Foot Assessment In Diabetes Mellitus Essays Example

Diabetes is recognized as a metabolic disorder that has the ability to cause high morbidity and mortality in the world. The World Health Organization (2006) noted that the prevalence of diabetes has been increasingly rapidly. This is especially in regard to type two diabetes, whose rates have increased in areas such as the Mediterranean region. The World Health Organization goes on to state that diabetes is the fourth most common death cause in this region. In Oman, diabetes ranks third when it comes to the causes of death. One of the assessments for diabetes is known as foot assessment (Ireland National Diabetes Program, 2011). Foot assessment is usually conducted with the intention of evaluating the risk of a patient so as to come up with a management plan that is effective (International Diabetes Federation, 2011). This assessment is usually carried out by a qualified person such as a general practitioner, a podiatrist or a well-trained diabetic physician or nurse (IDE, 2011).
The primary focus of this paper is on this foot assessment. The paper will particularly focus on the utilization of a monofilament when conducting foot assessment. The use of a monofilament is actually based on one of the guidelines of diabetes mellitus management (MOH, 2003). The paper aims to show a deficiency in the provision of this service. This will be done by conducting a mini audit. This mini audit was carried out at a Muscat health care center over a period of two days. This was done to evaluate both the level as well as the quality of care received by patients at this health care center. The audit was accompanied by a search and an analysis of current evidence and at the end of the audit, some recommendations for improvement of future practices were provided. According to Boulton (2008), a monofilament weighing about 10g is one of the instruments that can be used to detect the loss of senses in diabetic patients and this can then be extremely important in preventing complications that include foot ulceration.

Audit

According to the Research and Professional Development Organization (2012), a clinical audit is essentially a process that seeks to improve the quality and outcomes of patient care via a systematic review of current care practice against an explicit criteria accompanied by change implementation. Diabetes foot problem is fast becoming a prevalent health issue in Oman because of the enormous impact it has on diabetes patients. This audit was conducted on one of the health centers in Oman to establish if the health professionals working in this health center follow the policies and guidelines for diabetic foot assessment. The World Health Organization (2011), has postulated that patients with diabetes must have their feet checked for the diabetic foot diseases and should also be checked for other complications when diagnosis takes place. In addition, these patients must be examined for the same regularly after every three months or once a year. The first thing that was done in this case study was the identification of the mini-audit tool. The mentor then revised this tool. It is also important to note that permission was granted by the health center in carrying out the audit and, in addition, the entire process was supervised by the mentor. The criteria set for this audit was very specific. It stated that all patients with diabetes who are attendees of this health center or clinic should essentially be taken through a complete examination and assessment aimed at observing or detecting any foot problems. A monofilament should be used in every session to detect any diabetic related complications on the diagnosis day, and later at regular time intervals as dictated by the Ministry of health guidelines for diabetes mellitus primary health care (MOH, 2003). The official standard used in this audit was 95%, meaning that it was expected that not less than 95% of all the patients suffering from diabetes that visited this clinic would undergo foot assessment.
For purposes of convenience, a sample of 20 people suffering from type 2 diabetes and who visited the diabetic clinic over the course of the two days were included as participants. The focus of the audit was to observe if there was a carrying out of comprehensive foot assessment in this health center and to also observe the use of the monofilament in carrying out this assessment.

Results

Out of the total 20 patients who attended the clinic in the course of the two days for routine follow-up, about 80% of them were subjected to a full foot assessment and, in addition, a monofilament was used in these examinations. For the remaining 20%, they were not subjected to a complete foot assessment. It in fact emerged that there were varied reasons why some patients ultimately failed to undergo the foot assessment. One of the reasons for example was that some of the diabetic patients only came to the health center to collect medication. Others preferred to be assessed annually rather than on every visit. It also became clear in the course of conducting this audit that there were some staff members who lacked sufficient training and could therefore not carry out the foot assessments comprehensively.
In more general terms, the results from this audit seem to indicate that for most patients who made their way to the clinic, foot assessment was done on them including those who were on regular visits, initial assessments visits, as well as those, who were on their annual visits. An important thing to note and emphasize is that although the official standard set for foot assessment was not attained, a majority of the patients who were subjected to the assessment were actually those who had come for initial examination, or either for the annual or the regular follow up. It was also observed that there are other areas that could still be audited such as the particular assessment technique performed or the individuals who are supposed to carry out the assessment.

