5PROBLEMS IDENTIFIED IN THE CLINIC HIGH 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
6PRIORITISATION OF PROBLEMS SMART criteria is being used to chose the topic for QA.SERIOUSNESSMEASUREABLEAPPROPRIATENESSREMEDIALTIMELINESS
73.POOR DETECTION RATE OF DIABETIC FOOT PROBLEMS AMONG DM PATIENT PRIORITISATION OF PROBLEM USING SMARTPROBLEMSSMARTSCORE1. HIGH PREVALENCE RATE OF LATE BOOKING AT KKIA1520852. HIGH DEFAULTER RATE AMONG ANTENATAL FOLLOW UP AT KKIA903.POOR DETECTION RATE OF DIABETIC FOOT PROBLEMS AMONG DM PATIENT1004. RATE OF BP CONTROL AMONG HPT PATIENTS755. HIGH NUMBER OF DEFAULTER RATE AMONG DM PT.SCALE OF WEIGHTAGE1=Not too important3= Important5= Most important2=Not important4= Very important
8VERIFICATION 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).
9INTRODUCTIONDiabetic 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.
10LITERATURE REVIEWRabia 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).
11In 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%.
12Reiber 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).
13Based 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)
14SERIOUSNESSFailure to diagnose diabetic foot problems OR early detection will lead to end point of foot complication which is foot amputation.
15MEASURABLESelection on cases and evaluation can be obtained from patient’s recordsKnowledge and skill of examination of staff can be assessed by observation and self administered questionnaire
16APPROPRIATENESS ABLE TO PERFORM STUDY AS KKM has Clinical Practice Guideline for Management of Diabetic Foot 2004Sufficient staff
17REMEDIABLE Staff to be trained about knowledge and skills and go for refresher coursesTo refresh staff knowledge by doing CMECME-Foot examination was done in September for nurses prior to data collectionCME-Foot examination was done in September to the nurses prior to data collection
18TIMELINESSTo prevent further complications of diabetic foot by early detection and diagnosis.
19Key measures for improvement 2Key measures for improvement
20GENERAL OBJECTIVETo increase detection rate of Diabetic Foot Problems among diabetic patient.To identify the cause of failure and to achieve higher detection rate
21SPECIFIC 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.
22INDICATOR & STANDARD INDICATORS FORMULA STANDARD % of Diabetic Foot Problems among diabetic patientsNumber of DM patients withAbnormal foot examination X 100Numbers of selected DM patients40%
23Definitions Diabetic foot problems (From ADCM 2009) Peripheral neuropathy- Disorder of nerves apart from brain & spinal damage to the nerve of peripheral nervous system.2. Peripheral vascular disease- peripheral arterial disease (PAD) or peripheral artery occlusive disease (PAOD)
24Definitions-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.
25Definitions4. 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.
26POOR DETECTION RATE OF DIABETIC FOOT PROBLEM POOR COMMUNICATIONLACK of SKILLPOOR ATTITUDELACK of KNOWLEDGEAMONG MEDICALSTAFFPOOR DOCUMENTATIONLOW REFERRANCE TO PROTOCOL/ CPGPOOR DETECTION RATE OF DIABETIC FOOT PROBLEM
27Factors influencing low detection of Diabetic Foot Problems Lack of knowledge of staffLack of skill on foot examinationPoor documentation
28Flow chart APPOINTMENT FOR FOOT ASSETMENT FOOT EXAMINATION DONE BY NURSESNORMALRESULTABNORMALDOCUMENTATION1 YEAR FOOT CARE APPREFFERAL TO DOCTORSTAKE ACTION ACCORDINGLYTCA 3 TO 6/12LY
29Foot Examination by trained staffs STANDARD100%MODEL OF GOOD CAREAppointment for foot assessmentFoot Examination by trained staffsNoDiagnosis of foot problemsYesDocumentation of examination findingsRefer to doctors for further managementEnd TCA 1yrTake Action to :-EducationOptimize Sugar controlTreatment of complicationsReferral to respective unitEnd TCA 3-6 month
30Process of Gathering Information 3Process of Gathering Information
31INCLUSION AND EXCLUSION CRITERIA INCLUSION CRITERIAAll Diabetic patientsEXCLUSION CRITERIADiabetic patient who is known to have Diabetic Foot Problems.Type I DMPregnant mother
32COLLECTION OF DATADiabetic patient will be given appointment date for foot care assessment during their follow upAppointment per day was 15 patients per sessionFoot care assessment is done on Monday and Friday morningDedicated staff will contact patients via phone a day prior to appointment15 staff involved (6 staff nurses and 9 Jururawat Masyarakat)All patient that came during the session will be taken as sample
33INTERVENTION TOOLS FOR IMPROVEMENT Diabetic Foot Assessment FormStaff’s observation on skillStaff’s knowledge questionnaire
34Diabetic Foot Assessment Form Staff’s observation on skillStaff’s knowledge questionnaire
51Strategy for change Problems identified during re evaluation 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.Poor documentation.Proper and correct documentation briefing done to all staff.
