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Feet For a LifetimeFraser Health
Abbotsford Regional HospitalRenal Foot Care Pilot Project
Why Feet??
• Multiple co-morbidities for foot complications:– Diabetes– Peripheral Vascular disease– Peripheral neuropathy– Lower limb edema
Contributing factors for lower limb complications
• Poor Glycemic control• Smoking• Foot deformity• Previous amputation• History of foot ulcer• Dialysis!!!!
Additional Contributing Factors
• Poor hand dexterity• Visual impairment (retinopathy)• Unable to reach feet• Improper tools for foot care• Lack of knowledge regarding importance of
appropriate foot maintenance
Burden of disease in patients with ESRD and Diabetes Mellitus 2
Diabetes and ESRD-Risk factors
• 2-4% of diabetics have an ulcer/wound at any given time
• 10-15% will develop an ulcer in their lifetime
• Diabetics are 20x more likely to be hospitalized for non-traumatic limb amputation
Post Amputation and Mortality
• 3 year survival following lower extremity amputation is 50%
• 80% of those that survive will have another amputation within 5 years
Assessment and early interventionis not rocket science…
Foot Care pilot project initiated at Abbotsford Regional Hospital (ARH)
• When: Oct 2013
• Patient Population: Hemodialysis (HD) and Peritoneal dialysis (PD) patients
Purpose of this project?
• Quality Improvement
• Develop a PROCESS for dialysis patient access to podiatry services
• Raise awareness among patients and staff about the importance of proper foot care
Our Goals:
• Reduction in rates of lower limb amputations and complications
• Reduction in total hospitalized days
• Reduction in overall mortality
ACCOMPLISHMENTS TO DATE
• Developed and implemented an R.N. foot assessment screening tool
• Implemented:• Regular foot assessments:
“Socks Off Week”, every 6 weeks
• Regular podiatric intervention:• FREE weekly clinics (most cannot afford)• Held on dialysis unit to accommodate pts with
transportation issues
Regular foot assessments every 6 weeks
Skin:– Dry/fungus = cream or fungal cream may be
ordered
– Heavy callus build up, cracks fissures or ulceration = podiatry referral
(Ulcers may be present under a callus)
Foot Cool? •May indicate PVD
Foot Hot? •May indicate inflammation, infection, Charcot foot
Erythema• Redness and cold = indicative of poor vasculature
Podiatry referral, vascular referral, imaging
• Redness with heat = indicative of infection Podiatry referral, nephrologist made aware,
antibiotics prescribed
Nails
Ingrown toenails?Infection? Podiatry referral
Unkempt and thick? Podiatry referral
Deformity
Podiatric referral
Footwear Appropriate?Always wearing sandals can be indicative of an undiagnosed foot issue!!
Sensation
• Diabetic• Peripheral vascular disease diagnosis• Claudication• Numbness, tingling, pain, loss of sensation• Feeling like a spider is crawling up leg
HIGH RISK for ULCERATION due to PVD (whether it’s been officially diagnosed or not)
What are we finding under our patients socks and shoes…??
Case Study 1Impact of weekly debridement
• Mrs S: – 61 Yr old– Poorly controlled diabetic– PVD– Hx previous amputation and ulceration– Home Nursing x 1 yr for ulcer
Discharged pt as was not healing.
ARH patient ST
Exposed Bone
5 weeks Debridement X 4
Weekly Debridement 6 months-Healed
Case Study 2: Impact of delayed identification of advanced
disease
• Mr J: 56 yr old• Poorly controlled diabetic• Severe PVD• Severely infected ulcers to 2nd toe of both
feet.• Antibiotic treatment, weekly dressing
changes.
Case Study 22 Weeks later
- Bone protruding through second toes bilaterally- X-ray to rule out osteomyelitis, referral to vascular surgeon- Weekly podiatry treatment (dressing changes) while waiting for
vascular consult
Left foot Right foot
• Admission and surgery March 14th • Amputation of 2nd & 3Rd toe (R foot)
Referral to procedure = 60 days
• Re-admission & surgery May/14; gangrene R 1st toe, 1st toe amputated
• Re-admission Aug/14; R foot infection; excision of R 2nd, & 3rd metatarsals Sep/14
• Admissions since 1st assessment = 3; Total LOS = 118 days• Left foot ulcers completely healed
Case Study 2
Results of Foot Screen by RN
ARH HD – 6 week Foot Screen
Screening completed on approximately 80% of chronic HD population
Results of Foot Screen by RN
ARH PD – At routine clinic visit
Screening completed on approximately 100% of PD population
Podiatrist Clinic ActivitySummary of Foot Care Clinics with Podiatrist
HD and PD patients
Sep 2014 to Jul 2015
# Clinics # Appts
# Patients seen/month (some pts had multiple appointments)
Sep-2014 5 42 30Oct-2014 4 32 22Nov-2014 4 41 31Dec-2014 4 34 24Jan-2015 4 38 23Feb-2015 4 46 23Mar-2015 3 25 21Apr-2015 2 23 19May-2015 2 26 21Jun-2015 2 23 22Jul-2015 2 27 27
Total 36 357
Amputation Rate - ARH HD + PD Pre Intervention
(N=190)Post Intervention
(N=183)Relative
Difference (%)
Amputation rate (# patients with amp event / total pts) 2.6% 1.6% ↓ 38.5%
Preliminary Results – 1
Decreased 687 days in hospital for lower limb
related admissions!