Discussion

The National Diabetes Education Program NDEP, (2000) suggests that people who are diabetic are actually more vulnerable to the development of neuropathic diseases. These diseases can cause life threatening health problems and complications that include diabetic foot ulcers that in the worst case scenario could lead to the amputation of one leg. Such complications inadvertently affect people’s quality of life and can also significantly affects families (National Health Services Diabetes, 2012). Diabetic foot ulcers are also considered to be a huge cause for both mortality and morbidity among people who suffer from diabetes across the world (Diabetes UL, 2012). People who suffer from diabetes face an increased risk of amputation than their counterparts who are not diabetic (Diabetes UK, 2012). Out of 10, 000 people who suffer from diabetes, 20 have their lower limbs amputated in England (NHS Diabetes, 2012). Additionally, the amputation rate is increasing even in country like Oman whereby its shown over 145 lower limb amputations which represent about 51.8% of all amputations actually happened to diabetes patients since between 2002 to 2003 and this rate was expected to increase in the coming decade.
According to Crawford et al., (2007), it is possible for foot complications to be totally prevented by comprehensive foot examination. Crawford et al., (2007) conducted a systematic review combined with meta-analysis that essentially reviewed eleven cohort studies and five case-control studies. The intention was to measure or assess the value of the diabetic foot assessment. The particular patients involved in this study were reviewed for four or three years. The main finding of this review is that all the studies agreed that when there is proper and comprehensive foot assessment accompanied by regularly follow up as well as professional education and training exercise, there was a general decline in foot ulcers incidences. In addition, all the studies claim that clinical guidelines usually advise early detection of foot risk, and this can be done by yearly foot assessment for all people who suffer from diabetes but consideration should be given to the level; of risk for each as well as the most appropriate interventions for every classification (Crowford, 2007).
According to Diabetes UK (2011), as much as 80% of foot complications related to diabetes can actually be prevented through the provision of comprehensive foot assessment and care accompanied by efficient health education. The American Diabetes Association ADA (2007) has also come up with the Standards of Care guidelines that further postulate that all individuals suffering from diabetes are supposed to go through a foot assessment in order to detect the presence of foot complications that may have disastrous effects such as ulcerations or even foot amputation (ADA, 2007). Additionally, the ADA recommends frequent assessment as well evaluation whenever any abnormalities are identified or detected. All this is also in line with the recommendation given by the National Diabetes Education Program which states the diabetes patients ought to be examined at regular intervals of between one to six months in order to evaluate the level of risk and if necessary, to put in place an action plan.
NICE (2004) states that there exists two specific complications related to diabetes and that have the ability to affect the feet. One of these complications is the one that affects the larger vessels in the body that supply blood to the lower limbs and that leads to poor circulation resulting in the development of foot ulcers (NICE, 2004). The second complication is referred to as neuropathy and is generally caused by nerve damage resulting in the loss of sensation in the patient’s feet. A microfilament should be used to assess these sensory problems and to also perform pedal pulse assessment as detection of vascular disease is also important according to the American Diabetes Association. Another crucial element of foot assessment is skin integrity and is thus a feature that should also be explored.
Peripheral neuropathy essentially leads to the loss of sensation in both of the patient’s feet and the use of a monofilament in carrying out foot examinations is extremely helpful in preventive intervention and can actually save a patient from potential foot amputation (Dros, 2009).
The importance of utilizing a microfilament in carrying out foot assessment to detect the presence of diabetic neuropathy was examined in a systematic review conducted by Feng (2009). This review involved more 30 articles selected from various article databases, and one of the things explored was the Semmes-Weinstein Monofilament Examination (SWME). The main conclusion from this systematic review is that the use of the monofilament plays a very crucial role in the prevention of foot amputation in the patient. However, Dros (2009) is of the opinion that the monofilament does not have adequate accuracy when it comes to the detection of peripheral diabetes neuropathy. This conclusion was arrived at after a systematic review of various studies that explore the importance and the role played by this vice (monofilament) in the assessment of diabetes neuropathy through the use of Quality Assessment of Diagnostic Accuracy Studies so as to evaluate the quality of the tool or method used for assessment. Ultimately, the conclusion from this study was that a monofilament should not be the only instrument that is given priority when it comes to detecting neuropathy as many guidelines seem to suggest.
Baker argues that patients should essentially receive proper explanations about the monofilament and its importance as well as the site of application.
The use of a monofilament in foot assessment and examinations is considered to be a low-cost method that also saves time as it can be used to examine a relatively large population. Baraz (2014) conducted a study seeking to establish the monofilament’s accuracy when used on different foot sites during neuropathy examination. The Semmes-Weinstein monofilament was used for this assessment. The results from this study seemed to indicate that there was significant sensitivity attached to using the monofilament across different sites, and a similar sensory perception was exhibited. The conclusion by Baraz (2014) was that the use of the Semmes-Weinstein monofilament is quite effective when it comes to the detection of sensory loss that leads to neuropathy in diabetes patients. It is however quite expensive. It is recommended that the monofilament is used when examining large groups of patients.
Although the Oman guidelines do not mention any specific risk classification when it comes to foot assessment, these guidelines just like many others explicitly state that diabetic patients must have a foot examination whenever they go to a clinic (MOH, 2003). There is also a general agreement across all guidelines that foot surveillance should be applied to all patients regardless of the classification and should be done at least once a year by a health care professional who is adequately trained.
The National Health Standards (2001) state that all health care personnel are supposed to collaborate in order to oversee the achievement of optimal care in all patients. A multidisciplinary team approach is often recommended as an efficient foot care strategy (NICE, 2011). Simply put, it is possible to prevent foot complications related to diabetes if there is a collaboration between different health personnel. In Oman, multidisciplinary team approaches are being implemented across various primary care settings with the aim of identifying and catering to the basic needs of people suffering from diabetes. Normally, the team is made of a health educator, a dietician, and a specially trained diabetic nurse.
Another key member of this multidisciplinary team is the community health nurse (NICE, 2004). She plays a major role in the prevention of foot complications related to diabetes (Holdich and Robert, 2012). The most obvious way of doing this is by availing regular assessment of the foot which also includes an assessment of foot sensations and skin and foot structure.
These community nurses are charged with the responsibility of providing education to diabetic patients about the basics of self-foot assessment as well as the preventive measures that can help in keeping the feet healthy (Fitzgerald and Rayan 2009).

