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Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Initiative
Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Initiative
Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Initiative
Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Initiative
Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Initiative
Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Initiative
Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Initiative
Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Initiative
Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Initiative
Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Initiative
Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Initiative
Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Initiative
Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Initiative
Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Initiative
Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Initiative
Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Initiative
Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Initiative
Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Initiative
Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Initiative
Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Initiative
Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Initiative
Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Initiative
Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Initiative
Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Initiative
Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Initiative
Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Initiative
Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Initiative
Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Initiative
Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Initiative
Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Initiative
Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Initiative
Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Initiative
Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Initiative
Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Initiative
Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Initiative
Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Initiative
Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Initiative
Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Initiative
Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Initiative
Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Initiative
Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Initiative
Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Initiative
Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Initiative
Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Initiative
Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Initiative
Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Initiative
Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Initiative
Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Initiative
Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Initiative
Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Initiative
Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Initiative
Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Initiative
Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Initiative
Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Initiative
Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Initiative
Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Initiative
Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Initiative
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Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Initiative

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Foot ulcer and lower extremity amputation risk reduction has been identified as a priority focus by the Champlain Regional Diabetes Advisory Committee. As a result the Champlain Diabetes Foot Care …

Foot ulcer and lower extremity amputation risk reduction has been identified as a priority focus by the Champlain Regional Diabetes Advisory Committee. As a result the Champlain Diabetes Foot Care Expert Committee was established to develop a best practice “tool box”, training module, and evaluation strategy to support the uptake of best practices for reducing foot ulcers and amputations for people living with Diabetes across the Champlain region. The tool box reflects many elements of the RNAO Best Practice Guidelines and includes documents and resources for health care providers and patients. To download the Tool Box, please sign up at http://champlaindrcc.ca/foot_care_tool_box.html.

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  • 1. The Champlain Diabetes Foot Ulcer and Amputation reduction strategy and Best Practice Training Initiative: A little background 1The Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Training Initiative Nov 2012
  • 2. People with diabetes are at risk for developing foot complications • ~ 15 % will develop a foot ulcer • Less then 37 % of people surveyed in the Champlain region reported ever receiving a foot exam • Amputation rates in the Champlain region are higher than the provincial average • 85 % of lower extremity amputations are preceded by a non-healing ulcer • Most ulcers are preceded by a ‘pivotal event’ i.e. injury 2The Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Training Initiative Nov 2012
  • 3. The Champlain Diabetes Foot Ulcer Expert Committee 3The Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Training Initiative Nov 2012
