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2015
Foot Care Initiative in Dialysis Patients
Fraser Health Authority
Dr Shaoyee Yao
Background
Burden of Lower Limb disease
Lower limb disease
affects 30-40% of
prevalent dialysis
patients
Ndip,A et al. Dia...
Background
Lower limb disease associated with significant morbidity
and mortality in dialysis patients
Orimoto et al. J Va...
Background
Kaminski M Et al. NDT 2015
Can we alter
these risk factors
to improve
outcomes ?
Project Intent
• To establish a multi disciplinary approach to early
detection and treatment of lower limb lesions in
pati...
Project Outline
Pilot at ARH over 2 years duration measuring
outcomes before and after intervention
Outcomes of interest:
...
Intervention
“Socks Off Week”
“Socks Off Week”
’60 Second’ Foot
assessment: performed on
all dialysis patients by Renal
RN every 6 weeks
Our “Clinic”
Preliminary Results
A
B
C
Hospitalization rate by complication – ARH HD + PD
Pre Intervention (N=190) Post Intervention (N=183) Absolute Difference ...
Hospitalization rate by complication - HD + PD
Post RCH + SMH (N=600) Post ARH (N=183) Absolute Difference Relative Differ...
Preliminary Results -3
Mortality 
ARH Pre
Intervention
RCH + SMH Post
ARH Post
Intervention
N= 190 600 183
Event data end ...
Caveats
• Preliminary data without full statistical 
analysis (pending) 
• Short follow up of 1 year
– Longer intervention...
Costs 
Service Cost (Dec 1, 2013- Nov 30, 2014)
Podiatry:
 Partial MSP covered ($23 / visit) 
$150/new consult , $79/follo...
Next Steps
• Pilot continues until Dec 1, 2015 (2 years)
• Final data expected May 2016
• Expansion of intervention to SMH...
Thank You
• Sarah Lacroix (Project Coordinator)
• Dr Scott Schumacher (Podiatrist)
• Welman Lee, Dr Daniel Schwartz,
Ruth ...
Fraser Health Foot Care Project Shows Reduced Amputation, Hospitalization and Length of Stay in Dialysis Patients
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Fraser Health Foot Care Project Shows Reduced Amputation, Hospitalization and Length of Stay in Dialysis Patients

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Dr. Shaoyee Yao presents data at the 2015 BC Kidney Days meeting which shows preliminary data on our foot care quality improvement initiative. This preliminary data suggests that preventative and proactive foot care in patients with end-stage renal disease can reduce amputation rates, hospitalization rates and length of stay.

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Fraser Health Foot Care Project Shows Reduced Amputation, Hospitalization and Length of Stay in Dialysis Patients

  1. 1. 2015 Foot Care Initiative in Dialysis Patients Fraser Health Authority Dr Shaoyee Yao
  2. 2. Background Burden of Lower Limb disease Lower limb disease affects 30-40% of prevalent dialysis patients Ndip,A et al. Diabetes Care 2010
  3. 3. Background Lower limb disease associated with significant morbidity and mortality in dialysis patients Orimoto et al. J Vasc Surg 2013 5 year survival: 43% (CORR Data 2010) 5 year survival with foot lesion: 23%
  4. 4. Background Kaminski M Et al. NDT 2015 Can we alter these risk factors to improve outcomes ?
  5. 5. Project Intent • To establish a multi disciplinary approach to early detection and treatment of lower limb lesions in patients with ESRD
  6. 6. Project Outline Pilot at ARH over 2 years duration measuring outcomes before and after intervention Outcomes of interest: 1. Rates of limb amputation 2. Days of hospitalization per year 3. All cause mortality
  7. 7. Intervention “Socks Off Week”
  8. 8. “Socks Off Week” ’60 Second’ Foot assessment: performed on all dialysis patients by Renal RN every 6 weeks
  9. 9. Our “Clinic”
  10. 10. Preliminary Results A B C
  11. 11. Hospitalization rate by complication – ARH HD + PD Pre Intervention (N=190) Post Intervention (N=183) Absolute Difference Relative Difference (%)   n (%) n (%) Lower Limb Infection  17 (8.9%) 8 (4.4%) (-) 9 ↓ 50.6% Lower limb revascularization  4 (2.1%) 4 (2.2%) 0 ↑ 4.8% Peripheral Vascular Disease  8 (4.2%) 12 (6.6%) (+) 4 ↑ 57.1% Lower limb angiogram 1 (0.53%) 2 (1.1%) (+) 1 ↑ 108% Hospitalization rate – discharges excluding amputation (Lower limb infection, LL revascularization, LL angiogram, PVD) 30 (15.8%) 26 (14.2%) (-) 4 ↓ 10.1% Hospitalization rate - discharges including amputation 36 (18.9%) 32 (17.5%) (-) 4 ↓ 7.4% Amputation Rate - ARH HD + PD   Pre Intervention (N=190) Post Intervention (N=183) Absolute Difference 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% Average Length of Stay - 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
  12. 12. Hospitalization rate by complication - HD + PD Post RCH + SMH (N=600) Post ARH (N=183) Absolute Difference 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% Amputation Rate - HD + PD   Post RCH + RCH (N=600) Post ARH (N=183) Absolute Difference Relative Difference (%) Amputation rate (# patients with amp event / total pts) 3.0% 1.6% --- ↓ 46.7% Preliminary Results - 2 Hospitalization days - HD + PD Post RCH + SMH (N=600) Post ARH (N=183) Absolute Difference 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% Average Length of Stay - 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
  13. 13. 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
  14. 14. Caveats • Preliminary data without full statistical  analysis (pending)  • Short follow up of 1 year – Longer intervention time likely to show greater  improvements 
  15. 15. Costs  Service Cost (Dec 1, 2013- Nov 30, 2014) Podiatry:  Partial MSP covered ($23 / visit)  $150/new consult , $79/follow up  $44 080.50 Unit Clerk  $1198.40 Nursing Project Coordinator  (with hours for Nurse Champion) $35 609.96 TOTAL $80 888.76
  16. 16. Next Steps • Pilot continues until Dec 1, 2015 (2 years) • Final data expected May 2016 • Expansion of intervention to SMH and RCH • Perform cost benefit analysis • Coordinate with the BCPRA to create a province wide strategy
  17. 17. Thank You • Sarah Lacroix (Project Coordinator) • Dr Scott Schumacher (Podiatrist) • Welman Lee, Dr Daniel Schwartz, Ruth Burns, Jan Olsen • All the Renal Nurses at ARH!!

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