Background The diabetic foot examination (DFE) is an important part of care for patients with diabetes and should be documented on every patient once per year. However, the rate of yearly DFE is variable among primary care providers. Our objectives were to measure our rate of DFE performance on patients with diabetes and to use a quality improvement intervention to improve compliance with DFE performance.
Methods Patients were eligible for inclusion if they received primary care in an academic affiliated primary care practice and had a diagnosis of diabetes. We performed a chart review to measure our baseline rate of DFE. A team of people, including primary care physicians and nurses, used Plan-Do-Study-Act cycles of change to improve the rate of DFE. We tested patient education posters, a DFE template in the EMR for patients with diabetes, and a team approach in which patient care technicians and nurses performed the DFE and alerted the provider to the results. The outcome of interest was appropriate documentation of the DFE, which was defined as a visual inspection, a pulse examination, a test of sensation, and a monofilament examination. The effects of each change were tracked using a run-chart method for a 12-month intervention period.
results We identified 337 patients who met the inclusion criteria. Our chart review revealed that our baseline rate of yearly DFE was 17%. After the 12-month intervention period, the rates of DFE at our center improved from the baseline of 17 to 84%. After implementation of the patient education posters, the proportion of patients with a documented DFE increased minimally. Implementation of the templated note in the EMR yielded an additional improvement from 20 to 53%. Finally, we found the implementation of the team approach to the foot examination increased our rate of DFE documentation from 53 to 84%. Barriers that were identified when implementing these cycles of change included the time constraints of the clinic visit and provider acceptance of their need to improve rates of DFE in their personal practice.
Conclusion Our data demonstrate that applying cycles of change, using a team of physicians and nurses and patient care technicians, can improve the rates of DFEs. These data suggest that applying a team approach to other clinical outcomes may improve rates of compliance with guidelines for the care of other chronic diseases, such as coronary artery disease or asthma.
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