560-Article Text-3549-1-6-20190306

Online Journal of Rural Nursing and Health Care, 19(1)
https://doi.org/10.14574/ojrnhc.v19i1.560

Implementation of a Comprehensive Diabetic Foot Exam Protocol in rural primary care

Kathy L. Murphy Buschkoetter DNP, FNP-BC 1

Warseal Powell DNP, FNP-BC 2

Linda Mazour. M.D. 3

1 Family Nurse Practitioner, Franklin County Memorial Hospital and Rural Health Clinics,

kathy.murphynp@gmail.com

2 Assistant Professor, University of South Alabama School of Nursing, University of South

Alabama School of Nursing, warsealpowell@southalabama.edu

3 Medical Director, Franklin County Memorial Hospital and Rural Health Clinics

lsmazour@fcmh.biz

Abstract

Background: Patients with type-2 diabetes mellitus have an increased risk for foot ulcerations and

lower extremity amputations. Evidence-based practice guidelines recommend annual foot

screening at least yearly for patients with type-2 diabetes. Comprehensive foot exams that include

assessments for loss of protective sensation and peripheral artery disease prove beneficial in

reducing morbidity and decreasing the incidence of diabetic foot ulcerations. Despite the known

benefits of preventive screenings, a limited number of rural providers adhere to well-established

treatment guidelines for patients with type-2 diabetes.

Purpose/Aim: The purpose of this quality improvement project was to increase the number of

comprehensive foot examinations for adults with type-2 diabetes mellitus in rural primary

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care. The overarching aim was that 75% of adult patients with type-2 diabetes would consistently

experience a comprehensive foot exam and risk assessment within 15 weeks of project initiation.

Methods: The quality improvement project design involved the introduction of a comprehensive

diabetic foot exam protocol in four Rural Health Clinics. Utilizing the Plan-Study-Do-Act quality

improvement model, retrospective data was collected from 60 patients to evaluate the percent of

patients with type-2 diabetes that received a foot exam in 2017. Educational programs were

presented to primary care providers and clinic nurses to introduce the protocol. The project

implementation occurred as a 1-week pilot in one Rural Health Clinic then system-wide for 14

weeks.

Results: The retrospective data revealed 42% of patients with type-2 diabetes received a foot

exam in 2017. All primary care providers and clinic nurses attended educational sessions on

screening guidelines and protocol introduction. Following the 15-week project, 68% of patients

with type-2 diabetes experienced a comprehensive foot exam and risk assessment.

Conclusions: Implementation of a clinically relevant tool in rural primary care resulted in

significant improvement in primary care provider adherence to recommended diabetes foot

screening guidelines.

Keywords: Type-2 Diabetes, Rural, Adults, Foot Exam, Guidelines

Implementation of a Comprehensive Diabetic Foot Exam Protocol in rural primary care

Diabetic foot ulcers (DFU) are the leading cause of non-traumatic lower extremity

amputations in the United States (Centers for Disease Control and Prevention [CDC], 2017) and

costs related to the treatment of DFUs are well over a billion dollars annually (Hicks et al., 2016).

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Diabetic peripheral neuropathy (DPN) and peripheral artery disease (PAD) are directly related to

the development of ulcerations of the foot and lower extremity (Boulton, 2013). With the loss of

protective sensation resulting from peripheral neuropathy, patients with diabetes are increasingly

susceptible to injuries and trauma of the foot and ankle enhancing the possibility of developing

foot ulcerations (American Diabetes Association [ADA], 2017). In over half of patients with DFU,

PAD is present further complicating diagnosis and treatment (Brownrigg, Apelqvist, Bakker,

Schaper, & Hinchliffe, 2013). Through tertiary prevention in patients diagnosed with type-2

diabetes mellitus (T2DM), assessments for signs of DPN and PAD facilitate identification of

patients with loss of protective sensation and impaired perfusion that are at risk for developing

long-term complications such as foot ulceration and lower limb amputation (Boulton, 2013;

Markakis et al., 2016). Comprehensive foot care that includes screening exams and risk

assessments (RA) for patients with diabetes reduces the rate of ulcerations nearly 75% and

amputation up to 85% (Hershey, 2017; Pocuis, Man-Hoi Li, Janci, & Thompson, 2017).

