This program sought to standardize diabetic ulcer assessments and timely referral to vascular/podiatry services.
Edward-Elmhurst Health and Frontier Nursing University
- Community outpatient clinic
- Integrated healthcare system/network
- In 2017, the Center for Disease Control & Prevention announced an increased prevalence of Type 2 diabetes mellitus throughout the United States, affecting over 12% of the adult population (1). About 15-25% of patients with diabetes will develop a non-healing diabetic foot ulcer (DFU), with a 50-70% recurrence rate (2).
- In patients who have diabetes and require an amputation, nearly 85% of these amputations are due to a DFU (2). Globally, every 30 seconds, there is a diabetic patient who will receive a lower extremity amputation due to a DFU (3).
- Among patients with diabetes, those with DFUs who require an amputation have a two-fold increased mortality risk. Many patients with a DFU become unemployed (50-79%), generating financial difficulties and an overall drop in their productivity and quality of life (4,5).
- Edward-Elmhurst Health is an integrated health system in Illinois. Elmhurst hospital has received Magnet and Plaintree recognition for excellence in nursing care and patient centered philosophy.
- The Center of Health’s affiliated clinics (associated with Elmhurst hospital) have established themselves as one of the leading multi-specialty medical groups in DuPage County, providing primary care and a range of specialty care including a wound care clinic.
- The Elmhurst Wound Care Clinic (EWCC) offers in-depth specialty care to treat acute and chronic wounds.
- Its care is the result of collaboration of physicians from a variety of disciplines (internal and family medicine, podiatry, infectious disease, and vascular, plastic and general surgery) along with advanced practice nurses, certified wound/ostomy nurses, physical therapists with wound care certification, and other skilled technicians.
- At the EWCC, clinicians discovered a discrepancy between guidelines for treatment of DFU recommendations and what was actually implemented in practice.
- For example, in 2013, 8.1% of the DuPage county population had diabetes, but within the diabetic population, only 88% of individuals had a yearly diabetic foot screening.
- Chart audits for the second half of 2017 indicated lack of documentation of a peripheral neuropathy exam (45%), and probe to bone on wound assessment (90%). Also, 60% of patients in this clinic with DFUs reported owning therapeutic diabetic foot wear, and only 17% had adequate glycemic control (A1c<7).
- Thus, a multidisciplinary approach to diabetic foot care, influenced by the Chronic Care Model (CCM) and the Institute for Health Improvement Model (IHI), was deemed necessary to address these discrepancies.
Patient Population Served and Payor Information
- The clinic treats patients with diabetic foot ulcers at the Elmhurst Wound Care Clinic; it is located in a suburb of Chicago, IL.
- Payor information: 62% of the EWCC’s patients have Medicare insurance plans, 36% have commercial plans, 1% are uninsured patients or having pending Medicaid approval
- The clinic manager, clinic staff, and medical directors at EWCC.
- Advisors for the project included Joan Slager, CNM, DNP, CPC, FACNM and Niessa Meier, DNP, CNM Faculty at Frontier Nursing University
- This Quality improvement project was part of doctorate in nursing practice (DNP) degree of one of the nurse practitioners at EWCC, this project was on a volunteer basis, without any outside funding.
Research + Planning
- The template from IHI tools for quality improvement project was implemented.
- A standardized method was developed for identifying abnormal diabetic foot exams, improving the quality of patients’ overall care, and promoting more expedient referrals to different podiatry or vascular services within the EWCC.
- Research for the project was conducted through Medline, CINAHL, EBSCO, and PubMed search engines.
Tools or Products Developed
- Footcare for a Lifetime, developed by U.S. Department of Health and Human Services [USDHHS] (2013), was used as a shared decision-making (SDM) tool.
- The Lower Extremity Amputation Prevention (LEAP) tool, developed by the Health Resources and Services Administration (HRSA, 1992), was used to examine diabetic feet in patients and identify abnormal diabetic foot exams. The LEAP checklist also served as an indicator of the clinic’s improvements in standard of care.
- Training for the project took place at the EWCC, from January 2018 through September 2018.
- The training consisted of one-on-one reviewing of the diabetic foot exam (vascular and neuro-assessment) and skills competency of the nursing team.
- Use of Footcare for a Lifetime was reviewed with nursing and PT clinicians.
- Electronic medical record
Team Members Involved
- During the 8-week intervention, the implementation team conducted 4 Plan-Do-Study-Act (PDSA) rapid cycles with tests of change (TOC). The intervention included:
- A kick off meeting
- Daily huddles
- Weekly team meetings
- Mid-day huddles
- Patients with diabetes were identified using diagnoses within the electronic record or referral orders.