  • 4. Membership • Dr. Janine Malcolm (Co-Chair) Endocrinologist- DRCC Specialist Lead • Sharon Brez (Co-Chair) APN- The Ottawa Hospital • Wendy Gifford University of Ottawa • Dr. Greg Rose Infectious disease physician • Dr. Karle-Andre Lalonde Orthopedic surgeon • David Walker Chiropodist – Champlain Regional Program • Lena Peslar MacMillan Chiropodist – Champlain Regional Program • Angela Samson Diabetes Nurse Educator –Eastern Counties • Nancy Knudsen Health Services Manager, Sandy Hill CHC • Barbara Neuwelt Manager CDEP-O • Pierre Boulay DRCC Regional Director • Leah Bartlett DRCC Health Information Analyst • Olga Nikolajev DRCC Outreach Coordinator • Clement Habiyakare (admin. support) DRCC Executive Assistant 4The Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Training Initiative Nov 2012
  • 5. Accountability • The Champlain Diabetes Foot Ulcer Expert Committee is accountable to the Champlain Regional Diabetes Advisory Committee 5The Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Training Initiative Nov 2012
  • 6. Vision A unified, evidence based strategy is in place to improve foot care for people living with diabetes in the Champlain region. 6The Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Training Initiative Nov 2012
  • 7. Purpose • Reduce foot ulcer risk for adults with diabetes • Reduce lower extremity amputation rates • Provide services that meet the needs of clients/patients/practitioners • Promote uptake of best practices for foot ulcer reduction through implementation of the Champlain diabetes foot ulcer prevention tool kit • Describe and track referral pathways for specialist foot care services • Increase public awareness of foot ulcer risk and ways to reduce this risk 7The Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Training Initiative Nov 2012
  • 8. 2 phased strategy planned • Primary ulcer prevention Fall 2011- Fall 2013 • Ulcer Management Fall 2012-Fall 2014 8The Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Training Initiative Nov 2012
  • 9. Goals Every person living with Diabetes: • receives a standardized foot risk assessment at least annually • at higher ulcer risk receives timely self management education and referral for appropriate care • who has an ulcer receives immediate care from a multidisciplinary team 9The Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Training Initiative Nov 2012
  • 10. Every provider of foot care: • understands how to perform standardized, evidence based foot risk assessment • understands how to stratify foot ulcer risk • knows how to refer to the appropriate care provider • is linked to foot care resources in their community • is aware of established foot care performance metrics and records them for evaluation 10The Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Training Initiative Nov 2012
  • 11. Why BPG’s? • Growing consumer, political and professional expectation that care delivery and policy is evidence based • Volume and quality of evidence is variable • Implementation of best practice improves outcomes and can save health care dollars 11The Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Training Initiative Nov 2012
  • 12. Why RNAO BPG selected? Current literature and guidelines reviewed - RNAO BPG selection supported by Champlain expert panel members • Evidence based • Simple and clear – user friendly • Includes guidance related to clinical practice, education, organizational implementation and sustainability • Tried and tested successfully in various practice settings • Already known to many in our community • Alligned with our regional goals 12The Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Training Initiative Nov 2012
  • 13. Reducing Foot Complications for People with Diabetes RNAO Best Practice Guidelines 13The Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Training Initiative Nov 2012
  • 14. The Champlain Diabetes Foot Ulcer and Amputation reduction strategy and Best Practice Training Initiative 14The Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Training Initiative Nov 2012
  • 15. Objectives At the end of this workshop, you will be able to: • Understands how to perform standardized, evidence based foot risk assessment • Understands how to stratify foot ulcer risk • Know how to refer to the appropriate care provider • Assess foot care self-management ability and provide education for the prevention of foot ulcers • Link to foot care resources in their community • Be aware of established foot care performance metrics and records them for evaluation • Conduct a foot risk assessment for patients with diabetes 15The Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Training Initiative Nov 2012
  • 16. Prevention is the key Reduction in the incidence of foot ulcers • Prevention of traumatic events • Early identification • Prompt treatment Achieved by: • risk assessment by health professional • self care education and behaviours • regular follow-up 16The Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Training Initiative Nov 2012
  • 17. 5 Key Risk Previous Ulcers Factors Lack of self-care Loss of protective Sensation Impaired Structural Circulation abnormalities 17The Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Training Initiative Nov 2012
  • 18. Adapted RNAO Risk Assessment Algorithm 18The Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Training Initiative Nov 2012
  • 19. Foot Ulcer Risk Assessment 19The Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Training Initiative Nov 2012
  • 20. Foot Ulcer Risk Assessment (1-4) 20The Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Training Initiative Nov 2012