In rural health clinics (RHC) located in Franklin and Webster counties of south-central

Nebraska, management and treatment of patients with T2DM by primary care providers (PCP)

demonstrates significant variability and lack of adherence to well-established evidence-based

practice (EBP) screening guideline recommendations for annual foot exams. Specifically,

providers inconsistently perform and document annual foot exams for adult patients with T2DM.

In RHCs, the compliance rate for yearly diabetic foot exams in 2017 was 42% significantly well

below the national rate of 68% (CDC, 2017) and Nebraska rate of 68% (Department of Health and

Human Services [DHHS], 2015). Although evidence demonstrates the effectiveness of

comprehensive foot examinations (CFE) in reduction and prevention of foot ulcers (ADA, 2017;

Oxendine, 2014), PCPs identified barriers to annual foot exam recommendations, similar to those

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found in literature review, including lack of adequate knowledge, time constraints, and strongly

held negative attitudes and opinions as to the usefulness and practicality of EBP guidelines (Bus

& Van Netten, 2016; Furthauer, Flamm, & Sonnichsen, 2013; Vigersky, Fitzner, & Levinson,

2013).

The purpose of this quality improvement project was to increase the number of CFE for

adults with T2DM in rural primary care. The research question for this project was: In rural adult

patients, ages 19 years and older, with T2DM, does the use of a Comprehensive Foot Exam

Protocol incorporated into existing electronic medical records improve PCP adherence to EBP

guideline recommendation for an annual CFE and risk assessment, compared to the non-use of

Comprehensive Foot Exam Protocol.

Significance/Literature Review

Diabetes in the United States

National statistics estimate that over 30 million people in the U.S. have diabetes. While 23.1

million (7.2%) have a diagnosis of diabetes the remaining 7.2 million are undiagnosed and

unaware of their disease (ADA, 2017). Overall, prevalence of diabetes is higher in minority

populations of American Indians/Alaska Natives, non-Hispanic blacks, and people of Hispanic

ethnicity (CDC, 2017). However, the percentage of adults of all races with diabetes increases with

age reaching 25.2% in those aged 65 and older. Geographical patterns indicate the highest

incidence of diabetes in the southern and Appalachian regions, followed by Midwestern states.

Rural residents experience a 17% higher rate of T2DM compared to urban residents (Ross et al.,

2014; National Rural Health Association, 2015).

Diabetes is a leading cause of morbidity and mortality creating a significant public health

and economic burden for patients, healthcare systems, and society (ADA, 2017). Economic

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burden associated with diabetes is primarily related to the cost of preventable diabetes

complications (Welch et al., 2015). Patients with T2DM that developed neuropathy have up to a

20% lifetime risk of developing foot ulceration (Pocuis et al., 2017). Additionally, the lifetime

risk significantly increases to 30-35% with concomitant risk factors such as PAD and foot

deformity (Brownrigg et al., 2013). Patients with a DFU have ulcer recurrence rates of 30-40% in

the first year after an ulcer episode (Bus & Van Netten, 2016). Care of DFUs is estimated to cost

nearly $1.4 billion/year (Hicks et al., 2016) consuming well over a third of total resources allocated

for treatment of T2DM and resulting complications. Ulcer prevention, however, represents only a

small portion of the total expenditures utilized for diabetic foot care. As the incidence and cost of

diabetes continue to rapidly rise, providing high quality evidence-based preventive care is vital to

reduce diabetes-associated morbidity and lessen the economic burden.

