KLINIK KESIHATAN KLINIK KESIHATAN KAMPUNG PANDANKAMPUNG PANDAN

QA STUDY 2011

POOR DETECTION RATE OF DIABETIC FOOT PROBLEMS AMONG DIABETIC PATIENT AT KK KG PANDAN

PANDAN

TEAM MEMBERSTEAM MEMBERS

DR. SAMURAH A RAHMAN

DR. PREMINI A/P GANESPATHY

DR. IBRAHIM AHMAD FUAD

S/N MOLINA

Outline of Problems1

PROBLEMS IDENTIFIED IN THE CLINICPROBLEMS IDENTIFIED IN THE CLINICHIGH PREVALENCE RATE OF LATE BOOKING ATTENDING KKIAHIGH DEFAULTER RATE AMONG ANTENATAL FOLLOW UP AT KKIAPOOR DETECTION RATE OF DIABETIC FOOT PROBLEMS AMONG DM PATIENTSPOOR RATE OF BP CONTROL AMONG HPT PATIENTSHIGH NUMBER OF DEFAULTER RATE AMONG DM PATIENTS

PRIORITISATION OF PROBLEMSPRIORITISATION OF PROBLEMSSMART criteria is being used to chose the topic for QA.

SERIOUSNESS

MEASUREABLE

APPROPRIATENESS

REMEDIAL

TIMELINESS

SCALE OF WEIGHTAGESCALE OF WEIGHTAGE

PROBLEMSS M A R T SCORE

1. HIGH PREVALENCE RATE OF LATE BOOKING AT KKIA

15 15 20 15 20 85

2. HIGH DEFAULTER RATE AMONG ANTENATAL FOLLOW UP AT KKIA

20 20 15 15 20 90

3.POOR DETECTION RATE OF DIABETIC FOOT PROBLEMS

AMONG DM PATIENT

20 20 20 20 20 100

4. RATE OF BP CONTROL AMONG HPT PATIENTS

15 15 15 15 15 75

5. HIGH NUMBER OF DEFAULTER RATE AMONG DM PT.

15 20 20 20 15 90

PRIORITISATION OF PROBLEM USING SMARTPRIORITISATION OF PROBLEM USING SMART

1=Not too important 3= Important 5= Most important

2=Not important 4= Very important

VERIFICATION STUDYVERIFICATION STUDYData taken from the audit (ADCM-Audit Diabetes Control Management) which was conducted from24/4/09- 14/4/10, among DM patient in KK PANDAN , only 6.5% patient were found to have diabetic foot problems.

Detection of diabetic foot problems among diabetic patient in Kuala Lumpur was only 3%.(13 clinics).

INTRODUCTIONINTRODUCTION

Diabetic foot problems are common complication of diabetes mellitus patients that eventually affects the majority of DM patients which is associated with significantly higher morbidity and disability.

LITERATURE REVIEWLITERATURE REVIEW

• Rabia K et al (2007) reported that prevalence of peripheral neuropathy in primary care setting at University Malaya was 41%, foot ulcer 9.5% and peripheral vascular disease 16%.

• Prevalence of peripheral neuropathy in Turkish Diabetic patient was 40.4% by clinical examination. Ebras et al (2011).

• In the Third National Health Morbidity Survey 2006, the prevalence of limb amputation among diabetic patient was 4.3%.

• Mimi O et al (2003) reported prevalence of foot deformity among diabetic patients attending primary care setting at University Malaya was 17.7%.

• Reiber GE et al (1995) found out that 15% of patients with diabetes mellitus will develop a lower extremity ulcer during the course of their disease. The prevalence of foot ulceration in patient attending a diabetic outpatient clinic in Malaysia has been reported as 6%.Ganesen (1992).

• Based on literature review primary health care provider should be able to detect 70-80% diabetic foot problems (Peripheral neuropathy, peripheral vascular disease, foot deformity, ulcer and amputation)

SERIOUSNESSSERIOUSNESS

Failure to diagnose diabetic foot problems OR early detection will lead to end point of foot complication which is foot amputation.

