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Save a Leg: Building Integrated Diabetes Foot Services in Western Sydney

Western Sydney Local Health District
Project Added:
1 December 2015
Last updated:
18 October 2016

Save a Leg: Building Integrated Diabetes Foot Services in Western Sydney


This project developed a 60-second diabetic foot screening tool and educated patients, nurses and clinicians on the importance of using the tool and completing regular foot checks. Electronic referral templates and clinical pathways were also developed, to improve timely access to hospital foot services. 

View a poster from the Centre for Healthcare Redesign graduation, December 2015.

Save a Leg poster


To develop an integrated model for diabetes foot care in Western Sydney.


  • Increases consumer awareness and understanding of diabetic foot complications and the importance of regular foot care.
  • Increases screening of patients with diabetes for foot complications.
  • Reduces variation of foot screening practices across Western Sydney.
  • Provides early identification and timely intervention to prevent and appropriately manage diabetic foot complications.
  • Improves communication between service providers and appropriate referrals of patients into hospital-based foot services.

Project Status

Key dates 

  • Project started:  February 2015


Implementation - The initiative is ready for implementation or is currently being implemented, piloted or tested.


Diabetes is responsible for 60% of all amputations in Australia, with diabetes-related amputation rates increasing over 30% between 1998 and 2011. In fact, Australia has one of the worst diabetes-related lower limb amputation rates in the developed world, at nearly 20 per 100,000 people, compared to an average of 12 per 100,000 people.

Western Sydney has been identified as a diabetes ‘hot spot’, with estimates of over 200,000 people likely to be affected by the disease. There is fragmented and inconsistent diabetic foot screening performed in primary and community settings in WSLHD, with no available data on the frequency of screenings, annual reviews and dissemination of results.

Therefore, WSLHD needs to be proactive in combating this burden of disease by a ‘whole of system’ approach. This requires a strategy which includes prevention, patient and staff education, interdisciplinary treatment of foot ulcers and close monitoring. These strategies can potentially reduce amputation rates in WSLHD by 49-85%. All people with diabetes should be examined at least once a year for potential foot problems, while patients with demonstrated risk factors should be examined every 1-6 months.

In a sample of diabetes patients across 11 general practices (GPs) in WSLHD, a staggering 79% had not received a foot check in the last 12 months. The findings also confirmed that there are highly inconsistent screening practices across WSLHD and insufficient patient education about the risk of diabetic foot complications.


Whilst root cause analysis has identified several solutions, three solutions were prioritised based on the ‘Easy, Attractive, Social and Timely (EAST) Framework’ which informs the ability to influence and ease of implementation. Implementation of these three solutions is being piloted at 11 GP sites to demonstrate and monitor the effect of each solution.

Solution 1: Development and implementation of a two stage diabetic foot screening tool

  • Developed a 60-second minimum standard screening tool.
  • Developed an infographic to educate patients with diabetes and clinicians on the complexity of diabetic foot disease and easy steps for patient self-management, with prompts for future foot checks. Save a Leg infographic

Solution 2: Primary health care nurses to provide diabetes foot screening

  • Delivered education sessions to practice nurses, with the aim of improving competency in the use of resources on diabetic foot complications
  • Nurses were encouraged to perform diabetic foot screening using the 60-second minimum standard screening tool. 

Solution 3: Electronic referral templates and pathways

  • Updated and distributed referral forms to hospital foot services.
  • Created an electronic version of the referral form, to improve the timely and appropriate referral of patients to hospital foot services.

Implementation sites

  • Blacktown Hospital
  • Westmead Hospital
  • 11 participating GPs within WSLHD


  • 11 participating GPs within WSLHD
  • Three participating private podiatry practices within WSLHD
  • Sanofi Aventis
  • Diabetes NSW
  • Western Sydney Close The Gap Team
  • Aboriginal Medical Services
  • Western Sydney Primary Health Network


  • Data from the PenCAT clinical audit tool will be collected from participating GPs pre- and post-implementation, including target patient population, number of foot checks completed and number of diabetes cycles of care completed within the last twelve months.
  • Pre- and post-implementation GP questionnaires and interviews will be undertaken to assess satisfaction with solutions implemented, impact on clinical practice and suggestions for future improvement.
  • Pre- and post-implementation surveys and interviews will be used to assess the impact of the project on the patient journey and experience.
  • An audit of hospital referrals will be reviewed for signs of increased use of services via participating pilot practices.
  • The adoption of the 60-second foot check screening tool by 11 GP nurses will be measured by the use of the screening tool and consistency of screening practices across WSLHD.

Lessons Learnt

  • A multidisciplinary team was required to work on the initiative. This allowed a combination of administrative and clinical input in several sectors, including primary, secondary and tertiary healthcare.
  • Patient-centered solutions are effective.
  • Strong executive and clinical sponsorship, direction and engagement and alignment with organisational goals was critical for success.
  • There were a large number of problems and solutions that were identified, but we had to limit our scope and place other solutions on hold.
  • Communication and content is something that we would do differently next time, both internally and to sponsors and stakeholders. Promotion of the project to the wider community would also be a bigger focus, to generate awareness of the initiative.

Further reading


Sumathy Ravi Western Sydney Diabetes Initiative Coordinator
Western Sydney Local Health District
Phone: 02 8670 0017

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