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Measuring the process and outcomes of foot ulcer care with guidelinebased nursing quality indicators

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Abstract

The Nursing Quality Indicators for Reporting and Evaluation (NQuIRE) initiative at the Registered Nurses’ Association of Ontario (RNAO) is an international database of quality indicators measuring the structure, processes and outcomes of evidence-based nursing practice. The indicators are derived from RNAO best practice guidelines (BPG) to monitor and evaluate the impact of guideline implementation on nursing practice and patient outcomes. Participation in NQuIRE is a program requirement for service and academic organizations in the RNAO Best Practice Spotlight Organization© (BPSO©) Designation. As part of the development of RNAO’s second edition of the Assessment and Management of Foot Ulcers for People with Diabetes (2013) clinical practice guideline, six quality indicators related to the assessment of ulcers, patient education, monitoring of ulcer healing and use of offloading devices were developed. These indicators enable BPSOs to demonstrate the contribution of evidence-based nursing practice in delivering quality care and optimizing health outcomes for people with diabetes.

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Objectives Diabetic foot ulcer (DFU), a serious complication of diabetes, is associated with increased morbidity and mortality and presents a substantial socioeconomic burden. However, DFU quality of care has been insufficiently studied. Therefore, the aim of this study was to evaluate the quality of DFU care at an interdisciplinary wound care clinic in Canada, based on an extended Donabedian model: structure, process and outcome quality indicators combined with patient characteristics. Methods This was a retrospective cohort study of 140 adult patients with diabetes who were treated between 2012 and 2018 at a wound care clinic in a university-affiliated hospital in the Québec City area of Canada. Twenty-two internationally recognized quality-of-care indicators were identified from the literature. Data were collected from medical files, and the results were used to document the selected quality-of-care indicators. Results The principal indicators regarding structure and process were met, and outcome indicators were influenced by study population characteristics, particularly peripheral artery disease and critical limb ischemia. Moreover, this study highlights that quality-of-care indicators are essential when evaluating DFU outcomes, as structure and process indicators can also affect wound healing outcomes. Conclusions This study suggests that DFU care at a Canadian wound care clinic, with an interdisciplinary approach, meets most quality-of-care indicators. The socioeconomic burden of DFUs for patients, health-care organizations and policymakers, and the paucity of quality and performance evaluations, call for more studies evaluating DFU care.
Article
A comprehensive data quality assessment is necessary to expand a nursing database that is designed for evaluating the impact of implementing Best Practice Guidelines (BPG) developed by the Registered Nurses' Association of Ontario (RNAO). This case report presents a method to standardize data quality assessments of the Nursing Quality Indicators for Reporting and Evaluation (NQuIRE) database by developing a data quality framework (DQF) and assessing key dimensions of the framework using a data quality index (DQI). The data quality index is a single key performance metric for assessing the quality of the database. The aims of sharing this case report are 2-fold: (1) to promote best practices for assessing data quality by developing and implementing a data quality framework and (2) to demonstrate an unprecedented method of assessing the data quality of a nursing database.
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Background Improved blood-glucose control decreases the progression of diabetic microvascular disease, but the effect on macrovascular complications is unknown. There is concern that sulphonylureas may increase cardiovascular mortality in patients with type 2 diabetes and that high insulin concentrations may enhance atheroma formation. We compared the effects of intensive blood-glucose control with either sulphonylurea or insulin and conventional treatment on the risk of microvascular and macrovascular complications in patients with type 2 diabetes in a randomised controlled trial. Methods 3867 newly diagnosed patients with type 2 diabetes, median age 54 years (IQR 48-60 years), who after 3 months' diet treatment had a mean of two fasting plasma glucose (FPG) concentrations of 6.1-15.0 mmol/L were randomly assigned intensive policy with a sulphonylurea (chlorpropamide, glibenclamide, or. glipizide) or with insulin, or conventional policy with diet. The aim in the intensive group was FPG less than 6 mmol/L. in the conventional group, the aim was the best achievable FPG with diet atone; drugs were added only if there were hyperglycaemic symptoms or FPG greater than 15 mmol/L. Three aggregate endpoints were used to assess differences between conventional and intensive treatment: any diabetes-related endpoint (sudden death, death from hyperglycaemia or hypoglycaemia, fatal or non-fatal myocardial infarction, angina, heart failure, stroke, renal failure, amputation [of at least one digit], vitreous haemorrhage, retinopathy requiring photocoagulation, blindness in one eye,or cataract extraction); diabetes-related death (death from myocardial infarction, stroke, peripheral vascular disease, renal disease, hyperglycaemia or hypoglycaemia, and sudden death); all-cause mortality. Single clinical endpoints and surrogate subclinical endpoints were also assessed. All analyses were by intention to treat and frequency of hypoglycaemia was also analysed by actual therapy. Findings Over 10 years, haemoglobin A(1c) (HbA(1c)) was 7.0% (6.2-8.2) in the intensive group compared with 7.9% (6.9-8.8) in the conventional group-an 11% reduction. There was no difference in HbA(1c) among agents in the intensive group. Compared with the conventional group, the risk in the intensive group was 12% lower (95% CI 1-21, p=0.029) for any diabetes-related endpoint; 10% lower (-11 to 27, p=0.34) for any diabetes-related death; and 6% lower (-10 to 20, p=0.44) for all-cause mortality. Most of the risk reduction in the any diabetes-related aggregate endpoint was due to a 25% risk reduction (7-40, p=0.0099) in microvascular endpoints, including the need for retinal photocoagulation. There was no difference for any of the three aggregate endpoints the three intensive agents (chlorpropamide, glibenclamide, or insulin). Patients in the intensive group had more hypoglycaemic episodes than those in the conventional group on both types of analysis (both p<0.0001). The rates of major hypoglycaemic episodes per year were 0.7% with conventional treatment, 1.0% with chlorpropamide, 1.4% with glibenclamide, and 1.8% with insulin. Weight gain was significantly higher in the intensive group (mean 2.9 kg) than in the conventional group (p<0.001), and patients assigned insulin had a greater gain in weight (4.0 kg) than those assigned chlorpropamide (2.6 kg) or glibenclamide (1.7 kg). Interpretation Intensive blood-glucose control by either sulphonylureas or insulin substantially decreases the risk of microvascular complications, but not macrovascular disease, in patients with type 2 diabetes. None of the individual drugs had an adverse effect on cardiovascular outcomes. All intensive treatment increased the risk of hypoglycaemia.
