Download Evidenced Based Health Practice: PICO Presentation

Evidenced Based
Health Practice:
PICO Presentation
By: Anna Ingersoll, RN
PICO Question
• In 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 patients
I- daily foot temperature
C- no daily foot temperature
O- reduce the incidence rate of diabetic ulcer
formation
Literature Results
• Key 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: Pubmed
• Final Search: “effectiveness of daily skin assessment
on diabetic feet”
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.2007.06.028
Evaluation of Articles
• Both 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.
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: Quantitative
Design: 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.
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: Quantitative
Design: physician-blinded, randomized multicenter trial
Methods: 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.
Ethical Considerations
• Study 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.
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. Participants’ 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.
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. Participants’ 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.
Relevant to current practice
•
How would these findings be communicated?
•
what level
o Patients should have these statics available at their PCP office
and/or Diabetic clinic.
•
Individual level
o Through individual research and education
•
Standard of Care
o 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
o It should be the responsibility of physicians and other professionals to
acknowledge preventative interventions for this specific group.
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.
Implications of Research
Articles
• While 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.
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:
o In patients with diabetes, does assessing ones feet daily, compared to not
assessing ones feet daily, reduce the incidence rate of diabetic
complications?
o In patients with diabetes, does proper diabetic education, compared to
having no diabetic education, reduce the risk of diabetic complications?
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.