Hospitalization days - ARH HD + PDPre Intervention
(N=190)Post Intervention
(N=183)Absolute
DifferenceRelative Difference
(%)Total days (all events excluding amputation) 1080 834 (-) 246 ---
Hospital days Per person 5.68 4.56 --- ↓ 19.7%
Total days (all events including amputation) 1718 1031 (-) 687 ---
Hospital days Per person 9.04 5.63 --- ↓ 37.7%
Average Length of Stay (in Days) - ARH HD + PDPre Intervention
(N=190)Post Intervention
(N=183)Absolute
Difference
Amputation only 36.0 32.1 (-) 3.9
Other reasons (Lower limb infection, Lower limb Revascularization, Lower limb Angiogram, PVD)
106.3 32.8 (-) 73.5
Hospitalization rate by complication – ARH HD + PDPre Intervention
(N=190)Post Intervention
(N=183)Relative Difference
(%)
n (%) n (%)
Lower Limb Infection 17 (8.9%) 8 (4.4%) ↓ 50.6%
Lower limb revascularization 4 (2.1%) 4 (2.2%) ↑ 4.8%
Peripheral Vascular Disease 8 (4.2%) 12 (6.6%) ↑ 57.1%
Lower limb angiogram 1 (0.53%) 2 (1.1%) ↑ 108%
Hospitalization rate – discharges excluding amputation(Lower limb infection, LL revascularization, LL angiogram, PVD)
30 (15.8%) 26 (14.2%) ↓ 10.1%
Hospitalization rate - discharges including amputation 36 (18.9%) 32 (17.5%) ↓ 7.4%
Preliminary Results – 1
Amputation Rate - HD + PD Post RCH + RCH
(N=600)Post ARH (N=183)
Relative Difference (%)
Amputation rate (# patients with amp event / total pts)
3.0% 1.6% ↓ 46.7%
Preliminary Results – 2 cont’d
Hospitalization days - HD + PD
Post RCH + SMH (N=600)
Post ARH (N=183) Relative Difference (%)
Total days (all events excluding amputation) 4362 834 ---
Hospital days Per person 7.27 4.56 ↓ 37.3%
Total days (all events including amputation) 5914 1031 ---
Hospital days Per person 9.86 5.63 ↓ 42.9%
Hospitalization rate by complication - HD + PDPost RCH + SMH
(N=600)Post ARH (N=183) Relative
Difference (%)
n (%) n (%)
Lower Limb Infection 51 (8.5%) 8 (4.4%) ↓ 48.2%
Lower limb revascularization 26 (4.33%) 4 (2.2%) ↓ 49.2%
Peripheral Vascular Disease 39 (6.5%) 12 (6.6%) ↑ 1.5%
Lower limb angiogram 4 (.7%) 2 (1.1%) ↑ 44.7%
Hospitalization rate – discharges excluding amputation(Lower limb infection, LL revascularization, LL angiogram, PVD)
120 (20.0%) 26 (14.2%) ↓ 29.0%
Hospitalization rate - discharges including amputation
145 (24.2%) 32 (17.5%) ↓ 27.7%
Preliminary Results – 2 cont’d
Average Length of Stay (in Days) - HD + PDPost RCH + SMH
(N=600)Post ARH (N=183)
Absolute Difference
Amputation only 62.1 32.8 (-) 29.3
Other reasons (Lower limb infection, Lower limb Revascularization, Lower limb Angiogram, PVD)
36.4 32.1 (-) 4.3
Preliminary Results -3Mortality
ARH Pre Intervention RCH + SMH Post
ARH Post Intervention
N= 190 600 183
Event data end date 30-Nov-13
# Patients Deceased on or before event data end date
34 105 26
Rate 17.9% 17.5% 14.2%
30-Nov-14
Let’s change this:
To This:
Patient Centered Care
Together, we CAN make a difference !
Presented by:Sarah Lacroix, R.N.Lead Project Foot Care Coordinator, [email protected]: 604-809-9326