Evidenced Based Health Practice: - PowerPoint Presentation

Slide1

Evidenced Based Health Practice: PICO Presentation

By: Anna Ingersoll, RNSlide2

PICO QuestionIn patients with diabetes, does taking ones foot temperature daily,

compared to not checking a daily foot temperature, reduce the incidence rate of diabetic ulcer

formation??P- diabetic patientsI- daily foot temperatureC- no daily foot temperatureO- reduce the incidence rate of diabetic ulcer formation

vsSlide3

Literature ResultsKey words;

diabetic ulcer formation, ulcer prevention, diabetic daily skin assessment, diabetic skin breakdown, checking foot temperatures in diabetic patients, reducing diabetic ulcer formation

Search Engine: PubmedFinal Search: “effectiveness of daily skin assessment on diabetic feet”Slide4

Research Articles

# 1- Armstrong, D., Holtz-Neiderer, K., Wendel

, C., Mohler, J., Kimbriel, H., & Lavery, L. (2007). Skin Temperature Monitoring Reduces the Risk for Diabetic Foot Ulceration in High-risk Patients. The American Journal of Medicine, 120(12)1042-1046. doi: 10.1016/j.amjmed.2007.06.028

# 2-

Lavery

, L., Higgins, K.,

Lanctot, D., Constantinides, G.,

Zamorano, R., Athanasiou, K., Armstrong, D., & Agrawal, C. (2007). Preventing Diabetic Foot Ulcer Recurrence in High-Risk Patients. American Diabetes Association Diabetes Care, 30 (1) 14-20. doi: 10.1016/j.amjmed.2007.06.028Slide5

Evaluation of ArticlesBoth articles contain

quantitative research. Both

articles involved individuals diagnosed with diabetes who are participating in daily temperature monitoring of feet by using a specific thermometer.Both articles used the intervention of taking ones foot temperature in multiple spots.Slide6

Evaluation of Article # 1

Theory: The objective of this study was

to evaluate the effectiveness of home temperature monitoring to reduce the incidence of foot ulcers in high-risk diabetic patients.Type of Study: QuantitativeDesign: physician-blinded, randomized controlled trial

Methods:

There were 225 diabetic subjects for this trial. They were divided up into two groups; one group was the Standard Therapy Group and the second was the Dermal Thermometry Group. Both groups received therapeutic footwear, diabetic foot education, regular foot care, and performed a structured foot inspection daily. The difference being that the second group used an infrared skin thermometer to measure temperatures on 6 foot sites twice daily. Those with greater than a 4 degree difference from left to right side would told to contact the study nurse to report these findings and reduce activity until temperatures were normal.

Findings:

A total of 8.4% subjects had ulcer formation over the study period. Those in the Standard Therapy Group were 2/3 likely to ulcerate, whereas the Dermal Group was only 1/3 likely.Slide7

Evaluation of Article # 2

Theory: The study was to evaluate the effectiveness of a temperature monitoring instrument to reduce the incidence of foot ulcers.

Type of Study: QuantitativeDesign: physician-blinded, randomized multicenter trialMethods:

There were

173 subjects who were divided into two categories of: standard therapy/structured foot examination, or enhanced therapy groups. Each group received proper footwear, diabetic foot education and regular foot care. Subjects in the structured group performed a specific foot exam daily and recorded their findings. Subjects in the enhanced group used an infrared skin thermometer to measure each foots temperature daily using six access points. Each group were given specific instructions when to contact the study nurse.

Findings:

Subjects in the enhanced group had fewer foot ulcers then the standard group/structured foot group (8.5% compared to 29.3%) Meaning that those in the standard/structured group were 1.5 times more likely to develop an ulcer.Slide8

Ethical ConsiderationsStudy

1- While it was expected that all subjects would use the thermometer twice daily, there was no indication as to whether all participants were strict with this. Also, it was expected that all subjects would test 6 different areas on their foot and there was no indication as to whether this was strictly followed.

