The facility at which I am employed is located on a Native American Reservation in North Central Montana. There is a high rate of enrolled members who are diagnosed with diabetes, many of which are further classified as uncontrolled and have multiple complications. I work in the Diabetes Management Department as the Diabetes Educator, Diabetes Nurse, and the Diabetic Foot Care Specialist. The patient safety problem that I have identified involves an increase in the number of patients diagnosed with diabetes who were presenting to the clinic with different types of chief complaints related to their feet. Some of those diagnoses included in-growing toenails, onychomycosis, macerations, ulcerations, fissures, corns, and callosities. Many of those patients also had musculoskeletal diagnoses such as hammertoe, claw toe, early-stage Charcot Foot, prominent metatarsal heads, and Taylor’s bunions. NURS 3150 3151 week 1 Discussion: Choosing the Type of Research for a Research Problem.
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The Research and The Potential Cause
Indian Health Services (IHS) (2020) state as many as 10 – 20% of native American patients diagnosed with diabetes who attend a scheduled diabetes exam will have an acute problem related to foot care such as infection, toenail overgrowth, and callosities that needs immediate treatment. The authors continue to state that it is essential to inspect the feet of the diabetic patient at each exam visit because there may also be other factors that increase the risk of injuries such as peripheral arterial disease and sensory neuropathy (IHS, 2020).
Using the Electronic Health Record system, a report was generated to determine which patients diagnosed with any form of diabetes were due for an annual foot exam (had not had a documented foot exam in the past eleven months) and which of those patients also had a full diabetes examination scheduled. In 2018, 35% of the diabetic population of the reservation had a complex foot examination completed. In 2019, only 19% of the diabetic population had a diabetic foot exam documented. After careful review and comparison, it was noted that the patients who attended the scheduled full diabetes examinations were not always receiving the annual foot examination from the nurses or the providers. The nurses should have been removing the shoes of those patients with diabetes and performing a foot exam with 10-g monofilament plus one other sensory test, such as vibratory perception with a tuning fork. This exam was not being completed and was leading to poor outcomes.
Realizing that this facility cannot be the first facility to experience this challenge, further research was conducted to determine what evidence-based practice guidelines might have been established recently through studies that proved effective in increasing the number of diabetic foot exams. Vanderbilt University Medical Center conducted a study to improve foot exam completions by implementing posters for rooms and developing a template for charting that proved successful (Agency for Healthcare and Research Quality, 2014). The Centers for Disease Control and Prevention (CDC) (2017) reports that in 2016 over 82% of adults who are also diagnosed with diabetes in Montana have had an annual foot exam completed.
Change in Practice
The importance of annual foot exams for patients diagnosed with diabetes and the gathered data was shared with the appropriate leaders at the facility. After two weeks of collaboration, a few steps were implemented to help ensure the patients were educated, the nurses were trained and supported, and the patient outcomes were improved. Some of the critical elements of change included the following: NURS 3150 3151 week 1 Discussion: Choosing the Type of Research for a Research Problem
- A Diabetic Foot Exam Template was developed to help facilitate accurate and efficient documenting
- Each of the nurses in the clinic participated in education related to foot exams and are provided additional education quarterly to help them learn about what may be abnormal and interventions to take.
- Each exam room is stocked with 10-g monofilament (sensory testing) and a tuning fork (for vibratory perception testing)
- Each exam room and every nursing station has a graphic hanging that shows how to perform the sensory testing.
- Each of the 22 exam rooms has a sign hung that states, “Do You Have Diabetes? We would LOVE to see your feet” Please make sure your nurse takes off your shoes!”
- The Foot Care Nurse reviews upcoming appointments and orchestrates daily huddles with providers and nurses
Impact on Patient Outcomes
To date, the changes implemented have been positive, not only for the patient outcomes but also for nurse-provider communications. At this point, I have not run updated reports to get exact numbers but have noticed differences in patient care as well as responses from patients during patient interactions. The impacts on patients and processes are as follows:
- Fewer patients are presenting to Urgent Care for chief complaint related to their feet, i.e., “sore on the toe,” “infected in-grown.”
- Increased number of patients scheduling appointments for routine foot care
- Increased number of patients receiving Annual foot exam from nurse or provider during an office visit.
- Nurses and providers are calling Foot Care Nurse more often with questions, for specific patient education, to schedule appointments for patients while they are with the patient.
The Research Question and Why
How often do nurses perform foot exams on patients diagnosed with diabetes at Rocky Boy Health Center?
To answer this question and to increase the number of foot exams performed, a quantitative methodology will be used. There is a distinct correlation in the variables; the nurse and the patient diagnosed with diabetes and foot exams. The information is easily gathered from the facility’s database. The data has been collected and compared to state and national indicators. Research has been conducted and evidence-based guidelines reviewed concerning improving nurse compliance with conducting foot exams. New processes have been established at the facility, and patient outcomes are improving. Continued monitoring and measuring are needed before I can say with certainty that these new implementations have been a real success.
Agency for Healthcare and Research Quality (2014). Toolkit for implementing the chronic care
model in an academic environment: Diabetes foot exam. Retrieved July 13, 2020 from
Centers for Disease Control and Prevention, 2017. U.S. Diabetes surveillance system: Foot
exams by state. Retrieved July 13, 2020 from
Indian Health Services (2020). Foot care: Diabetes standards of care & clinical practice
resources. Retrieved 12 July 2020, from https://www.ihs.gov/diabetes/clinician-resources/soc/foot-care1/