  • 21. 1. Presence/History of foot ulcers • Ask “ have you ever had a sore on your foot that took more than 2 weeks to heal” yes/no • Let client know you will now examine their feet for un-identified ulcers 21The Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Training Initiative Nov 2012
  • 22. 2. Protective Sensation using Semmes-Weinstein 10 gram monofilament 1. Show the monofilament to the patient and demonstrate on their arm to show that it will not hurt 2. Have patient close eyes, look away and ask them to say ‘yes’ when they feel you touching their foot 3. Hold the monofilament perpendicular to the skin and gently push until it bends, hold in place for 1-3 seconds 4. Lift the monofilament and move onto the next area- DO NOT BRUSH IT AGAINST THE SKIN. 5. Do not test over calluses. 6. Test each of the sites as indicated on the diagram, re-test the areas that the patient did not feel . 22 7. Document loss of protective sensation at any site.The Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Training Initiative Nov 2012
  • 23. Sensation test sites 23The Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Training Initiative Nov 2012
  • 24. 3. Structural abnormalities • Toe deformities • Hallux valgus (bunion) • Amputation (where and when) • Charcot foot Structural abnormalities can lead to callus and ulcer formation 24The Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Training Initiative Nov 2012
  • 25. Toe deformities • Claw or hammer toe 25The Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Training Initiative Nov 2012
  • 26. Hallux Valgus aka ‘bunion’ 26The Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Training Initiative Nov 2012
  • 27. Amputation 27The Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Training Initiative Nov 2012
  • 28. Charcot Foot • Neuroarthropathy occurring in the foot • Nerve damage from diabetes  • decreased sensation • muscle atrophy • joint instability • Acute stage  inflammation and reabsorption of bone • later the arch falls and ‘rocker bottom’ foot develops 28The Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Training Initiative Nov 2012
  • 29. Charcot foot 29The Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Training Initiative Nov 2012
  • 30. • Structural abnormalities of the foot lead to development of corns, calluses and ulcers 30The Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Training Initiative Nov 2012
  • 31. Thick toe nails 31The Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Training Initiative Nov 2012
  • 32. How to assess Callus in the foot Types of Callus • Physiological: reaction to local stresses, creating a callus to protect from injury, when cause of stress removed, skin returns to normal thickness • Pathological: callus becomes inflamed and painful if stress continues beyond the skin’s coping ability, often in a weight bearing area • stress must be removed or further breakdown occurs resulting in bleeding beneath the callus resulting in pre-ulcerative lesion 32The Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Training Initiative Nov 2012
  • 33. Callus Physiological Callus Pathological Callus 33The Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Training Initiative Nov 2012
  • 34. Corns 34The Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Training Initiative Nov 2012
  • 35. Ulcer Development: Picture of pre-ulcer Picture of ulcer 35The Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Training Initiative Nov 2012
  • 36. Ulcers PreUlcer Lesion Ulcer 36The Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Training Initiative Nov 2012
  • 37. Infected ulcer 37The Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Training Initiative Nov 2012
  • 38. 4. Circulation • Ask “do you have pain in the calf when walking or on exertion that is relieved with rest within 10 minutes? ” AND • Palpate dorsalis pedis and posterior tibial NOTE: If answer is NO to above question, 38 no need to palpate for pulsesThe Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Training Initiative Nov 2012
  • 39. Pedal pulses • Dorsalis pedis- place • Posterior tibial- place the fingers just lateral fingers just behind and to the extensor tendon slightly below the of the great toe medial malleolus 39 NOTE: Answer to question must be YES and pulses absentThe Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Training Initiative Nov 2012
  • 40. Results of the 4 Risk Factors • MUST assess ALL 4 risk factors • Presence of any of these factors is associated with higher foot ulcer risk 40The Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Training Initiative Nov 2012
  • 41. Practice of foot assessment • Use the form and fill out the assessment with your partner • Practice with monofilament on your hand 41The Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Training Initiative Nov 2012
  • 42. 5. Self Care Assessment 42The Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Training Initiative Nov 2012
  • 43. Case study 43The Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Training Initiative Nov 2012
  • 44. Foot Wear Guide What to look for • Some heel height • Heel should be enclosed and firm • Sole should be firm and flex at the ball of the foot • Shoe lining can be removed • Shoe laces or straps that can be adjusted How should they fit • Space, or thumbnail of space, between your longest toe and end of shoe • Fit well, no pressure, room for your toes • Ball of your foot should line up with widest part of the shoe • Minimal slip in the heel • Shoe feels good when walking or standing 44The Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Training Initiative Nov 2012