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To assess the ability of the 4-week healing rate to predict complete healing over a 12-week period in a large prospective multicenter trial of diabetic patients with foot ulceration. We examined the change in ulcer area over a 4-week period as a predictor of wound healing within 12 weeks in patients who were seen weekly in a prospective, randomized controlled trial. Wound area measurements at baseline and after 4 weeks were performed in 203 patients. The midpoint between the percentage area reduction from baseline at 4 weeks in patients healed versus those not healed at 12 weeks was found to be 53%. Subjects with a reduction in ulcer area greater than the 4-week median had a 12-week healing rate of 58%, whereas those with reduction in ulcer area less than the 4-week median had a healing rate of only 9% (P < 0.01). The absolute change in ulcer area at 4 weeks was significantly greater in healers versus nonhealers (1.5 vs. 0.8 cm(2), P < 0.02). The percent change in wound area at 4 weeks in those who healed was 82% (95% CI 70-94), whereas in those who failed to heal, the percent change in wound area was 25% (15-35; P < 0.001). The percent change in foot ulcer area after 4 weeks of observation is a robust predictor of healing at 12 weeks. This simple tool may serve as a pivotal clinical decision point in the care of diabetic foot ulcers for early identification of patients who may not respond to standard care and may need additional treatment.
Article
Diabetic foot and venous leg ulcers result in severe personal suffering, leading to costly healthcare in the billions of dollars. Recent advances in wound treatment and the development of new and innovative products can accelerate the healing of these ulcers. Therefore, it has become increasingly important to identify those ulcers that are not going to respond to conventional, standard care. Results from several studies demonstrate the potential of initial wound healing rates as predictive indicators of eventual healing and clinical outcomes in diabetic foot and venous leg ulcers. The use of initial wound healing rates can lead to a more timely and cost-effective intervention with new and effective approaches.
Article
Background: Ulceration of the feet, which can result in loss of limbs and even death, is one of the major health problems for people with diabetes mellitus. Objectives: To assess the effectiveness of patient education on the prevention of foot ulcers in patients with diabetes mellitus. Search strategy: Eligible studies were identified by searching the Cochrane Wounds Group Specialised Register, (September 2004) and the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 3, 2004). Selection criteria: Prospective randomised controlled trials (RCTs) which evaluated educational programmes for the prevention of foot ulcers in people with diabetes mellitus. There was no restriction on language of the publications. Data collection and analysis: Two reviewers undertook data extraction and assessment of study quality independently. Main results: Nine RCTs were included. Four trials compared the effect of intensive with brief educational interventions; two of these reported clinical endpoints. One study involving high-risk patients reported a reduction in ulcer incidence (Peto OR: 0.28 (95% CI 0.13 - 0.59)) and amputation rate (Peto OR: 0.32 (95% CI 0.14 - 0.71)) after one year. The other RCT did not find an effect at seven years follow-up. Participants' foot care knowledge significantly improved with education in two trials. In one trial foot care knowledge improved significantly in the control group, in contrast to the intervention group. Non-calcaneal callus was significantly reduced by education in one trial. One RCT did not find that patient foot care education, as part of a general diabetes education program, reduced foot ulceration compared with usual care. Patient education as part of a complex intervention, targeted at both people with diabetes and doctors, reduced the number of serious foot lesions at one year in one RCT (OR: 0.41(95% CI 0.16 -1.00)) and improved foot care behaviour. Evidence from three RCTs comparing the effect of patient-tailored education in addition to usual care was conflicting.The methodological quality of the nine included RCTs was poor. The internal validity score (range 0 - 10) of individual RCTs ranged from 2 to 5. Authors' conclusions: RCTs evaluating education for people with diabetes, aimed at preventing diabetic foot ulceration, are mostly of poor methodological quality. Weak evidence suggests that patient education may reduce foot ulceration and amputations, especially in high-risk patients. Foot care knowledge and behaviour of patients seem positively influenced by patient education in the short term. Because of conflicting results and the methodological shortcomings more RCTs are needed.
