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BC Kidney Days 2015 - Foot Care Nursing Breakout Session

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Sarah Lacroix presents the implementation and results of our foot care prevention strategy at the nursing breakout session as part of the 2015 BC Kidney Days.

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BC Kidney Days 2015 - Foot Care Nursing Breakout Session

  1. 1. Feet For a Lifetime Fraser Health Abbotsford Regional Hospital Renal Foot Care Pilot Project
  2. 2. Why Feet?? • Multiple co-morbidities for foot complications: –Diabetes –Peripheral Vascular disease –Peripheral neuropathy –Lower limb edema
  3. 3. Contributing factors for lower limb complications • Poor Glycemic control • Smoking • Foot deformity • Previous amputation • History of foot ulcer • Dialysis!!!!
  4. 4. 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
  5. 5. Burden of disease in patients with ESRD and Diabetes Mellitus 2
  6. 6. 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
  7. 7. 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
  8. 8. Assessment and early intervention is not rocket science…
  9. 9. Foot Care pilot project initiated at Abbotsford Regional Hospital (ARH) • When: Oct 2013 • Patient Population: Hemodialysis (HD) and Peritoneal dialysis (PD) patients
  10. 10. 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
  11. 11. Our Goals: • Reduction in rates of lower limb amputations and complications • Reduction in total hospitalized days • Reduction in overall mortality
  12. 12. 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
  13. 13. Regular foot assessments every 6 weeks
  14. 14. 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)
  15. 15. Foot Cool? •May indicate PVD Foot Hot? •May indicate inflammation, infection, Charcot foot
  16. 16. 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
  17. 17. Nails Ingrown toenails? Infection?  Podiatry referral Unkempt and thick?  Podiatry referral
  18. 18. Deformity  Podiatric referral
  19. 19. Footwear Appropriate? Always wearing sandals can be indicative of an undiagnosed foot issue!!
  20. 20. 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)
  21. 21. What are we finding under our patients socks and shoes…??
  22. 22. Case Study 1 Impact 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.
  23. 23. ARH patient ST
  24. 24. Exposed Bone
  25. 25. 5 weeks Debridement X 4
  26. 26. Weekly Debridement 6 months-Healed
  27. 27. 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.
  28. 28. Case Study 2 2 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
  29. 29. • 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
  30. 30. Results of Foot Screen by RN ARH HD – 6 week Foot Screen Screening completed on approximately 80% of chronic HD population
  31. 31. Results of Foot Screen by RN ARH PD – At routine clinic visit Screening completed on approximately 100% of PD population
  32. 32. Podiatrist Clinic Activity Summary 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 30 Oct-2014 4 32 22 Nov-2014 4 41 31 Dec-2014 4 34 24 Jan-2015 4 38 23 Feb-2015 4 46 23 Mar-2015 3 25 21 Apr-2015 2 23 19 May-2015 2 26 21 Jun-2015 2 23 22 Jul-2015 2 27 27 Total 36 357
  33. 33. 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 + PD Pre Intervention (N=190) Post Intervention (N=183) Absolute Difference Relative 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%
  34. 34. Average Length of Stay (in Days) - ARH HD + PD Pre 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 + PD Pre 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
  35. 35. 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%
  36. 36. Hospitalization rate by complication - HD + PD Post 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 + PD Post 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
  37. 37. Preliminary Results -3 Mortality 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
  38. 38. Let’s change this:
  39. 39. To This: Patient Centered Care
  40. 40. Together, we CAN make a difference !
  41. 41. Presented by: Sarah Lacroix, R.N. Lead Project Foot Care Coordinator, FHA s.lacroixresearch@gmail.com Mobile: 604-809-9326

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