Date of Award

Fall 12-18-2020

Document Type

DNP Project

Project Team Faculty Member

Dr. Elise M. Harmon, DNP, RN


pediatric toe walking, neurologic exam in toe walking, performance improvement


Successful management of toe walking, a common patient complaint addressed by pediatric orthopedic providers, requires detection of concerning neurologic causes for toe walking. However, nurse practitioners in an outpatient orthopedic clinic were not following recommended guidelines for the history and physical exam for children who toe walk, resulting in delayed referrals and poorer patient outcomes. A performance improvement project was initiated that included an educational intervention, chart review, and data analysis. The goal was to improve the performance and documentation of neurologic exam when nurse practitioners saw patients for an initial visit for toe walking. A literature review provided evidence-based guidelines for practice and informed the educational intervention. The Institute for Healthcare Improvement’s Models, including Plan-Do-Study-Act cycles, were utilized for implementation and evaluation. Descriptive statistics were used for analysis of pre- and post- intervention findings. The number of pertinent history and physical points charted improved post-intervention. Post-intervention data did not have enough power to determine impact because of the small number of patients seen and referred, but a trend towards increased referral occurred. The nurse practitioners verbalized understanding of the education provided and expressed willingness to apply this knowledge to practice. A standardized neurologic exam does have an impact on the diagnosis of and referral pattern for neurologic disorders in pediatric toe walking. An educational intervention had an impact on the understanding of the neurologic exam, with some improvement of documentation of salient points.

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