Study 2- For those subjects in the standard group, whose incidence risk was much higher then the enhanced group, there was no indication how group 1 did with their daily foot assessment. If a patient(s) were to not complete their daily assessment, this could increase the risk from lack of care rather then what instrument was used or not used.Slide9

Criteria for Study # 1

Strength:

Randomization and blinding procedures. All participants had equal conditions regarding instructions, education and proper foot wear. The study was conducted in the participant’s natural environment.Quality:

There was some possibility of bias. P

articipants

’ personal opinions,

both negative

or positive, towards strict instructions of using the thermometer twice daily in 6 different spots, may have influenced the results. It was also impossible to make sure participants used the thermometer correctly at all times

.Credibility: This article was published in The American Journal of Medicine, which is a credible journal along with the benefit of being a peer reviewed journal.

Does study make a contribution to EBP?

Yes, this study

demonstrates that daily interventions amongst the diabetic population is important to help reduce the incidence rate of diabetic ulcer formation. It

indicates that

the subjects found temperature monitoring to

be beneficial. It indicates that education and assistance with

obtaining equipment as this would be beneficial for one’s health

which correlates to

healthier living.Slide10

Criteria for Study # 2

Strength:

Randomization and blinding procedures. All participants had equal conditions regarding instructions, education and proper foot wear. The study was conducted in the participant’s natural environment.Quality:

There was some possibility of bias. P

articipants

’ personal opinions,

both negative

or positive, towards strict instructions of using the thermometer daily in 6 different spots, may have influenced the results if they did not follow these strict guidelines. It was also impossible to make sure participants

in group 2 used the thermometer correctly at all times and that participants in group 1 followed the strict foot exam designated to them.Credibility: This article was published in The American Diabetes Association

,

which is

peer reviewed and a credible organization.

Does study make a contribution to EBP?

Yes, this study

demonstrates that daily interventions amongst the diabetic population is important to help reduce the incidence rate of diabetic ulcer formation. It

indicates that

the subjects found temperature monitoring to

be beneficial. It indicates that

continued education

and assistance with

obtaining proper equipment would be beneficial for one’s health

which correlates to

healthier living and decreases preventative medical care.Slide11

Relevant to current practice

How would

these findings be communicated?what levelPatients should have these statics available at their PCP office and/or Diabetic clinic.

Individual level

Through individual research and education

Standard of Care

Along with diabetic education, food planning, medication administration, and glucose monitoring, daily skin assessments including monitoring of ones foot temperature should be part of daily routines.

Professional Level

It should be the responsibility of physicians and other professionals to acknowledge preventative interventions for this specific group. Slide12

Relevant to current practice

Diabetes education, early prevention and early treatment are all implications that should be practiced on a daily basis.

By preventing a diabetic ulcer from forming, not only is one increasing their quality of life, but also decreasing future complications.This can not fall on just one discipline, patient’s need to be their own advocates, but also the physician needs to take charge and ensure the patient has been given the proper tools and resources to make a difference.Daily skin assessments, including daily temperature monitoring should be the standard of care for all diabetic patients. However as a society, we are not there yet. I don’t feel it is an intervention that is discussed with this population. I am unclear if it is because it is a newer revelation or if for some reason it hasn’t gain popularity yet.Slide13

Implications of Research ArticlesWhile this article’s findings concluded that daily temperature monitoring can decrease ulcer formation, there were other implications that they did not take into consideration.

According to the first study; quality of life, functional status, self-efficacy, satisfaction with care and cost will need to be addressed in future articles and research.

While the authors felt that this study mirrored other projects, they go onto suggest completing a study over an extended period of time with more test subjects would conclude the same information.Slide14

Barriers

Potential barriers for this population is whether there are resources available to them. Every diabetic patient receives a glucose monitor at time of diagnosis, so why not include a foot thermometer in this practice? I am not sure if it is cost related, unpopularity of treatment or something not listed.

Other PICO questions to consider:In patients with diabetes, does assessing ones feet daily, compared to not assessing ones feet daily, reduce the incidence rate of diabetic complications?In patients with diabetes, does proper diabetic education, compared to having no diabetic education, reduce the risk of diabetic complications?Slide15

Conclusion

Patients and families must bridge the gap between physician examinations by taking responsibility in daily skin assessment

of feet.Self-monitoring is essential to identify areas on the foot that are at risk for injury.

Once injury occurs, it is extremely important to continue monitoring and assessing as it can help prevent worsening complications such as lower extremity amputation.

Continuing education with this group of individuals is key to success at improving their quality of life as well as helping decrease further medical interventions.