Burden of Diabetes in Franklin and Webster Counties of Nebraska

According to the CDC (2017), the incidence of diagnosed diabetes in Nebraska is 11.6%

notably above the national average of 7.2%. Similar prevalence rates are found in Franklin

(10.8%) and Webster (11.1%) counties. High rates of obesity further complicate the burden of

diabetes for rural Nebraskans. In the U.S., the rate of obesity for rural residents is nearly 26%

appreciably more than the 20% rate in urban populations. Nebraska has experienced a significant

increase in obesity rates from 20% to 31% over the past 18 years. In Franklin and Webster

counties, obesity rates average 33% exceeding the state and national average (CDC, 2017).

Defining Rural Population and Rural Health Inequities

The concepts of rural and urban are complex, multifaceted, and continue to evolve. The

U.S. Census defines rural as “all population, housing, and territory not included within an

urbanized area, population > 50,000, or urban cluster, population of 2500-49,999” (Ratcliffe, Burd,

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& Fields, 2016). Similarly, the U.S. Department of Agriculture defines rural as “areas of open

country and settlements with fewer than 2,500 residents” (Cromartie & Parker, 2017; U.S.

Department of Agriculture, 2016). The number of people living in rural areas is only 16% of the

U.S. population however they reside on 75% of the total land mass. Nebraska is considered a rural

state with over 35% of the population residing in areas with less than 2,500 residents. According

to the Census Bureau (2016), Franklin County covers 574 square miles with a population average

of 5.6 person per square mile and Webster County covers over 577 square miles with a population

average 6.6 person per square mile. The RHCs are located in communities within Franklin County

including Franklin (pop. 1000), Hildreth (pop. 318), Campbell (pop. 347), and Red Cloud (pop.

1020) in Webster County (US Census, 2016).

Rural residents experience significant healthcare disparities related to greater population risk

for poor health, limited access to healthcare providers and systems, and reduced life expectancy

when compared to urban residents. Vulnerability of rural populations is accentuated by isolated

geographic locations that intersect with low socio-economic status combined with higher number

of unhealthy habits, fewer community resources, and limited employment opportunities (National

Rural Health Association, 2015). When comparing rural versus urban statistics, rural residents

experience high rates of obesity related to sedentary lifestyles and an elevated burden of chronic

disease demonstrated by increased incidence of heart and lung disease, diabetes, cancer and stroke

(Ross et al., 2014; Vigersky et al., 2013). Abuse and misuse of alcohol, tobacco, and prescription

medications are characteristics of rural populations that also contribute to lower overall life

expectancy (CDC, 2017).

Diabetic Peripheral Neuropathy Identification

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Diabetic peripheral neuropathy (DPN), a microvascular complication resulting from

diabetes, affects both small and large sensory fibers and is manifested by paresthesia, dysesthesia,

and deficits in normal sensations that profoundly impact patient function and productivity

(Alleman et al., 2015; Van Netten et al., 2016). Approximately half of all patients with diabetes

will develop neuropathy (Markakis et al., 2016; Pocuis et al., 2017). DPN is directly related to the

development of foot ulcers and is a leading cause of amputations in the diabetic population (ADA,

2017; Bus & Van Netten, 2016). Prevalence of DPN is highest in patients with T2DM and often

times underreported and undertreated (Schaffer, Sandau, & Diedrick, 2013). Screening patients

with T2DM for neuropathy is essential for early treatment, reduction of complications, and

decreased morbidity (Bus & Van Netten, 2016).

Key to reducing and preventing foot ulcers and amputations is the identification of those

patients at increased risk through a CFE and RA. According to the ADA (2017), all adults with

T2DM should undergo a CFE at the onset of diabetes diagnosis and continue annually to identify

high-risk conditions. Those patients identified with loss of protective sensation and impaired

perfusion are at higher risk and should have a foot exam at each visit. Furthermore, comprehensive

foot care programs that include RA based on EBP guidelines demonstrate improvement in diabetes

care and patient outcomes (Bus & Van Netten, 2016; Oxendine et al., 2014).