Recommendations

At the end of this audit, several findings came out very clearly. First of all, it emerged that the optimal standards of 95% of patients having been subjected to feet assessment was not achieved. It is, therefore, imperative that different measures are immediately instituted in order to raise the percentage of diabetes patients who are subjected to feet assessment so as to improve the overall quality of care to patients suffering from diabetes. Additionally, the findings seem to indicate that many health care providers do not actually adhere to the guideline’s given by the ministry of health in relation to foot assessment in diabetes patients. These guidelines state that patients exhibiting signs of foot complications should be assessed and examined immediately followed by regular or annual examinations that utilize a monofilament as the examination tool since it is able to detect any symptoms and signs of peripheral neuropathy using it..
For purposes of improving health care services in the future, the recommendation is that a set of guidelines related to diabetic foot complications is developed in an evidence-based mode and that risk classification categories are utilized in the management and the referral pathways.
The other recommendation is that all patients are required to go through foot assessment regardless of the reason that brought them to a diabetic health in the first place. Additionally each health center should have more than one monofilament on standby if there is a tendency of more than ten patients visiting the clinic daily (NHS, 2008).
There are other areas that could be audited in future such as auditing of the people carrying out the foot assessments and their level of training, the tools and instruments used for carrying out the foot assessments, the management and referral pathway used to establish its effectiveness and so on. It is also shown that there is a shortage of qualified health personnel in health institutions who can carry out comprehensive foot examinations, and this impacts negatively on results and increases the risk of complications.

Conclusion

This paper brings forth a comprehensive and critical review of the current foot assessment performance. This has been done by considering evidence-based practice and examining weak areas in the provision of the service through a mini audit conducted in a primary health institution located in Muscat. Foot assessment is a crucial preventive measurement that is supported by evidence, and the monofilament is one of the most effective tools in carrying out this assessment and helps to indicate defects in aspects such as foot sensation. The foot assessment must be conducted on each visit to the health clinic by a diabetes patient for at least once a year. There is also a great need for the frequency and referral pathways to be based on guidelines that are evidence-based (NICE, 2004). Additionally, the prevention as well as the management of foot complications related to diabetes must be performed by specialized professional teams and a multidisciplinary team work approach should be adopted when it comes to disseminating diabetes services (Bakker et al., 2012). Community nurses are part of this team and play a crucial role in people empowerment, for example by educating people on self-foot surveillance and foot complications management. It is clear that foot complications is a huge threat to the globe that requires collaborations from different health stakeholders as well the assemblage of different resources in order to be eradicated.