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Show Diabetic Foot Exams: Making The Assessment a Part of Clinic Flow Ann Clark MD, Shaun Curran PA-C, Lauren Wood MD, Erin McAdams MD, Katie Traylor PharmD, Michael Black, Kyesha Tsosie, Holly Vrondos, Margaret Alfors, Barbara Navas, Sara Schofield RN, Susan Saffel-Shrier MS RD, Bernadette Kiraly MD, Erika Sullivan MD Aim Statement • • Methods Increase the rate of diabetic foot or lower extremity exams by 50% from baseline in all type 2 diabetic patients at Sugar House Clinic seen between November 1, 2015 through April 30, 2016 Patients had to have been seen in our clinic for any reason in the past year to be included Background • Lifetime risk of a person with diabetes developing a foot ulcer may be as high as 25% Results Sugarhouse Diabetic Foot Exams • Identified all type 2 diabetic patients at Sugar House Clinic using our EMR's population management module, noting that our rate for annual foot exams was 38.68% in October 2015 (total of 698 patients in the diabetes registry) Month October • Created a process flow diagram for diabetic patient appointments including our process intervention, which was having medical assistants put out diabetic foot exam equipment at the beginning of every diabetic patient visit and placing the order for a diabetic foot exam in the EMR Foot Exam Total Type 2 Percentage of Diabetic Order Diabetes Patients with Signed Patients Completed Foot Exam 270 698 38.68% November 295 700 42.14% December 300 711 42.19% January February March April 326 342 358 364 716 731 748 761 45.53% 46.79% 47.86% 47.83% Sugar House Diabetic Foot Exams 60% • Annual incidence of diabetic foot ulcers is ~2% 50% 45.53% 42.14% 40% • Up to 50% of older patients with type 2 diabetes have one or more risk factors for foot ulceration 42.19% 38.68% 10% 0% October • Rate of foot exams performed increased most significantly during the first month of the intervention (3.46% between October and November) and during the third month (3.34% between December and January). • Rate of diabetic foot exams was similar at both Sugar House and Madsen Clinics from January to April 2016 (2.3% and 2.37%, respectively), despite Madsen not implementing our intervention November December January February March April • Integration of our process intervention into clinic was successful in increasing the rate of diabetic foot exams performed by 24%; however, we did not reach our goal of a 50% increased exam rate Diabetic Foot Exams • Presented the new diabetic appointment clinic flow to all Sugar House staff during our monthly Clinic Quality Meeting in October 2015, thus initiating our process intervention 60% 50% 45.53% 42.14% 40% 46.79% 47.86% • Intervention was most successful during months when an educational session was implemented: medial assistant in-service or faculty meeting skillset presentation 47.83% 42.19% 38.68% Sugarhouse 30% Madsen 20% 18.21% 19.20% 16.83% 17.55% January February March April 10% 0% • Presented on the diabetic foot exam at the Family Medicine Division's faculty meeting in December 2015 to review proper exam techniques and foot exam charting in the EMR November December • One major limitation was that diabetic foot exams were only counted as performed if an order for "Diabetic Foot Exam Performed" was signed in the EMR, meaning that not all exams that were actually performed were included in the dataset References and Acknowledgements • • Diabetic foot exams were documented as complete only if the order for "Diabetic Foot Exam" was signed in the EMR • At the end of the intervention cycle, the rate of foot exams had increased to 47.83%, which is an increase of 24% from baseline. Conclusions October • Completion of annual foot exams is one of the metrics that are tracked for diabetic care through our population management module in the EMR 47.83% 20% • Held an in-service training for medical assistants in November 2015 during which they learned the new diabetes appointment clinic workflow, incorporating the new foot exam components Boulton AJM, et al. 47.86% 30% • Risk factors for foot ulcers include: peripheral neuropathy, peripheral vascular disease, cigarette smoking, poor glycemic control, diabetic nephropathy, visual impairment, history of foot ulcer, previous amputation, and foot deformity • Components of the foot exam include: history, general inspection (dermatologic and musculoskeletal), neurological assessment, and vascular assessment 46.79% • Prior to our intervention, the rate of diabetic foot exams was 38.68%, based on a total of 698 diabetic patients. • Boulton AJM, et al. Comprehensive Foot Examination and Risk Assessment: A Report of the Task Force of the Foot Care Interest Group of the American Diabetes Association, with endorsement by the American Association of Clinical Endocrinologists. Diabetes Care, Volume 31, Number 8, August 2008. I would like to thank the Sugar House Health Center's providers and staff, Susan Pohl MD, Amanda Johnson, and Nicole Edwards for their help and dedication in making this project possible |