MEASURABLEMEASURABLE

Selection on cases and evaluation can be obtained from patient’s records

Knowledge and skill of examination of staff can be assessed by observation and self administered questionnaire

APPROPRIATENESSAPPROPRIATENESS

ABLE TO PERFORM STUDY AS

a. KKM has Clinical Practice Guideline for Management of Diabetic Foot 2004

b.Sufficient staff

REMEDIABLEREMEDIABLE

Staff to be trained about knowledge and skills and go for refresher courses

To refresh staff knowledge by doing CME

CME-Foot examination was done in September for nurses prior to data collection

• CME-Foot examination was done in September to the nurses prior to data collection

TIMELINESSTIMELINESS

To prevent further complications of diabetic foot by early detection and diagnosis.

Key measures for improvement2

GENERAL OBJECTIVEGENERAL OBJECTIVE

To increase detection rate of Diabetic Foot Problems among diabetic patient.

To identify the cause of failure and to achieve higher detection rate

SPECIFIC OBJECTIVESSPECIFIC OBJECTIVESTo identify and to determine the cause of low pick up rate in diagnosing diabetic foot problems.To formulate strategies and plan appropriate remedial measures to overcome identified problem.To evaluate the remedial measure implemented.

INDICATOR & STANDARDINDICATOR & STANDARDINDICATORS FORMULA STANDARD

% of Diabetic Foot Problems among diabetic patients

Number of DM patients withAbnormal foot examination X 100----------------------------------------------Numbers of selected DM patients

40%

DefinitionsDefinitions

Diabetic foot problems (From ADCM 2009)

1.Peripheral neuropathy- Disorder of nerves apart from brain & spinal cord @ damage to the nerve of peripheral nervous system.

2. Peripheral vascular disease- peripheral arterial disease (PAD) or peripheral artery occlusive disease (PAOD)

DefinitionsDefinitions

-refers to the obstruction of large arteries not within the coronary, aortic arch vasculature or brain. PVD can result from atherosclerosis, inflammatory processes leading to stenosis, embolism or thrombus formation.

3. Foot Deformity- distortion or general disfigurement of the foot.

DefinitionsDefinitions4. Ulcers- a local defect, or excavation of the

surface, of an organ or tissue produced by sloughing of necrotic inflammatory tissue.

5. Amputation- intentional surgical removal of a limb or body part. It is performed to remove diseased tissue or relieved pain.

POOR DETECTION RATE OF DIABETIC

FOOT PROBLEM

AMONG MEDICAL

STAFF

POOR ATTITUDE

POOR ATTITUDE

LACK of KNOWLEDGE

LACK of KNOWLEDGE

LACK of

SKILL

LACK of

SKILL

POOR DOCUMENTATION

POOR DOCUMENTATION

LOW REFERRANCE

TO PROTOCOL/

CPG

LOW REFERRANCE

TO PROTOCOL/

CPG

POOR COMMUNICATION

POOR COMMUNICATION

Factors influencing low detection of Factors influencing low detection of Diabetic Foot ProblemsDiabetic Foot Problems

Lack of knowledge of staff

Lack of skill on foot examination

Poor documentation

Flow chartFlow chart

RESULT

1 YEAR FOOT CARE APP

DOCUMENTATION

FOOT EXAMINATION DONE BY NURSES

APPOINTMENT FOR FOOT ASSETMENT

NORMALABNORMAL

REFFERAL TO DOCTORS

TCA 3 TO 6/12LY

TAKE ACTION ACCORDINGLY

Yes

No

Appointment for foot assessment

Foot Examination by trained staffs

Diagnosis of foot problems

Documentation of examination findings

Refer to doctors for further management

End TCA 1yrTake Action to :- 1.Education2.Optimize Sugar control3.Treatment of complications4.Referral to respective unit

End TCA 3-6 month

STANDARD

100%

100%

100%

100%

100%

100%

MODEL OF GOOD CAREMODEL OF GOOD CARE

Process of Gathering Information3

INCLUSION AND EXCLUSION CRITERIAINCLUSION AND EXCLUSION CRITERIA

INCLUSION CRITERIAAll Diabetic patients

EXCLUSION CRITERIADiabetic patient who is known to have Diabetic Foot Problems.