Provider Non-adherence to Established Guidelines

The U.S. Preventive Services Task Force was created in 1984 to promote development of

EBP guidelines for preventive service in primary care (Agency for Healthcare Research & Quality

[AHRQ], 2015). Over the last 30 years, clinical preventative guidelines were published by

universities, interest groups, and organizations based on overwhelming evidence that demonstrates

primary, secondary, and tertiary prevention efforts reduce costs, enhance the quality of care, and

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improve patient outcomes. In 1989, the ADA established screening and treatment guidelines for

patients with diabetes. Highly graded evidence that combines stringent glycemic control, regular

preventive screenings, and early detection and treatment of secondary complications demonstrates

significant reduction in morbidity and mortality related to diabetes (ADA, 2017; Khoong et al,

2013). Despite the well-established benefit of adhering to screening guidelines, a limited number

of rural providers adhere to EBP screening guidelines (Jones, Crabb, Turnbull, & Oxlad, 2014;

Ross et al., 2014; Khoong et al., 2013; Vigersky, Fitzner, & Levinson, 2013).

Theoretical Frameworks

This project was guided by the Health Belief Model developed by Hochbaum (1958) and

Awareness-to-Adherence Model developed by Pathman et al. (1996). The Health Belief Model

(HBM) was developed to integrate stimulus-response theory with cognitive theory in explaining

behavior (Hochbaum, 1958). Influenced by Kurt Lewin’s (1951) theories that perceptions of

reality, rather than objective reality, influence behavior. In HBM, a combination of perceived

susceptibility and perceived seriousness of the condition or situation combines into a perceived

threat. The perceived threat has a cognitive component that is influenced by weighing the benefits

and barriers to the actions. When considering PCP adherence to EBP screening guidelines,

provider experience, knowledge, and attitude appear to have greater weight than guidelines based

on robust research. Benefits and barriers to adherence are considered before action is taken to

follow the recommendations.

To further address guideline adherence, the theoretical framework, Awareness-to-

Adherence, developed by Pathman et al. (1996) that focuses on physician non-adherence to

national guidelines for childhood immunizations was used. The model describes a progression of

steps through awareness, agreement, adoption, and adherence. In 1999, Cabana et al. expanded

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the model and added multi-directional flow pathways that described a sequence of behavior change

and defined barriers to guideline adherence. Since that time, multiple studies utilized the

theoretical model to guide research on adherence to evidence-based guidelines (Khoong et al.,

2013; Radwan, Akbari, Rashidian, Anou-Dagga, & Elsous, 2017; Widyahening, Van der Graaf,

Soewondo, Glasziou, & Van der Heijden, 2014).

Purpose/Aims

The purpose of the QI project was to increase the number of annual foot exams completed

in adults, age 19 and older, with a diagnosis of T2DM in rural primary care. The overarching aim

of the project was that 75% of all adult patients with T2DM presenting for primary care in four

rural health clinics would consistently experience a CFE and RA within 15 weeks of project

initiation.

Methods

A letter of approval was obtained from the University of South Alabama Institutional

Review Board prior to implementation of the quality improvement (QI) project. Exemption status

was granted (Institutional Review Board IRB00000286, DHHS FWA00001602).

Subjects/Participants

The participants in the project were the PCPs in four RHCs located in Franklin and Webster

Counties in south-central Nebraska. The PCPs included one full-time family practice physician,

four full-time family nurse practitioners (NP), and one part-time family nurse practitioner. The

family practice physician is a medical doctor with over 30 years of experience. All five NPs are

masters prepared and vary in advanced practice experience from six months to 23 years. The

patient population was adults age 19 years and older with a diagnosis of T2DM.

