NU823 Unit 4 Manuscript Draft Example

Moving the Diabetic Foot Exam Into Rooming: A Manuscript Draft Built on the SQUIRE 2.0 Headings for a Primary Care Diabetes Journal, Reporting a Twelve-Week Quality Improvement Project at a Composite Two-Clinic Community Health Center

[Student Name]

Purdue University Global

NU823: DNP Project Dissemination

Unit 4 Manuscript Draft

[Instructor Name]

[Date]

The project, health center and every figure are composite; the word limit, table count and journal requirements are bracketed until the current instructions for authors are read.

Title Page and Abstract

Title: Moving the Diabetic Foot Exam Into Rooming at a Community Health Center: A Quality Improvement Report. Authors and affiliations: [names], [health center], [university]. Corresponding author: [name, email]. Word count: [main text count]; tables: [3]; figures: [2].

Structured abstract. Statement of problem: Annual comprehensive foot exams for adults with diabetes were documented for [54] percent of patients at a two-clinic community health center. Description: While rooming eligible patients, medical assistants working under a standing order checked sensation with a monofilament and a tuning fork and inspected both feet, after which providers set the risk level and sent high-risk patients to podiatry. Assessment: Coverage was charted week by week as a run chart, and each component's fidelity was tracked. Results: Over twelve weeks, [598] patients were examined; coverage at scheduled diabetes visits rose from a baseline median of [41] percent to [84] percent; podiatry saw [70] percent of referred high-risk patients within a month. Lessons learned: Rooming-based exams were delivered reliably; access to podiatry after the exam, especially for uninsured patients, limited the pathway.

Introduction

Problem description. Diabetes-related foot disease is common and costly, and the annual comprehensive foot exam, including monofilament testing for loss of protective sensation, is recommended yearly for all adults living with diabetes (American Diabetes Association Professional Practice Committee, 2024). Our health center's registry showed a documented exam in the previous twelve months for only [54] percent of its [2,346] adult patients with diabetes.

Available knowledge. A task force report describes the components of the comprehensive foot exam, including inspection, monofilament testing at defined sites and vibration testing, and the findings that place a patient at higher risk (Boulton et al., 2008). A meta-analysis of quality improvement strategies in diabetes care found that such strategies increased the likelihood of screening for foot abnormalities across 22 trials, with a relative risk of 1.27 (Tricco et al., 2012).

Rationale. In our clinics the exam depended on the provider remembering it during a short visit. Moving it to rooming, a step every visit already includes, was expected to make it routine.

Specific aims. By week six, three in four eligible scheduled visits at the main clinic ([75] percent) would include the exam; nine in ten exams ([90] percent) would record every element; and four in five high-risk patients with no podiatrist of their own ([80] percent) would have a podiatry visit inside [30] days.

Methods

Context. The health center serves a largely low-income population at a main clinic and a satellite, with [22] exam rooms, about [12] medical assistants and no podiatrist on staff. Rooming already included standing-order tasks such as vaccines.

Intervention. Five components: a huddle flag for patients with an open foot-exam gap; the exam at rooming under a standing order, after one hour of training and three signed-off exams per assistant; risk classification by the provider using international categories (Schaper et al., 2024); a written referral agreement with a community podiatry group for high-risk patients; and documentation in a new flowsheet linked to the care-gap report.

Study of the intervention. Delivery was assessed with Carroll and colleagues' framework for implementation fidelity (Carroll et al., 2007): content adherence from the flowsheet, coverage from the care-gap report, quality of delivery from a nurse educator's observations of monofilament technique, and patient responsiveness from recorded refusals. Changes during implementation, including wider eligibility from [week 5] and a split exam at the satellite during a staffing gap, were documented as they occurred.

Study of the intervention says how the team knew the protocol was delivered; measures say what the protocol was expected to change, and the draft keeps them in separate sections.

Measures. The primary measure was weekly protocol coverage: exams completed at scheduled diabetes visits by patients with an open gap, divided by those visits. Secondary measures were coverage under the wider rule, unique patients examined, the registry's annual exam rate by source, and referral completion within [30] days. Balancing measures were rooming time and deferrals.

Analysis. Each week's coverage went onto a run chart whose center line was the median of [12] pre-launch weeks, and the shift, trend and run rules were fixed before launch (Perla et al., 2011). In-clinic exams were counted separately from outside podiatry reports.

Ethical considerations. The project was reviewed as quality improvement under [the health center's and university's review process]. No identifiable patient information is reported.