  • 45. Foot Wear Guide Shoe Buying tips • Always buy your shoes at the end of the day • One foot may be bigger, always fit the larger • If shoe “looks worn” it may be time to buy new shoes • Wear shoes made for each season and activity • Check your feet more frequently when you are wearing new shoes 45The Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Training Initiative Nov 2012
  • 46. Foot Care Tool Box Content 46The Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Training Initiative Nov 2012
  • 47. Foot Care Tool Box Content Assess: • Risk Assessment Algorithm • Foot Ulcer Risk Assessment • Your Foot Ulcer Profile (for clients/patients) Education Resources for clients/patients: • Care Tips for Your Feet • Guide for Good Foot Wear • Diabetes Foot Care Teaching Record 47The Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Training Initiative Nov 2012
  • 48. Foot Care Teaching Record 48The Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Training Initiative Nov 2012
  • 49. Foot Care Tool Box Content Evaluation: • Program’s goals and objectives • Program’s indicators of success • Evaluation forms • Client/patient evaluation surveys Implementation Resources: • Project “backgrounder” • RNAO foot ulcer risk assessment guidelines • RNAO implementation tool kit 49 • Link to on-line education programThe Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Training Initiative Nov 2012
  • 50. Champlain region Chiropody Program Referral Criteria & Process Criteria: • At high risk for ulcers, amputations • Typically, patient has no 3rd party insurance • Urgent referrals will be prioritized • Patients are seen until stabilized Locations: o East Ottawa (Vanier Parkway & Donald) o Embrun o Downtown Ottawa (Somerset & Bank) o Cornwall o Nepean o Beachburg o Western Ottawa (Carling & Richmond) o Pembroke o Rockland o Lanark o Carleton Place o Kemptville 50 o HawkesburyThe Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Training Initiative Nov 2012
  • 51. Referral Process RISK FACTORS for Foot Ulceration in People with Diabetes 1. Foot ulcer or a wound that took > 2 weeks to heal now or in the past. 2. Loss of sensation at any one site (determined after testing the 4 sites: great toe, first, third and fifth metatarsal heads using the 10 gram/5.07 monofilament). 3. Callus present on soles of feet or toes or abnormal foot shape (e.g. claw or hammer toes, bunion, obvious bony prominence, Charcot foot or joint). 4. Pedal pulses (dorsalis and posterior tibial) absent and history of lower limb pain on exertion that is relieved with rest (intermittent claudication). RISK STATUS Lower risk - if NO to all items 1 – 4 Higher risk - if YES to any. Refer to the Champlain Chiropody Program as follows. • One- on-one treatment for advanced foot care management: Anyone with diabetes who is at higher risk. (See above.) • Urgent appointment: Anyone at higher risk who has an ulcer or an infection • Group Health Education: 51 Anyone with diabetes who has not had recent foot health education. The program is particularly geared to people at low risk.The Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Training Initiative Nov 2012
  • 52. Evaluation How will we know if we are changing practice? How will we know that the change is an improvement? 52The Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Training Initiative Nov 2012
  • 53. Potential evaluation indicators Outcome Indicators: What did we achieve? • % of clients (describe) with a completed, standardized foot ulcer risk assessment within a determined time frame. Example: percentage of all new referrals within past 3 or 6 months • % of higher risk clients/patients receiving self- management education Process Indicators: What did we do? - How was it done? • Number/ percentage of staff receiving training * • % of standardized assessment forms completed correctly • % of clients/patients identified as “higher risk” • % of Clients/patients referred for consultation by 53 ChiropodistThe Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Training Initiative Nov 2012
  • 54. Potential evaluation indicators Balancing indicators: What else happened as a result of implementing this new practice? • Number of clients/patients referred for consultation • Provider satisfaction • Client/Patient satisfaction • Client/Patient confidence with self-management practices 54The Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Training Initiative Nov 2012
  • 55. Foot Care Tool Box Content Resources for Providers: • Monofilaments purchase resources • Instructions for use of monofilaments • Location and Palpation of Pedal Pulses • Structural and biomechanical abnormalities • How to assess callus in the foot • Community of Care Foot Care Resource lists Referral: • www.champlaindrcc.ca (diabetes education, foot care, 55 Self-Management)The Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Training Initiative Nov 2012
  • 56. Foot care Resources Champlain DRCC foot care: http://www.champlaindrcc.ca/health_care_provid ers/find_foot_care_services.html Chiropody College of Ontario: http://www.cocoo.on.ca/m1.htm Canadian Diabetes http://www.diabetes.ca/diabetes-and- Association: you/healthy-guidelines/foot-care-a-step-toward- good-health/ Registered Nurses http://rnao.ca/bpg/guidelines/assessment-and- Association of Ontario: management-foot-ulcers-people-diabetes http://rnao.ca/sites/rnao-ca/files/Diabetes_Foot_- __Risk_Assessment_Education_Program_Full.p df 56The Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Training Initiative Nov 2012
  • 57. Happy feet 57The Champlain Diabetes Foot Ulcer and Amputation Reduction Strategy and Best Practice Training Initiative Nov 2012

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