Setting

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Franklin County Memorial Hospital (FCMH) is a critical access hospital (CAH) in

Franklin, NE with three provider-based RHCs located in Franklin County and one-independent

RHC in neighboring Webster County. The healthcare system serves residents in both counties and

surrounding areas including people from north-central Kansas. While some patients travel

between 40 to 60 miles to receive care, most patients have access to primary care within a 15-

minute drive from their home. The QI project was conducted in the four RHCs.

Tools

The Michigan Neuropathy Screening Instrument (MNSI) is a valid measure of distal

peripheral neuropathy in patients with T2DM (Herman et al., 2012; University of Michigan, 2017).

The MNSI includes a two-step process: (1) assess neuropathic symptom history from the patient

through a 15-item questionnaire, and (2) a physical examination by providers to evaluate

appearance and sensation of the feet. Three clinical tests utilizing three different tools are utilized

in the neurological EBP screening guidelines recommended (ADA, 2017; University of Michigan,

2017) for a CFE to identify loss of protective sensation (LOPS): (1) Single-use 10-g/5.07

monofilaments, also known as Semmes-Weinstein monofilaments, is placed perpendicular to the

skin with pressure applied until the monofilament buckles. It should be held in place for

approximately one second and then released at the first, third, and fifth metatarsal heads on the

plantar surface and dorsal between base digit one and two (ADA, 2017). The sensitivity of the

monofilament test ranged from 0.41 to 0.93, and specificity ranged from 0.68 to 1.00 (Dros,

Wewerinke, Bindels, & Van Weert, 2009). (2) 128-Hz tuning forks used to test vibratory sensation.

Vibration sensation should be tested by placing the tuning fork over the dorsum of the great toe on

the boney prominence of the DIP joint. Evidence of usefulness is documented in clinical cohort

studies (ADA, 2017; Schaper et al., 2016). (3) Tendon hammer is used to assess ankle reflexes.

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The Achilles tendon should be stretched until the ankle is in a neutral position before striking with

tendon hammer. The absence of ankle reflexes is associated with increased risk of foot ulcer

(ADA, 2017; Schaper et al., 2016).

Intervention Implementation and Data Collection

The Plan-Do-Study-Act (PDSA) quality improvement model (Langley et al., 2009) was used

to guide planning and implementation of the QI project. The model provided a construct for

designing, implementing, measuring, and distributing a quality improvement study (Institute for

Healthcare Improvement [IHI], 2017). In this QI project, the “Plan” phase involved focused

discussions with stakeholders that included retrospective chart data that further defined the

problem as lack of adherence to EBP screening guidelines in patients with T2DM. In the “Do”

phase, the CFE protocol was developed from EBP guidelines. A template was created in the

electronic medical record, and an educational session about the project was developed for

providers and staff. In the “Study” phase, the template was introduced and discussed with

stakeholders and revisions were made to improve the functionality of the protocol. During the

“Act” phase, a one-week trial of the CFE and RA protocol in one RHC was implemented to

determine the functionality of the questionnaire and template. No changes were made, and the

project was implemented system-wide. The PDSA cycle was repeated during system-wide project

implementation.

Retrospective chart review was completed by randomly selecting a sample total of 60 adult

patients with T2DM from the electronic diabetes registry utilizing T2DM ICD10 codes E11-E11.9.

The retrospective chart review included demographic data collection and data extraction from

dictation, clinic notes, and assessment data to determine if a foot exam was completed and

documented over the previous 12 months. Process measures included the percentage of adult

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patients, age 19 years and older, with a diagnosis of T2DM receiving a foot exam within the

previous 12 months.

Prior to implementation of the project, educational training sessions were conducted for all

PCPs and clinic nursing staff on screening guideline recommendation for annual foot exam,

demonstration of CFE with RA, and the introduction of the foot exam protocol in the electronic

medical record. Trial implementation of the foot exam protocol was conducted over a one-week

period to evaluate usability and time involvement with no changes recommended. The project was

implemented system-wide in four rural health clinics and data collected from all adult patients, age

19 years and older, with T2DM that presented for primary care during the 15-week study period.