- At the first visit, the clinic secretary added the SDM tool as well as the LEAP tool to a new patient’s folder.
- The support staff made sure each patient was seated in an exam chair with shoes and socks removed.
- Each clinician began the assessment of the diabetic foot utilizing the LEAP tool and engaged the patient in the treatment of diabetic foot ulcer by discussing the contents of the SDM tool. They also initiated referrals to vascular or podiatry services as appropriate.
- Clinicians included physical therapists, advanced practice nurses, and registered nurses.
- Patients were given a multiple-choice question survey included in Diabetic Footcare for a Lifetime at the end of the visit to assess their engagement.
- Learnings and opportunities for improvement were discussed in daily huddles.
Cost of patient’s shared decision making tool copy
Where We Are
The 90-day intervention was completed; Elmhurst outpatient wound care clinic adopted to continue educating patient on diabetic foot care and use the LEAP tool on assessment of the diabetic foot ulcers.
- Foot exam quality: Over 90 days, a median of 90% Right Care for diabetic foot exams was achieved (Figure 1).
- Visit length: Patient visit length increased by 10 minutes in the first PDSA cycle, and then reduced to the baseline (75 minutes) most of the time in the remaining cycles. There were only two outliers – patients with multiple ulcers – who required more time during initial visits.
- Team engagement: median team engagement in daily huddles and team meeting was 92% (Figure 2). The team participation in daily huddles improved from 80% at the beginning of the first PDSA cycle, to 90% in the end of the fourth cycle. Average scores on the team engagement survey improved from 40% initially to 92% at the end of the 90-day project.
- Patient engagement: In the first cycle, there was zero participation, and by the end fourth cycle, 100% of patients were engaged with the SDM tool (Figure 3). Patient’s post visit survey baseline was 55% and improved to above median (75%) for the third and fourth cycles.
- Referrals to vascular/podiatry services: There was variation in utilization of the referral tracking log among the clinicians (Figure 4). In the first cycle, referrals were tracked by one provider for one team. In the second cycle referrals were tracked by one provider for both teams. In the third cycle, referrals were tracked by other team members. In the fourth cycle, each clinician tracked their own team referral. This imperfect tracking made assessment of referral patterns difficult.
- The most successful components of this project were patient education and engagement on diabetic foot care and the clinic team’s engagement.
- The diabetic foot exam became standardized which improved the clinicians’ skills.
- The intervention facilitated communication between clinicians and primary care providers.
- Daily huddles and team meetings allowed for a dialogue regarding team concerns and fostered shared decision making among staff and leadership. The EWCC’s team was able to create a culture of teamwork and dynamic communication.
- Entering patients in the tracking log remained challenging for the team, who struggled with staffing and taking responsibility of updating the tracking log.
- Study limitations:
- Bias: patient’s perceptions, cultural beliefs, level of comprehension, and language barriers may have influenced data collection.
- Generalizability: the design of the project was geared towards a clinic with multiple staff members, so a single provider clinic may not have enough time for both patient education and assessment using the LEAP tool in first visit, and may expand the patient education to the follow up visits.
Figure 1: Right Care
PDSA1-How many patient received SDM (Y(1)/N(0)).
PDSA2-LEAP checklist completed (Y(1)/N(0)).
PDSA3-Abnormal DF screening documented in log (Y(1)/N(0)).
PDSA4- Referral generated (Y(1)/N(0)).
Right Care measured by: calculating mean of the average of score.
Figure 2: Team Engagement
Figure 3: Patient Engagement
Table 4: Referrals to Vascular/Podiatry Services
- Centers for Disease Control and Prevention. National Diabetes Statistics Report, 2017. Retrieved from https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf
- Alavi, A. et al. Diabetic foot ulcers: Part I: Pathophysiology and Prevention. Journal of the American Academy of Dermatology. 2014; 70(1) doi:1.e. 10.1016/j.jaad.2013.06.055
- Järbrink K et al. The humanistic and economic burden of chronic wounds: a protocol for a systematic review. Systematic Reviews. 2017; 6(1),15
- Sloan FA et al. Receipt of care and reduction of lower extremity amputations in a nationally representative sample of U.S. Elderly. Health Services Research. 2010; 45:1740-1762.
- Siersma V. Health-related quality of life predicts major amputation and death, but not healing, in people with diabetes presenting with foot ulcers: the Eurodiale study. Diabetes Care. 2014; 37(3):694-700.
- Carls GS et al. The Economic value of specialized lower-extremity medical care by Podiatric Physicians in the Treatment of Diabetic Foot Ulcers. Journal of the American Podiatric Medical Association. 2011; 101, 93-115.