A QI project at Children’s helped improve the rate of foot exams for patients with type 2 diabetes. (Stock illustration)
When you think about type 2 diabetes in kids, you likely think about blood sugar, insulin and diet. But what about feet?
For kids—and adults—with diabetes, feet can be the canary in the coal mine when it comes to microvascular damage from high glucose levels. In the feet, neuropathy increases the risk of foot ulcers and even amputation. In the eyes, it can lead to vision loss, and in the kidneys to chronic kidney disease.
“Young people with type 2 diabetes are very different from adults,” said Mary Margaret Barr, M.D., a pediatric endocrinology fellow at Children’s of Alabama. “Their disease is usually much more aggressive. It causes issues earlier, and it can be harder to control.”
Current American Diabetes Association guidelines call for comprehensive foot exams upon diagnosis of type 2 diabetes and annually thereafter.
Yet when Barr set out to see how well clinicians documented complete foot exams in medical charts at Children’s, a large gap emerged.
Her review came after the hospital transitioned to a new electronic health record (EHR) system. She found that after the transition, documented foot exams in pediatric patients with type 2 diabetes fell from about one in four visits to almost none. “Basically, one or two kids out of 30 or 40 had a documented foot exam,” she said.
It wasn’t that clinicians didn’t know the guidelines; it was just different in the new system.
Recognizing that reality, the team launched a formal quality improvement project—later named UndeFEETed—to understand what was getting in the way and how to fix it.
A Small Exam That Takes Time—and Intention
A proper diabetic foot exam is not a glance at a pair of sockless feet. It requires time, tools and attention.
It starts with a neurological exam to test nerve sensation in the foot. A monofilament (soft strand of nylon) is tapped gently on the foot and toes to assess if the patient can feel where it is tapping without looking, followed by tuning fork vibration tests, a pinprick test, or a tendon hammer test to assess ankle reflexes. The vascular assessment includes checking blood flow in the foot and ankle.
For children—especially those who are younger or developmentally delayed—this exam can be challenging. And in a busy clinic, where providers juggle multiple screening requirements, preventive exams that aren’t automated can quietly fall away.
“There’s a really big list of screenings that come along with diabetes visits,” Barr noted. “It does get overwhelming.” But most of these other screenings are incorporated into the daily clinic flow, with documentation rates averaging more than 80%.
Plus, there’s no reimbursement for foot exams despite the time required to properly do one. “That’s frustrating,” Barr said.
She’s not surprised that when she presents the UndeFEETed data at conferences with other endocrinologists around the country. “Everyone’s like: Yeah—no one does foot exams.”
But a documented foot exam is more than just paperwork: it’s a safeguard that problems won’t be missed.
“If a foot problem was found, it could be addressed early rather than later,” Barr said.
That matters because children diagnosed with type 2 diabetes today will live with the disease for decades. Large studies show that by their mid-20s many already show signs of permanent nerve damage, Barr said.
Her team identified four main barriers to documented foot exams: lack of standardized documentation, limited access to exam tools, time pressures, and uncertainty about how to record the exam in the new EHR.
Physicians, nurse practitioners and clinic nurses worked together to redesign workflows. A new diabetes note template embedded foot exam documentation directly into routine visits. Supplies were in all exam rooms. Nurses helped flag when exams were due.
The team resisted adding pop-up alerts in the new EHR, which also helped. Instead, they built seamless, non-intrusive reminders into the charting process.
The results were striking. Within months, documented foot exams rose from less than 5% to more than 20%. Once more providers adopted the new template, documentation climbed to 50%—double the original goal.
However, after the initial changes were implemented and the system was running for a while, that figure dropped to about 30%. So Barr and her team are continuing to investigate other options in the EHR to help. They are also working with the nurses to identify the best way to communicate with the clinicians they work with most often, whether it’s a sticker or a certain word to help them remember to conduct a foot exam.
Barr hopes the work eventually leads to tracking long-term outcomes, including whether earlier and more consistent screening reduces complications. For now, the focus remains on getting the fundamentals right. “Our biggest goal is to make sure that kids who are about to graduate from pediatric care and go into the adult world have foot exams on record,” she said.
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