Article
The aim of this qualitative study was to explore nurses' perceptions regarding the implementation of a best practice guideline (BPG) on the assessment and management of foot ulcers for people with diabetes. Fourteen nurses from a community care setting and three hemodialysis units participated in five focus groups and one individual interview. The findings focus on key points regarding the impact of BPG implementation in the areas of patient outcomes, nursing practice, and interdisciplinary teamwork.
Article
Background: Ulceration of the feet, which can result in loss of limbs and even death, is one of the major health problems for people with diabetes mellitus. Objectives: To assess the effects of patient education on the prevention of foot ulcers in patients with diabetes mellitus. Search methods: We searched The Cochrane Wounds Group Specialised Register (searched 03 September 2014); The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2014, Issue 8). Selection criteria: Prospective randomised controlled trials (RCTs) that evaluated educational programmes for preventing foot ulcers in people with diabetes mellitus. Data collection and analysis: Two review authors independently undertook data extraction and assessment of risk of bias. Primary end points were foot ulceration or ulcer recurrence and amputation. Main results: Of the 12 RCTs included, the effect of patient education on primary end points was reported in only five. Pooling of outcome data was precluded by marked, mainly clinical, heterogeneity. One of the RCTs showed reduced incidence of foot ulceration (risk ratio (RR) 0.31, 95% confidence interval (CI) 0.14 to 0.66) and amputation (RR 0.33, 95% CI 0.15 to 0.76) during one-year follow-up of diabetes patients at high risk of foot ulceration after a one-hour group education session. However, one similar study, with lower risk of bias, did not confirm this finding (RR amputation 0.98, 95% CI 0.41 to 2.34; RR ulceration 1.00, 95% CI 0.70 to 1.44). Three other studies, also did not demonstrate any effect of education on the primary end points, but were most likely underpowered. Patients' foot care knowledge was improved in the short term in five of eight RCTs in which this outcome was assessed, as was patients' self-reported self-care behaviour in the short term in seven of nine RCTs. Callus, nail problems and fungal infections improved in only one of five RCTs. Only one of the included RCTs was at low risk of bias. Authors' conclusions: In some trials, foot care knowledge and self reported patient behaviour seem to be positively influenced by education in the short term. Yet, based on the only two sufficiently powered studies reporting the effect of patient education on primary end points, we conclude that there is insufficient robust evidence that limited patient education alone is effective in achieving clinically relevant reductions in ulcer and amputation incidence.
Article
We assessed the value of the medical history and physical examination in the diagnosis of peripheral vascular disease in diabetic subjects. We performed a cross-sectional study in 631 diabetic veteran enrollees of a general internal medicine clinic that compared data obtained from a history and clinical evaluation with the presence of severe peripheral vascular disease defined as an ankle-arm index (AAI) < or = 0.5 derived from Doppler blood pressure measurement. We identified 90 limbs with an AAI < or = 0.5. Results presented below apply to the right leg, but do not differ from the left. Diminished or absent foot peripheral pulses (sensitivity 65%, specificity 78%), venous filling time > 20 sec (sensitivity 22%, specificity 93.9%), age > 65 years (sensitivity 83%, specificity 54%), claudication symptoms in < 1 block (sensitivity 50%, specificity 87%), and patient reported history of physician diagnosed peripheral vascular disease (PVD) (sensitivity 80%, specificity 70%) had the largest positive (or smallest negative) likelihood ratios. Capillary refill time > 5 sec or foot characteristics (absent hair, blue/purple color, skin coolness, or atrophy) conveyed little diagnostic information. Individual factors did not change disease probability to a clinically important degree. A stepwise logistic regression model identified four factors significantly (p < 0.05) associated with low AAI: absent or diminished peripheral pulses, patient reported history of PVD, age, and venous filling time. Substitution of < 1 block claudication for PVD history in this model resulted in a small reduction in model accuracy. Many purportedly useful historical and exam findings need not be elicited in diabetic patients suspected of having severe peripheral vascular disease, since most information related to probability of this disorder may be obtained from patient age, self-reported history of physician diagnosed PVD (or < 1 block claudication), peripheral pulse palpation, and venous filling time.
Article
Best practice guidelines, although a recent phenomenon, have become a global movement in nursing. Scholars, practitioners, healthcare organizations, governments and the nursing associations have a unique opportunity to enhance quality and demonstrate joint accountability to patients, the healthcare system and the public as a whole. This article offers insight into the Registered Nurses Association of Ontario (RNAO) Nursing Best Practice Guidelines Project. Funded as a multi-year project by the Ministry of Health and Long-Term Care in 1999, the RNAO project is leading nursing's best practice guideline movement in Canada and reaching others abroad.
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