Improving diabetic foot evaluations and podiatry referrals in primary care

Abstract

Diabetic foot ulcers (DFU) are responsible for over 5% of diabetic deaths. DFUs can be prevented or delayed with early diagnosis and treatment of associated diabetic foot complications by utilizing annual comprehensive diabetic foot evaluations (DFE). Despite this, diabetics are not receiving evaluations per the American Diabetes Association's (ADA) recommendations on timeliness and completeness. The potential problem was identified and a needs assessment was undertaken to diagnose the need for change in practice. At one provider clinic in central Montana, less than two-thirds of diabetic adults received a DFE at their annual exam, compared to the national benchmark of 74.8%. Next, a literature review was utilized to gather and analyze evidence. The best solution was identified and a quality improvement project was proposed. Using the Plan-Do-Check-Act cycle, the outcomes were measured preintervention and weekly after implementation. Outcomes included: rates of Michigan Neuropathy Screening Instrument (MNSI), ADA risk assessment, DFE documentation, and podiatry referral completion. The 6- week project focused on nurse practitioner practice change including staff education, implementation of the DFE tools (MNSI and ADA risk assessment), documentation template, and new process flow. Podiatry referrals were included in the new process for patients who screened positive on the MNSI and ADA risk assessment. One hundred percent of patients received an MNSI, ADA risk assessment, documented DFE, and podiatry referral, when indicated. Only 96.67% of patients received an annual DFE that was congruent with the ADA guidelines, with one patient having an incomplete neurological exam documented in their chart. Improvement in rates of timeliness and completeness of DFEs and podiatry referrals were observed when utilizing these standardized assessments and processes. The project culminated in a reflective evaluation of how Montana State University's Doctor of Nursing Practice (DNP) program met the DNP essentials required for graduation.