Reducing lower extremity amputation in high risk d

Reducing lower extremity amputation in high risk diabetic patients : 

Reducing lower extremity amputation in high risk diabetic patients A part of the Quality Initiatives of Course 537 BMI Presented By Group #2 (Building Bridges): Ebtissam Al-Madi Shaimaá Hussein Abd El-Ghani

Outline of Presentation : 

Outline of Presentation 1-Background a-Quality Problem b-Setting c-Mission Statement d-stakeholder 2-Aim statement General Goal 3-Conceptual Model 4-Measurement Focus 5-Change Hypothesis/Intervention 6-Evaluation/Feedback

QUALITY PROBLEM : 

QUALITY PROBLEM Reducing lower extremity amputation in high risk diabetic patients

QUALITY PROBLEM : 

QUALITY PROBLEM The total number of Americans with Diabetes is 20,800,000. >60% of non traumatic lower-limb amputations occur in people with diabetes.

QUALITY PROBLEM : 

QUALITY PROBLEM In 2004, about 71,000 non traumatic lower-limb amputations were performed in people with diabetes. Hospital admissions for lower extremity amputations in patients with diabetes is 5.6 per 1,000 population. National health care quality report 2004 : table No 1.26a

Slide 6: 

Total costs of diabetes 2002 $32 billion Annual costs for estimated 86,000 amputations is over $1.1 billion exclusive of rehabilitation, surgeons' fees, prosthesis, loss of productivity, and resultant disability payments.

QUALITY PROBLEM : 

QUALITY PROBLEM In our diabetes center- Hospital Lower extremity amputation in patients with diabetes is 6.2 per 1,000 population Hospital Clinical Archives 2008

Recommendations : 

Recommendations For all patients with diabetes, perform an annual comprehensive foot examination to identify risk factors predictive of ulcers and amputations. The foot examination can be accomplished in a primary care setting and should include the use of a monofilament, tuning fork, palpation, and a visual examination. Provide general foot self-care education to all patients with diabetes A multidisciplinary approach is recommended for individuals with foot ulcers and high-risk feet, especially those with a history of prior ulcer or amputation http://www.guideline.gov/summary/ summary.aspx?doc_id=12185&nbr=006282&string=complication+AND+diabetes#s23

Benefits : 

Benefits Reducing the number of lower extremity amputations will have several benefits according to the IOM initiatives: Effectiveness: Improved quality of life Elimination of cost in the form of rehabilitation, prostheses and disability Timeliness: - Early discovery of ulcerations can prevent further complications leading to need for amputation Efficient: In 2002, costs of diabetes totaled $132 billion, including about $92 billion in direct medical expenditure and about $40 billion in lost productivity and premature death NHRQ report 2004

Benefitsof Recommendation : 

Benefitsof Recommendation The overall rate of lower extremity amputations in adults with diagnosed diabetes fell from 5.5 per 1,000 population in 1999-2001 to 4.1 per 1,000 population in 2003-2005 from implementation of the recommendations. National health care quality report 2007

Current Implementation : 

Current Implementation 38 % of adult Hispanics age 40 and over with diabetes received three recommended annual screenings—foot exams, eye exams and blood sugar level checks (hemoglobin A1c test). 47 % for Caucasian 47 % for African American. Diabetes-Related Amputations Increase for Hispanics. AHRQ News and Numbers, March 21, 2008. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/nn/nn032108.htm

Slide 12: 

In our hospital, diabetic center, only 32% of all diabetic patients receive recommended annual screenings, which lack completed education and screening.

Mission statement : 

Mission statement Reduce lower extremity amputation as one of major complication of diabetes mellitus, in our diabetes center- Hospital

Priorities : 

Priorities Patients: Improved care, quality of life Physicians: Less surgeries, less complications Hospital: Less cost Community: Lower debilitation, lower cost of rehabilitation, and lower loss of manpower

Stakeholders : 

Stakeholders Hospital Administration Physicians Head of Quality Management Nurses Staff (booking & Registration) Patients

Team : 

Team Head of Diabetes Center Head of Quality Management Chief Nurse Head of Registration/booking Representative physician Representative nurse

AIMS STATEMENT Reduce lower extremity amputation as one of major complication of diabetes mellitus, in our diabetes center- Hospital., from current 6.2 per 1,000 population (in 2008), to 4 per 1,000 population during the year 2009, through increasing of annual exams by 25% of diabetic patients in hospital (from 32% to 57%). : 

AIMS STATEMENT Reduce lower extremity amputation as one of major complication of diabetes mellitus, in our diabetes center- Hospital., from current 6.2 per 1,000 population (in 2008), to 4 per 1,000 population during the year 2009, through increasing of annual exams by 25% of diabetic patients in hospital (from 32% to 57%).