Results

All twelve implementation weeks showed protocol coverage above the baseline median of [41] percent, meeting the shift rule; coverage over the period was [84] percent. Content adherence rose from [84] percent in the first four weeks to [93] percent after vibration testing was reviewed with staff. Of [46] observed exams, technique was judged correct in [43]. In all, [598] patients were examined, and [44] were classified as high risk. The annual exam rate for the registry rose from [54] to [66] percent; Medical assistants accounted for [503] of the patients counted, providers for [95], and scanned reports from outside podiatrists for [71]. Referral completion within [30] days was [70] percent, rising from [57] percent to [81] percent after booking at checkout and reserved podiatry appointments began in [week 11]. Median rooming time increased by [3.5] minutes.

Discussion

Summary. Once the exam became part of rooming, it happened at most visits: coverage roughly doubled from baseline and stayed above target for twelve weeks.

Interpretation. The improvement in screening is consistent with the effect of quality improvement strategies on foot screening reported across trials (Tricco et al., 2012), although our single-site design cannot be compared directly with trial results. The weakest step was not the exam but what follows it: about one in three high-risk patients did not reach podiatry within a month, and cost was a barrier for uninsured patients, since the partner practice did not offer reduced fees.

Limitations. There was no comparison clinic. Outreach calls in [week 8] and outside reports contributed to the annual rate, which is why in-clinic exams are reported separately. For three and a half weeks a documentation error hid [41] exams, later recovered. Eligibility widened mid-project. Twelve weeks cannot show effects on ulcers or amputations.

Conclusions. The foot exam can be moved from the provider to rooming staff and delivered reliably in a community health center. The value of the exam depends on what happens next, and access to podiatry needs as much planning as the exam itself.

Cover Note to the Instructor

The draft follows SQUIRE 2.0, which separates study of the intervention from measures and treats context as part of the findings (Ogrinc et al., 2016). It is compressed for a primary care readership: theory is reduced to the fidelity framework, and the literature is limited to what the rationale needs. The main text is about [3,400] words against a bracketed limit of [3,500]; the SQUIRE checklist, completed with page and line numbers, is attached. Nothing has been submitted.

References

American Diabetes Association Professional Practice Committee. (2024). 12. Retinopathy, neuropathy, and foot care: Standards of care in diabetes 2024. Diabetes Care, 47(Suppl. 1), S231-S243. https://doi.org/10.2337/dc24-S012

Boulton, A. J. M., Armstrong, D. G., Albert, S. F., Frykberg, R. G., Hellman, R., Kirkman, M. S., Lavery, L. A., LeMaster, J. W., Mills, J. L., Sr., Mueller, M. J., Sheehan, P., & Wukich, D. K. (2008). Comprehensive foot examination and risk assessment: A report of the Task Force of the Foot Care Interest Group of the American Diabetes Association, with endorsement by the American Association of Clinical Endocrinologists. Diabetes Care, 31(8), 1679-1685. https://doi.org/10.2337/dc08-9021

Carroll, C., Patterson, M., Wood, S., Booth, A., Rick, J., & Balain, S. (2007). A conceptual framework for implementation fidelity. Implementation Science, 2, Article 40. https://doi.org/10.1186/1748-5908-2-40

Ogrinc, G., Davies, L., Goodman, D., Batalden, P., Davidoff, F., & Stevens, D. (2016). SQUIRE 2.0 (Standards for QUality Improvement Reporting Excellence): Revised publication guidelines from a detailed consensus process. BMJ Quality & Safety, 25(12), 986-992. https://doi.org/10.1136/bmjqs-2015-004411

Perla, R. J., Provost, L. P., & Murray, S. K. (2011). The run chart: A simple analytical tool for learning from variation in healthcare processes. BMJ Quality & Safety, 20(1), 46-51. https://doi.org/10.1136/bmjqs.2009.037895

Schaper, N. C., van Netten, J. J., Apelqvist, J., Bus, S. A., Fitridge, R., Game, F., Monteiro-Soares, M., Senneville, E., & IWGDF Editorial Board. (2024). Practical guidelines on the prevention and management of diabetes-related foot disease (IWGDF 2023 update). Diabetes/Metabolism Research and Reviews, 40(3), Article e3657. https://doi.org/10.1002/dmrr.3657

Tricco, A. C., Ivers, N. M., Grimshaw, J. M., Moher, D., Turner, L., Galipeau, J., Halperin, I., Vachon, B., Ramsay, T., Manns, B., Tonelli, M., & Shojania, K. (2012). Effectiveness of quality improvement strategies on the management of diabetes: A systematic review and meta-analysis. The Lancet, 379(9833), 2252-2261. https://doi.org/10.1016/S0140-6736(12)60480-2