Implementing Standardized Best Practices for Reducing Diabetes Foot Ulcer Risk in a Large Academic Clinic

Abstract

Foot ulcers are a common, often preventable complication of diabetes associated with burdens and costs. Recent reports indicate eastern Ontario has a disproportionately high incidence of lower extremity amputation and low foot examination rates. In response, the Ottawa Hospital made diabetes foot ulcer prevention a quality improvement priority. Using formal QI methods, foot ulcer risk assessment and stratification, referral processes and self management education were standardized and implemented at 15 weekly diabetes clinics attended by 11 endocrinologists, multiple rotating medical residents and 9 nurses over an 8-month period. The Registered Nurses Association of Ontario and Canadian Diabetes Association practice guidelines informed the process. QI strategies including chart audits, learning sessions, current and future state mapping, and stakeholder surveys, enabled an understanding of practice variations, user needs and concerns and environmental factors impacting care. Evidence-based clinical protocols, documents and resources were developed, tested and adjusted through a series of rapid change cycles. Performance expectations and targets were developed and shared across disciplines. Progress was measured weekly and communicated regularly. Significant improvements were achieved. More than 90% of newly referred patients receive a standardized, 5-item foot exam and risk assessment with over 30% presenting as “higher” risk for ulcers. Patients are informed of their risk factors, education is provided, referrals made for modifiable risk and charts flagged for follow up. Patients and practitioners are highly satisfied with the practice changes. We have demonstrated that even in busy, complex environments, practice can be standardized and change sustained using QI methods.