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 vs Diabetes is a metabolic disease in which the body’s inability to produce any or enough insulin causes elevated levels of glucose in the blood. The prevalence of diabetes mellitus is growing at epidemic proportions in the United States as well as worldwide. It is estimated that 7% of Americans are afflicted with diabetes and with the population increase, comes a rise in diabetes and complications from this disease. Research shows some alarming information stating that type 2 is rising amongst the young and obese population. So what can we do to help? What preventative interventions can we implement to help decrease this growing disease?

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 Scholl’s Center for Lower Extremity Ambulatory Research (CLEAR), Rosalind Franklin University of Medicine and Science, North Chicago, Ill b Southern Arizona Veterans Affairs Medical Center, Tucson c Department of Epidemiology and Biostatistics, College of Public Health, University of Arizona, Tucson d Department of Surgery, Texas A&M College of Medicine at Scott & White Memorial Hospital, Temple.

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. High temperatures gradients between feet may predict the onset of neuropathic ulceration and self-monitoring may reduce the risk of ulceration.

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. It is impossible to make sweeping generalizations about groups of people based solely on a few interviews, observations, or surveys. You can find general patterns or trends, but should never assume that what you have found is what exists or what will always exist. In fact, it is hard to make concrete generalizations about any occurrence that relates to people because people themselves are dynamic and situations are always changing

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 Patients 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.

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: 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?

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. Inspect your feet every day, and seek care early if you do get a foot injury. Make sure your health care provider checks your feet at least once a year - more often if you have foot problems. Your health care provider should also give you a list and explain the do's and don'ts of foot care. Most people can prevent any serious foot problem by following some simple steps. - See more at: http://www.diabetes.org/living-with-diabetes/complications/foot-complications/foot-care.html#sthash.CMyYHaBR.dpuf Take care of your diabetes. Work with your health care team to keep your blood glucosethe main sugar found in the blood and the body's main source of energy. Also called blood sugar.X in your target rangeThe range in which you and your healthcare team have decided would be best to keep your blood glucose. This range may be different for everyone.X.Check your feet every day. Look at your bare feet for red spots, cuts, swelling, and blisters. If you cannot see the bottoms of your feet, use a mirror or ask someone for help.Be more active. Plan your physical activity program with your health team.Ask your doctor about Medicare coverage for special shoes.Wash your feet every day. Dry them carefully, especially between the toes.Keep your skin soft and smooth. Rub a thin coat of skin lotion over the tops and bottoms of your feet, but not between your toes. Read more about skin care.If you can see and reach your toenails, trim them when needed. Trim your toenails straight across and file the edges with an emery board or nail file.Wear shoes and socks at all times. Never walk barefoot. Wear comfortable shoes that fit well and protect your feet. Check inside your shoes before wearing them. Make sure the lining is smooth and there are no objects inside.Protect your feet from hot and cold. Wear shoes at the beach or on hot pavement. Don't put your feet into hot water. Test water before putting your feet in it just as you would before bathing a baby. Never use hot water bottles, heating pads, or electric blankets. You can burn your feet without realizing it.Keep the blood flowing to your feet. Put your feet up when sitting. Wiggle your toes and move your ankles up and down for 5 minutes, two (2) or three (3) times a day. Don't cross your legs for long periods of time. Don't smoke.Get started now. Begin taking good care of your feet today. Set a time every day to check your feet. - See more at: http://www.diabetes.org/living-with-diabetes/complications/foot-complications/foot-care.html#sthash.CMyYHaBR.dpuf