connects to email in box) and can be forwarded to a mobile if we are not on site.  
• We’re communicating to the GP’s / community nurses what our plan is for their patients management and making sure they know if we have seen their patient in person or if they are being monitored remotely we need to rely on them letting us know if things are deteriorating.
• If there is a new acute issue (or a new patient) we still arrange to see the patient as an urgent outpatient ASAP and involve the multi-disciplinary HRFS team members as required.
• Promoting our HRFS to existing local referrers / private podiatrists / GP’s and asking them to contact us for advice if they have a patient who doesn’t wish to come to the hospital and we’ll support them to provide the best practice in community.
• Investigating arrangements for admissions of short day cases (up to 4hrs) for minor procedures that can be done in an outpatients procedure room rather than theatre if it would prevent admission or more surgery in a few months time. For example, tenotomy instead of an amputation, more extensive debridement, or toe amp where conservative management is not possible or not stable enough and no PAD concern. 
• If patients are almost healed we are discharging them to community care + letter to GP a little earlier than we normally would.

Infection control changes

• All patients are screened coming into the hospital – they all have to come in one entrance. There is a Separate entrance / exit for staff
• We wear our own clothes to and from the hospital, change into / out of uniform at work. We have clean / dirty bag for transporting.
• We wipe down our footwear with antibacterial wipes each night and move from dirty bag to clean bag.
• Several times a day high use items like door handles, keyboard, mouse, phone are wiped down.
• We designate 1 reserve room in outpatients for any patients with possible symptoms to be seen in. The room has been decluttered and only necessary items taken in. PPE available at the door and has special cleaning regime.

Physical distancing changes:

• Offices / clinics / meeting rooms have “maximum” number of people advised on posters on the doors.
• Maximum of 3 people in a clinic room at any one time. This means any relative / carer is asked to stay in waiting area (unless absolutely necessary e.g. dementia / language).  If we need another consultant and there are already 3 in the room already then someone has to go out (usually a podiatrist or relative)
• We’re separating out our work force and minimising contact. Each day each coordinating podiatrist has one of 3 roles with different responsibilities and a different “base” location. For example:

• • • The podiatrist doing the phone / VC reviews can do this from home. 
    • The podiatrist seeing urgent inpatients / ED is also manning the HRFS emergency phone line, triaging and is based in an office.
    • The podiatrist seeing the patients in person is in the outpatients clinic room.

• Each podiatrist has one day a week working from home and once direct patient contact (i.e. phone/VC reviews) is done they use this time for admin / letters and project/service development work.
• One podiatrist doesn’t attend the HRFS in person – they stay in a different area and are the “runner” e.g. get extra dressings / walkers etc from the store room and drop off to us. The consultants give input by phone / VC as much as possible.
• We’re staggering our start / finish times and lunch breaks. And we communicate during the day by phone, email, whats app group and VC for meetings.
• Shared office spaces have had some computers removed and put in other rooms (e.g. meeting rooms) to separate out staff to required social distancing levels.
• Student placements have been cancelled.

We have made multiple individual clinical practice changes as well to try and address challenges and still provide good quality evidence-based care for our DFD patients, including:

Services/clinical practice changes:

• • Ensuring everyone who needs an extended course of Ab’s for diabetic foot infections have enough to complete their planned course, plus a backup script if they’ve nearly finished just in case they can’t get back in.
  • If blood tests or repeat scripts, further imagining  are required the relevant consultant calls the patient to discuss and posts the requests out / ordered digitally so that when they do physically come in we have gathered all the information required to make clinical decisions.
  • Ensuring those doing their own dressings at home have enough dressings supply and a clear personal wound care plan to follow or have community nursing arranged.
  • We are minimising the use of TCC just in case patients cant get back in. Only new acute Charcot are likely to get a TCC at the moment and we’d hope to transition to a CROW as quickly as possible.

Infection control changes:

• We use our standard PPE for non-COVID patients (gloves + gown if required), but if we have a patient with symptoms or are COVID positive then full COVID PPE is used inc mask etc.
• Everything used is wiped down between patients / after use – inc chair, stool, trolley and any equipment such as Doppler, dermatemp.
• Wash hands and alcohol gel all the time.

Physical distancing changes:

• • If a patient refuses to come into the hospital to see us when we feel it is necessary - there have been a few - we advise them to see a community pod +/- GP and liaise with them regarding their treatment plan.
  • Waiting areas have had chairs removed / spaced out or notices put on alternate seats to encourage physical distancing.