523. 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)
60ABNA 48% 17.5% DATA 1 BEFORE TRAINING DATA 2 AFTER TRAINING DATA 3 AFTER REMEDIAL ACTIONSTANDARD
61ConclusionThis 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
63NEXT STEPThe foot care assessment protocol had been implemented as routine annual foot care assessment at KK Kampung PandanOur aim in future to create protocols for diabetic foot management to the patients
64The format of clinical monitoring protocol can also be applied to improve detection of other diabetic complicationsThese implementation steps will be share with other clinics in JKWPKL in order to improve the rate of detection of diabetic foot problems
65GANTT CHART 2010 2011 Briefing & Training Data collection AUGSEPOCTNOVDECJANFEBMARAPRMAYJUNProposal & verificationBriefing & TrainingData collectionAnalysis of dataRemedial measures & ReevaluationReport writingPlanningExecution
66REFERRENCES World Health Organization – Diabetes Program me King LB. Impact of Preventive Programmer on Amputation Rates in the Diabetic population. J Wound Ostomy Continence Nurs 2008; 35:Pecoraro RE, Reiber GE, Burgess EM. Pathways to diabetic limb amputation: basis for prevention. Diabetes Care 1990; 13:4. 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).Erbas, Tomris, Ertas, Mustafa. Prevalence of Peripheral Neuropathy and Painful Peripheral Neuropathy in Turkish Diabetic Patients. Journal of Clinical Neurophysiology 2011; 28:
676. Akbar DH, Mushtaq MA, Alagmdi AA 6. Akbar DH, Mushtaq MA, Alagmdi AA. Inadequate screening for micro vascular complications among diabetic patients. Diabetes International 2001; 11(1): The third National health Morbidity Survey (NHMS) Diabetes Group. Ministry of Health Malaysia, Abbas ZG, Archibald LK. Challenge for management of diabetic foot in Africa: doing with more. International Wound Journal 2007; Clinical Practice Guideline. Management of Type 2 Diabetes Mellitus.4th edition Clinical Practice Guideline. Management of Diabetic Foot Rajna Ogrin. Foot assestment in patient with diabetes. Australian Family Physician 2006; 35(6)
69Soal selidik untuk kakitangan klinik kesihatan kampung pandan Nama : ___________________________________________________Jawatan : ___________________________________________________Semua pesakit kencing manis perlu menjalani pemeriksaan kaki sekurang-kurangnya setahun sekali (Ya/Tidak)Pesakit yang mempunyai komplikasi perlu disaring lebih kerap (3-6 bulan sekali) (Ya/Tidak)Pesakit yang ada ulser, jangkitan kuman dan gangrene perlu dirujuk segera kepada doktor (Ya/Tidak)Sewaktu pemeriksaan kaki, anda perlu membandingkan keadaan kedua-dua kaki (Ya/Tidak)Pemeriksaan sensori pada kaki menggunakan 5.07 Semmes-Weinstein monofilament (10gm)Wire (Ya/Tidak)5.07 Semmes-Weinstein monofilament (10gm) wire hendaklah ditukar selepas _____kali penggunaanPenggunaan vibration test hendaklah menggunakan Tunning-fork 250 hz (Ya/Tidak)Bacaan ABSI _______ adalah abnormal dan memerlukan rujukan doktor.Namakan dua pulses/nadi yang perlu diperiksa sewaktu pemeriksaan kakia) ____________________b) ____________________Nyatakan apakah komplikasi diabetes kepada kaki pesakit (5Jawapan)Kenalpasti dan nyatakan abnormality pada pemeriksaan kaki berikut. (10 gambar kaki pesakit)
70Staff observational sheet Yes / No1. Patient’s biodata (Name, date, contact number and I/C numbers) filled up2. Both lower limbs being compared.3. Proper technique of foot examination carried out as in the foot examination forma. Inspectionb. Nerve assessment c. Vascular assessment4. Correct tools being used5. Post examination diagnosis6. Patients were informed about the examination findings7. Abnormal findings-refer to doctors or not