Type I DM Pregnant mother

COLLECTION OF DATA COLLECTION OF DATA • Diabetic patient will be given appointment date for

foot care assessment during their follow up• Appointment per day was 15 patients per session• Foot care assessment is done on Monday and Friday

morning• Dedicated staff will contact patients via phone a day

prior to appointment• 15 staff involved (6 staff nurses and 9 Jururawat

Masyarakat)• All patient that came during the session will be taken

as sample

INTERVENTION TOOLS FOR INTERVENTION TOOLS FOR IMPROVEMENTIMPROVEMENT

Diabetic Foot Assessment Form

Staff’s observation on skill

Staff’s knowledge questionnaire

Diabetic Foot Assessment Form

Staff’s observation on skill

Staff’s knowledge questionnaire

Diagnosis post examination

• Based on ADCM study diagnosis categorized into 5 categorya. Peripheral neuropathy

b. Peripheral vascular disease c. Foot deformity d. Foot ulcer e. Amputation

Instruments

Cotton bud

5.07 Semmes-Weinstein monofilamant Tendon Hammer

Tuning fork 128hz

Neurotip

Doppler and sphygmomanometer

Diabetic foot album

Analysis and Interpretation4

Result (From 4/10/2010-15/4/2011)• Total foot care examinations : 484 patients• Peripheral Neuropathy : 63 patients

(13%)• Peripheral Vascular Disease: 12 patients

(2.4%)• Foot deformity : 29 patients

(5.99%)• Foot ulcer : 13 patients

(2.68%)

• Amputation : 2 patient (0.4%)

• Total abnormal foot findings 163 patients (24%)

ABNA

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

DETECTION RATE (%)

% OF DETECTION

17.5%

STANDARDDATA 1 BEFORE

TRAINING

DATA 2 AFTER

TRAINING

STANDARD SET AT 40%

• This study had not achieved its own standard of detection: 40% detection of diabetic foot problems.

• Thus, reevaluation and remedial action were done

Strategies for Change5

Strategy for changeProblems identified during re evaluation1.Staff were not able to do correct examination

technique. Only 2 staff able to do complete and correct examination technique. All staffs incorrect technique recorrected by second CME.

2.Poor documentation. Proper and correct documentation briefing

done to all staff.

3. Seven of staff was unable to give correct diagnosis post examination. Each of them were re-educated on how to make a correct diagnosis.

4. Staff knowledge was assessed. Five staff scored between 70-80% Nine staff scored between 60-70% One staff score 56% The staff knowledge was assessed after second

CME (conducted on 19th May 2011)

Effects of Change6

• Analysis result post remedial action taken from 20.5.2011 until 18.8.2011

Staff knowledge

Pre remedial action Post remedial action

0% 0% 0% 0%

100% (15

staff)

Correct examination technique

Result: Detection of diabetic foot Result: Detection of diabetic foot problems (20.5.2011-18.8.2011)problems (20.5.2011-18.8.2011)

Total : 261 patientsPeripheral neuropathy : 116 patient (44.0%)Peripheral vascular disease :10 patients (8.4%)Foot deformity : 16 patients

(16.4%)Foot ulcer : 1 patient (1.5%)Amputation : 0.8%Total abnormal findings : 116 patients (72%)

13%

2.40%5.99%

2.68% 0.40%

44.0%

8.4%

16.4%

1.5% 0.8%0%5%

10%15%20%25%30%35%40%45%50%

Peripheral neuropathy

Peripheral vascular disease

Foot deformity Ulcer Amputation

Foot Complications detected

Pre remedial action Post remedial action

ABNA

17.5%

STANDARDDATA 1 BEFORE

TRAINING

DATA 3 AFTER REMEDIAL

ACTION

DATA 2 AFTER

TRAINING

48%

Conclusion• This study had achieved its own standard of

detection after reevaluation and remedial action: Able to achieved 72% detection of diabetic foot problems.