Our GOAL : 

Our GOAL S: Reduce lower extremity amputation M: from 6.2/1000 to 4/1000 amputations from 32% annual exams to 57% annual exams A: Thru implementations of Guidelines of NHRQ R: improving patient’s health care quality T: Within 1 year (2009)

CONCEPTUAL MODELS : 

CONCEPTUAL MODELS Reducing lower extremity amputation in high risk diabetic patients

Tools to use and implement : 

Tools to use and implement Establishment of flowchart of Patient flow from entry to diabetes center There is no current flowchart Fishbone diagram of causes of failure to implement guidelines

Our suggested flowchart : 

Our suggested flowchart

Why does failure happen? : 

Why does failure happen?

MEASUREMENTS : 

MEASUREMENTS Number of patients that were assessed as high risk patients as a process measurement (a process) Number of patients that were attribute to amputation surgery as outcome measurement( an outcome)

Measurement Grid : 

Measurement Grid

Validity and reliability of measures : 

Validity and reliability of measures Importance: Assessing diabetic patients for risk status during an annual foot examination would prevent many lower extremity amputations. Impact: With proper care and annual examination, perhaps up to 50% of amputation in diabetics can be avoided Feasible: These measures can be easily performed in the diabetic center during foot examination Scientific acceptability: ACFAS (American college of foot and ankle surgeon) recommends annual foot examination & ADA guidelines . Usability: Annual foot exam and assessing high risk patients has shown to be effective in diagnosing these patients and providing them with proper management plan .

CHANGE HYPOTHESIS : 

CHANGE HYPOTHESIS

Intervention specification : 

Intervention specification Promotion of self management Patients with diabetes need support as well as information to be effective managers of their health. train provider on how they can help patients in achieving self management goals.

Intervention specification : 

Intervention specification Delivery system design : Clinician knowledge of principal guidelines and awareness of the specific recommendations for foot care in diabetics. Clinician up-dated information about patients' status by determining responsible persons for each step in planned visits, commencing from registration and ending by the end-care provider. Assignment of staff responsible for follow up visits and determination of the follow up approach (who will contact patients and when)

Intervention specification : 

Intervention specification Decision Support Integrating annual foot exams into the routine care of diabetes patients as a reminder Review of guidelines and hold meetings with specialists for involvement in guideline selection and implementation. Benchmark with other organizations that have already implemented guidelines into their system Use of flow sheets to implement guidelines into daily practice.

Will it work in our setting? : 

Will it work in our setting? Hurdles to overcome: Customization and selection of practice guidelines to suit our environment and our culture Resistance from Hospital administration, Physicians and specialists Financial support will be needed to maintain our intervention.

Evaluation of our success : 

Evaluation of our success Evaluation measures : Providers are educating patients in performing self management and providing support activities Rates of provider adherence to guidelines Patient health outcome Health Care costs Patients’ awareness and knowledge

Evaluation of our success : 

Evaluation of our success Measurement Method? Patients’ survey (measure of patient awareness) Foot care behavior: patient self report chart Determination of self care activities

Evaluation of our success : 

Evaluation of our success 3. Health care costs: Hospital admission Hospital days Length of stay Amputation surgery Readmission to hospital

Capturing error introduced : 

Capturing error introduced Materials: May not suit patient’s education or culture May be too long. Staff: May need more training or workshops.

Our next steps : 

Our next steps Emphasize the importance of scientifically accepted, feasible and usable measurements. Access and benchmark with successful improvement stories of other health care organizations that have a similar environment Customization of measurements and small scale assessment, then wide-scale implementation.

Our trial : 

Our trial Over a period of 2 years (24 months), we measured: Number of patients with diabetes and no previous amputation High risk patients Patients receiving amputations These measurements were taken for a period of 12 months before the intervention, and 12 months after.

C chart -2 bell curves, before and after intervention. : 

C chart -2 bell curves, before and after intervention.

Conclusion : 

Conclusion Before the intervention, an average of 18.92 amputations were done per 400 population (4.7%) with a non normal distribution and a variance (sd=19.41) After the intervention, there was an average of 18.85 amputations per 400 population (4.7%), but with a normal distribution and small variance (sd=4.34). The last 5 measurements showed a downward trend (reduced number of amputations), therefore, further evaluation is warranted with the same intervention to evaluate whether this trend is stable and the intervention is effective.

References : 

References 1-http://diabetes.niddk.nih.gov/DM/PUBS/statistics/ www.guideline.gov 2- http://www.ahrq.gov/qual/measurix.htm 3-http://www.ahrq.gov/news/nn/nn032108.htm 4-.Cost-Effectiveness of Prevention and Treatment of the Diabetic Foot :Monica Maria Ortegon, MD1,2, William Ken Redekop, PHD2 and Louis Wilhelmus Niessen, PHD2. 2004 by the American Diabetes Association. 5- Netherlands Institute of Health Sciences, Erasmus University, Rotterdam, the Netherlands2 Institute for Medical Technology Assessment, Erasmus University, Rotterdam, the Netherland 6-Institute health improvement