1. KLINIK KESIHATAN KAMPUNG PANDAN
QA STUDY 2011

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

3. TEAM MEMBERS DR. SAMURAH A RAHMAN DR. PREMINI A/P GANESPATHY
DR. IBRAHIM AHMAD FUAD
S/N MOLINA

4. 1
Outline of Problems

5. PROBLEMS IDENTIFIED IN THE CLINIC
HIGH PREVALENCE RATE OF LATE BOOKING ATTENDING KKIA
HIGH DEFAULTER RATE AMONG ANTENATAL FOLLOW UP AT KKIA
POOR DETECTION RATE OF DIABETIC FOOT PROBLEMS AMONG DM PATIENTS
POOR RATE OF BP CONTROL AMONG HPT PATIENTS
HIGH NUMBER OF DEFAULTER RATE AMONG DM PATIENTS

6. PRIORITISATION OF PROBLEMS
SMART criteria is being used to chose the topic for QA.
SERIOUSNESS
MEASUREABLE
APPROPRIATENESS
REMEDIAL
TIMELINESS

7. 3.POOR DETECTION RATE OF DIABETIC FOOT PROBLEMS AMONG DM PATIENT
PRIORITISATION OF PROBLEM USING SMART
PROBLEMS S M A R T
SCORE
1. HIGH PREVALENCE RATE OF LATE BOOKING AT KKIA 15 20 85
2. HIGH DEFAULTER RATE AMONG ANTENATAL FOLLOW UP AT KKIA 90
3.POOR DETECTION RATE OF DIABETIC FOOT PROBLEMS AMONG DM PATIENT
100
4. RATE OF BP CONTROL AMONG HPT PATIENTS 75
5. HIGH NUMBER OF DEFAULTER RATE AMONG DM PT.
SCALE OF WEIGHTAGE
1=Not too important
3= Important
5= Most important
2=Not important
4= Very important

8. VERIFICATION STUDY
Data 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).

9. INTRODUCTION
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.

10. LITERATURE 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).

11. 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%.

12. 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).

13. 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)

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

15. MEASURABLE
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

16. APPROPRIATENESS ABLE TO PERFORM STUDY AS
KKM has Clinical Practice Guideline for Management of Diabetic Foot 2004
Sufficient staff

17. REMEDIABLE 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

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

19. Key measures for improvement2
Key measures for improvement

20. GENERAL OBJECTIVE
To increase detection rate of Diabetic Foot Problems among diabetic patient.
To identify the cause of failure and to achieve higher detection rate

21. SPECIFIC OBJECTIVES
To 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.

22. INDICATOR & STANDARD INDICATORS FORMULA STANDARD
% of Diabetic Foot Problems among diabetic patients
Number of DM patients with
Abnormal foot examination X 100
Numbers of selected DM patients
40%

23. Definitions 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)

24. Definitions
-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.

25. Definitions
4. 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.

26. POOR DETECTION RATE OF DIABETIC FOOT PROBLEM
POOR COMMUNICATION
LACK of SKILL
POOR ATTITUDE
LACK of KNOWLEDGE
AMONG MEDICAL
STAFF
POOR DOCUMENTATION
LOW REFERRANCE TO PROTOCOL/ CPG
POOR DETECTION RATE OF DIABETIC FOOT PROBLEM

27. Factors influencing low detection of Diabetic Foot Problems
Lack of knowledge of staff
Lack of skill on foot examination
Poor documentation

28. Flow chart APPOINTMENT FOR FOOT ASSETMENT
FOOT EXAMINATION DONE BY NURSES
NORMAL
RESULT
ABNORMAL
DOCUMENTATION
1 YEAR FOOT CARE APP
REFFERAL TO DOCTORS
TAKE ACTION ACCORDINGLY
TCA 3 TO 6/12LY

29. Foot Examination by trained staffs
STANDARD
100%
MODEL OF GOOD CARE
Appointment for foot assessment
Foot Examination by trained staffs No
Diagnosis of foot problems
Yes
Documentation of examination findings
Refer to doctors for further management
End TCA 1yr
Take Action to :-
Education
Optimize Sugar control
Treatment of complications
Referral to respective unit
End TCA 3-6 month

30. Process of Gathering Information3
Process of Gathering Information

31. INCLUSION AND EXCLUSION CRITERIA
INCLUSION CRITERIA
All Diabetic patients
EXCLUSION CRITERIA
Diabetic patient who is known to have Diabetic Foot Problems.
Type I DM
Pregnant mother

32. 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

33. INTERVENTION TOOLS FOR IMPROVEMENT
Diabetic Foot Assessment Form
Staff’s observation on skill
Staff’s knowledge questionnaire

34. Diabetic Foot Assessment Form
Staff’s observation on skill
Staff’s knowledge questionnaire

36. Diagnosis post examination
Based on ADCM study diagnosis categorized into 5 category
a. Peripheral neuropathy
b. Peripheral vascular disease
c. Foot deformity
d. Foot ulcer
e. Amputation

37. Instruments Neurotip Cotton bud Tuning fork 128hz
5.07 Semmes-Weinstein monofilamant
Tendon Hammer

38. Doppler and sphygmomanometer

42. Diabetic foot album

45. Analysis and Interpretation4
Analysis and Interpretation

46. Result (From 4/10/ /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%)

47. Amputation : 2 patient (0.4%)
Total abnormal foot findings 163 patients (24%)

48. ABNA 17.5% STANDARD SET AT 40% DATA 1 BEFORE TRAINING
DATA 2 AFTER TRAINING
STANDARD

49. This study had not achieved its own standard of detection: 40% detection of diabetic foot problems.
Thus, reevaluation and remedial action were done

50. 5
Strategies for Change

51. Strategy 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.

52. 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)

53. 6
Effects of Change

54. Analysis result post remedial action taken from 20.5.2011 until 18.8.2011

55. Staff knowledge
Pre remedial action
Post remedial action

56. Correct examination technique

58. Result: Detection of diabetic foot problems (20.5.2011-18.8.2011)
Total : 261 patients Peripheral 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%)

60. ABNA 48% 17.5% DATA 1 BEFORE TRAINING DATA 2 AFTER TRAINING DATA 3
AFTER REMEDIAL ACTION
STANDARD

61. 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

62. 7
The Next Step

63. NEXT 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

64. 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

65. GANTT CHART 2010 2011 Briefing & Training Data collection
AUG
SEP
OCT
NOV
DEC
JAN
FEB
MAR
APR
MAY
JUN
Proposal & verification
Briefing & Training
Data collection
Analysis of data
Remedial measures & Reevaluation
Report writing
Planning
Execution

66. REFERRENCES 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:

67. 6. 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)

68. THANK YOU…

69. Soal 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 penggunaan
Penggunaan 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 kaki
a) ____________________
b) ____________________
Nyatakan apakah komplikasi diabetes kepada kaki pesakit  (5Jawapan)
Kenalpasti dan nyatakan abnormality pada pemeriksaan kaki berikut. (10 gambar kaki pesakit)

70. 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. Inspection
b. Nerve assessment c. 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