Analysis/Evaluation

Data analysis was completed utilizing SPSS program (Cronk, 2014). Baseline process data

was collected from 60 random retrospective chart reviews of 2017 data. All PCPs and office

nursing staff attended the educational session on screening guideline recommendations for patients

with T2DM, foot exam and risk assessment demonstration, and introduction of the foot exam

protocol in the electronic medical record. Data was collected from all adult patients with T2DM

presenting to the rural health clinic during the 15-week project and analyzed for the percentage of

CFE and RA completed. Further analysis was completed for each of the four clinic sites and each

of the six PCPs identified as either medical doctor or nurse practitioner. The five nurse

practitioners were assigned NP1through NP5 in order of their employment hire dates.

Results

Sixty patients were randomly identified in the electronic medical record from ICD-10 codes

E11-E11.9 indicating diagnosis of T2DM. Demographic data was collect ensuring that all patients

selected were 19 years and older with a diagnosis of T2DM. Included in the 60 patients, 35%

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(n=21) were female ranging from 52-92 years of age, with a mean age of 72, and 65% (n=39) were

male, ranging from 38-85 years of age, with a mean age of 62. Table 1 shows retrospective data

collected from the convenience sample. Charts reviewed for 60 patients with T2DM revealed 42%

(n=25/60) had received a foot exam in the previous year (2017). The clinic site percentages varied

greatly from 52% (n=12/23) at Main Street Clinic, 40% (n=11/29) at Pool Medical Clinic, 29%

(n=2/7) at Hildreth Clinic, to none completed at Campbell Clinic. Data for each PCP was analyzed

and reported as percent of patients seen with T2DM receiving a foot exam. Percentages varied

from NP1 42% (n=14/25), MD 35% (n=7/20), NP2 29% (n=2/7), NP 5 33% (n=1/3), NP 3 20%

(n=1/5), to NP4 none completed.

Table 1

Percentage of adult patients with T2DM receiving a foot exam in 2017

Clinic Site n = number charts
reviewed

% of total charts
reviewed

n= number of foot
exams completed

% of patients receiving
foot exam

Pool Medical Clinic 29 48% 11 40%
Hildreth Clinic 7 12% 2 29%
Campbell Clinic 1 2% 0 0%
Main Street Clinic 23 38% 12 52%
Total 60 25 42%

Provider
PCP 1 (MD) 20 33% 7 35%
PCP 2 (NP1) 25 42% 14 56%
PCP 3 (NP2) 7 12% 2 29%
PCP 4 (NP3) 5 8% 1 20%
PCP 5 (NP4) 0 0 0 0
PCP 6 (NP5) 3 5% 1 33%
Total 60 25 42%

Data collection for 2018 was completed 15 weeks post project implementation. Eighty

adults patients, age 19 years and older, with T2DM presented for primary care. Demographic data

revealed 52.5% (n=42) were female ranging in age from 26-89 with a mean age of 67 and 47.5%

(n=38) were male ranging in age from 47-84 with a mean age of 66. Table 2 shows data collected

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from 80 patients with T2DM presenting for primary care during the 15-week intervention. The

percentage of patients receiving a CFE and RA was 63% (50/80). Clinic site percentages varied

from 88% (n=29/33) at Main Street clinic, 75% (n=3/4) at the Hildreth Clinic, 43% (n=18/42) at

Pool Medical Clinic, to no completions at the Campbell Clinic (n=0/1). Data for each PCP

revealed percentage of patients seen with T2DM receiving a CFE and RA. Percentages ranged

from 88% (n=29/33) for NP1, 71% (n=5/7) NP2, 60% (n=3/5) NP3, 38% (n=11/29) MD, and 34%

(n=2/6) NP5, to none completed by NP4.

