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Feet For a Lifetime
Fraser Health
Abbotsford Regional Hospital
Renal 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 intervention
is 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 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.
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 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
• 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 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
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%
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
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 + 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
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
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, FHA
s.lacroixresearch@gmail.com
Mobile: 604-809-9326

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BC Kidney Days 2015 - Foot Care Nursing Breakout Session

  • 1. Feet For a Lifetime Fraser Health Abbotsford Regional Hospital Renal Foot Care Pilot Project
  • 2.
  • 3. Why Feet?? • Multiple co-morbidities for foot complications: –Diabetes –Peripheral Vascular disease –Peripheral neuropathy –Lower limb edema
  • 4. Contributing factors for lower limb complications • Poor Glycemic control • Smoking • Foot deformity • Previous amputation • History of foot ulcer • Dialysis!!!!
  • 5. 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
  • 6. Burden of disease in patients with ESRD and Diabetes Mellitus 2
  • 7. 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
  • 8. 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
  • 9. Assessment and early intervention is not rocket science…
  • 10. Foot Care pilot project initiated at Abbotsford Regional Hospital (ARH) • When: Oct 2013 • Patient Population: Hemodialysis (HD) and Peritoneal dialysis (PD) patients
  • 11. 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
  • 12. Our Goals: • Reduction in rates of lower limb amputations and complications • Reduction in total hospitalized days • Reduction in overall mortality
  • 13. 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
  • 14. Regular foot assessments every 6 weeks
  • 15.
  • 16.
  • 17.
  • 18. 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)
  • 19. Foot Cool? •May indicate PVD Foot Hot? •May indicate inflammation, infection, Charcot foot
  • 20. 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
  • 21. Nails Ingrown toenails? Infection?  Podiatry referral Unkempt and thick?  Podiatry referral
  • 23. Footwear Appropriate? Always wearing sandals can be indicative of an undiagnosed foot issue!!
  • 24.
  • 25. 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)
  • 26.
  • 27. What are we finding under our patients socks and shoes…??
  • 28.
  • 29.
  • 30. 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.
  • 35. 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.
  • 36. 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
  • 37. • 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
  • 38. Results of Foot Screen by RN ARH HD – 6 week Foot Screen Screening completed on approximately 80% of chronic HD population
  • 39. Results of Foot Screen by RN ARH PD – At routine clinic visit Screening completed on approximately 100% of PD population
  • 40. 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
  • 41. 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%
  • 42. 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
  • 43. 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%
  • 44. 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
  • 45. 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
  • 48. Together, we CAN make a difference !
  • 49. Presented by: Sarah Lacroix, R.N. Lead Project Foot Care Coordinator, FHA s.lacroixresearch@gmail.com Mobile: 604-809-9326

Editor's Notes

  1. Results #2 compare RCH+SMH to ARH (both post intervention time period)