• Improvement can be achieved with -continuous supervision on examination

technique. -Regular audit on documentation -Regular assessment on knowledge

The Next Step7

NEXT STEPNEXT STEP

• The foot care assessment protocol had been implemented as routine annual foot care assessment at KK Kampung Pandan

• Our aim in future to create protocols for diabetic foot management to the patients

• The format of clinical monitoring protocol can also be applied to improve detection of other diabetic complications

• These implementation steps will be share with other clinics in JKWPKL in order to improve the rate of detection of diabetic foot problems

GANTT CHARTGANTT CHARTAUG SEP OCT NOV DEC JAN FEB MAR APR MAY JUN

Proposal & verification

Briefing & Training

Data collection

Analysis of data

Remedial measures & Reevaluation

Report writing

20112010

Planning Execution

REFERRENCESREFERRENCES1. World Health Organization – Diabetes Program me

2. King LB. Impact of Preventive Programmer on Amputation Rates in the Diabetic population. J Wound Ostomy Continence Nurs 2008; 35: 479-482.

3. Pecoraro RE, Reiber GE, Burgess EM. Pathways to diabetic limb amputation: basis for prevention. Diabetes Care 1990; 13: 513-21

4. Rabia K, Khoo EM. Prevalence of Peripheral Arterial Disease in patients with Diabetes Mellitus in a Primary Care Setting. Med J Malaysia 2007; 62(2).

5 Erbas, Tomris, Ertas, Mustafa. Prevalence of Peripheral Neuropathy and Painful Peripheral Neuropathy in Turkish Diabetic Patients. Journal of Clinical Neurophysiology 2011; 28: 51-55.

6. Akbar DH, Mushtaq MA, Alagmdi AA. Inadequate screening for micro vascular complications among diabetic patients. Diabetes International 2001; 11(1): 2204

7. The third National health Morbidity Survey (NHMS) Diabetes Group. Ministry of Health Malaysia, 2006.

8. Abbas ZG, Archibald LK. Challenge for management of diabetic foot in Africa: doing with more. International Wound Journal 2007; 305-13.

9. Clinical Practice Guideline. Management of Type 2 Diabetes Mellitus.4th edition 2009.

10. Clinical Practice Guideline. Management of Diabetic Foot 2004.

11.Rajna Ogrin. Foot assestment in patient with diabetes. Australian Family Physician 2006; 35(6)

THANK YOU…THANK YOU…

Soal selidik untuk kakitangan klinik kesihatan kampung pandan

Nama : ___________________________________________________Jawatan : ___________________________________________________ 1. Semua pesakit kencing manis perlu menjalani pemeriksaan kaki sekurang-kurangnya setahun sekali

(Ya/Tidak)2. Pesakit yang mempunyai komplikasi perlu disaring lebih kerap (3-6 bulan sekali) (Ya/Tidak) 3. Pesakit yang ada ulser, jangkitan kuman dan gangrene perlu dirujuk segera kepada doktor

(Ya/Tidak) 4. Sewaktu pemeriksaan kaki, anda perlu membandingkan keadaan kedua-dua kaki (Ya/Tidak) 5. Pemeriksaan sensori pada kaki menggunakan 5.07 Semmes-Weinstein monofilament (10gm)Wire

(Ya/Tidak) 6. 5.07 Semmes-Weinstein monofilament (10gm) wire hendaklah ditukar selepas _____kali

penggunaan7. Penggunaan vibration test hendaklah menggunakan Tunning-fork 250 hz (Ya/Tidak) 8. Bacaan ABSI _______ adalah abnormal dan memerlukan rujukan doktor.9. Namakan dua pulses/nadi yang perlu diperiksa sewaktu pemeriksaan kaki

a) ____________________b) ____________________

10. Nyatakan apakah komplikasi diabetes kepada kaki pesakit (5Jawapan)11. Kenalpasti dan nyatakan abnormality pada pemeriksaan kaki berikut. (10 gambar kaki pesakit)

Staff observational sheet Yes / No

1. Patient’s biodata (Name, date, contact number and I/C numbers) filled up

2. Both lower limbs being compared.

3. Proper technique of foot examination carried out as in the foot examination form

a. Inspectionb. Nerve assessmentc. Vascular assessment

4. Correct tools being used

5. Post examination diagnosis

6. Patients were informed about the examination findings

7. Abnormal findings-refer to doctors or not

Staff observational sheet