Table 2

Percentage of adult patients with T2DM receiving a foot exam and risk assessment in 2018

Clinic Site n = number of patients
with T2DM presenting
during 15-week project

n=number of
foot exams
completed

% of patients
receiving a
foot exam

n= number of risk
assessments
completed

% of patients
receiving a risk
assessment

Pool Medical Clinic 42 18 43% 18 43%
Hildreth Clinic 4 3 75% 3 75%
Campbell Clinic 1 0 0% 0 0%
Main Street Clinic 33 29 88% 29 88%
Total 80 50 63% 50 63%

Provider
PCP 1 (MD) 29 11 40% 11 38%
PCP 2 (NP1) 33 29 88% 29 88%
PCP 3 (NP2) 7 5 71% 5 71%
PCP 4 (NP3) 5 3 60% 3 60%
PCP5 (NP4) 0 0 0% 0 0%
PCP 6 (NP5) 6 2 34% 2 33%
Total 80 50 63% 50 63%

Outcome measure results: (1) the goal to increase PCP and office nursing staff knowledge

of EBP guideline recommendations for CFE in patients with T2DM was met. One hundred percent

participation by PCPs and office nursing staff in educational sessions with demonstration of CFE

and RA with an opportunity for return demonstration; (2) CFE were performed and documented

on 63% (50/80) of adult patients with T2DM that presented for primary care within the 15-week

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project below 75% completion goal; and (3) RA were performed and documented in 63% (50/80)

of adult patients with T2DM within the 15-week project surpassing the 50% goal.

Discussion/Summary

This QI project showed overall improvement of documented CFEs for patients with T2DM

from 42% pre-implementation to 63% post-implementation. Three of the four RHCs showed

improved percentage of completion of CFE. Percentages varied from Hildreth Clinic (29%/75%),

Main Street Clinic (52%/88%), Pool Medical Clinic (40%/43%) to the Campbell Clinic (0%/0%)

that was unchanged. Five of six PCPs percentage of completion of foot exam improved.

Percentages varied from NP1 (52%/88%), NP2 (29%/60%), NP3 (20%/40%), MD (35%/38%),

NP 5 (33%/34%) to NP4 (0%/0%) who resigned from the practice prior to project completion.

Improving the quality of care for rural adult patients with T2DM is essential to reducing and

preventing long-term complications such as foot ulcerations. This QI project demonstrates the

effective use of PDSA QI Model in implementing EBP guideline recommendations into rural

clinical practice through the use of comprehensive diabetic foot exam protocol. The findings from

this QI project support local efforts to improve adherence to EBP screening guidelines with the

use of a clinically relevant tool incorporated into the existing EMR. Through input from PCPs in

the planning and implementation of the project, the CFE protocol was customized for local

provider usability. Significant improvement in adherence to EBP screening guideline

recommendation for an annual foot exam reveals successful planning and implementation of the

QI project. The simple streamlined process of this QI project provides ease in duplicating a similar

project in other rural health clinics.

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Limitations

The QI project has several limitations including convenience sample, small sample size,

and retrospective data collected by reviewing dictated notes in the EMR subject to individual

interpretation. The administration of the RHCs was very supportive of the QI project and the

strong support may have overly influenced the change process.

Conclusion

Chronic health conditions such as T2DM provide complex management challenges for rural

PCPs. The American Diabetes Association along with other national organizations and

educational institutions provide screening and treatment guidelines for patients with T2DM.

Evidence demonstrates use of evidence based practice screening guidelines improves clinical

outcomes and significantly reduces the risk of preventable diabetes complications. However,

multiple studies have shown that a limited number of rural PCPs utilize EBP screening guidelines

in clinical practice. Improving rural provider adherence to well-established guidelines is essential

to improving the care of rural residents with T2DM. Through QI initiatives in rural primary care,

clinically relevant tools such as the CFE protocol incorporated into existing electronic medical

record resulted in significant improvement in PCP adherence to evidence based practice screening

guideline recommendation for an annual foot exam enhancing patient care and improving patient

outcomes.

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