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, FHAs.lacroixresearch@gmail.comMobile: 604-809-9326