An Ounce of Prevention Is Worth Two Feet

Peripheral neuropathy is a prevalent and complex complication of diabetes mellitus. Classically characterized by burning or tingling in the lower extremities, neuropathy can gradually lead to numbness and loss of sensation. Deprived of normal protective sensation, patients are unable to feel pain in the affected area. Minor insults such as cuts, burns, or foreign bodies can go unnoticed, resulting in ulcerative wounds or even amputation if left untreated. Systematic screenings, such as annual foot exams, are central to reducing diabetes-related complications. One key component of the foot exam, the 10-gram (g) monofilament test, specifically tests for loss of protective sensation.
At a large academic medical center, a family medicine clinic sought to increase the number of patients receiving timely diabetic foot exams. Historically, providers were responsible for initiating and completing the entire foot exam, including monofilament testing. This proved challenging within the time constraints of a short clinic visit. Additionally, the electronic medical record (EMR) did not alert staff when the annual exam was due. As a result, exams were not consistently performed. To address this care gap, a collaborative team developed a more efficient workflow. Utilizing the shared governance structure, this workflow was presented to and approved by the organization’s multidisciplinary ambulatory care practice council.
The primary workflow revision shifted the monofilament testing from the providers to the certified medical assistants. This was determined to be within the scope of non-licensed clinical staff because it involves data collection rather than clinical judgment. In addition to completing the monofilament test, medical assistants streamlined the exam process by removing patient footwear and initiating documentation prior to the provider entering the room. These efficiencies enabled providers to complete the foot exam within the timeframe of the office visit.
To ensure success, capabilities of the EMR were maximized. For example, to decrease the chance of inadvertent exam omission, a best practice alert was integrated into the EMR to prompt staff when a patient’s annual foot exam is due. After the medical assistant documented monofilament results on the flowsheet, the provider then received an alert prompting them to review the findings and complete the remaining components of the exam. Another EMR modification was a revision to the exam flowsheet, making it more comprehensive and user-friendly. Lastly, adding foot exams to the health maintenance record made previous exams more easily accessible for review.
In the three months prior to the workflow change, an average of 23 diabetic foot exams were completed monthly in the observed clinic. Since implementing the new workflow, the monthly exam average has skyrocketed to 105. These impressive results have spurred interest from other clinics to adopt the process and utilize medical assistants to their full scope. The results also showcase the immediate benefit of implementing best practice alerts for health maintenance items. Most importantly, by increasing the completion rate of annual comprehensive foot exams, fewer patients with diabetes will experience the devastating effects of undetected sensory loss that could lead to ulceration and amputation.