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BC Kidney Days 2015 - Foot Care Nursing Breakout Session
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Transcript of BC Kidney Days 2015 - Foot Care Nursing Breakout Session
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Feet For a LifetimeFraser Health
Abbotsford Regional HospitalRenal Foot Care Pilot Project
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Why Feet??
• Multiple co-morbidities for foot complications:– Diabetes– Peripheral Vascular disease– Peripheral neuropathy– Lower limb edema
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Contributing factors for lower limb complications
• Poor Glycemic control• Smoking• Foot deformity• Previous amputation• History of foot ulcer• Dialysis!!!!
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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
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Burden of disease in patients with ESRD and Diabetes Mellitus 2
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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
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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
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Assessment and early interventionis not rocket science…
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Foot Care pilot project initiated at Abbotsford Regional Hospital (ARH)
• When: Oct 2013
• Patient Population: Hemodialysis (HD) and Peritoneal dialysis (PD) patients
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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
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Our Goals:
• Reduction in rates of lower limb amputations and complications
• Reduction in total hospitalized days
• Reduction in overall mortality
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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
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Regular foot assessments every 6 weeks
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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)
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Foot Cool? •May indicate PVD
Foot Hot? •May indicate inflammation, infection, Charcot foot
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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
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Nails
Ingrown toenails?Infection? Podiatry referral
Unkempt and thick? Podiatry referral
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Deformity
Podiatric referral
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Footwear Appropriate?Always wearing sandals can be indicative of an undiagnosed foot issue!!
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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)
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What are we finding under our patients socks and shoes…??
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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.
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ARH patient ST
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Exposed Bone
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5 weeks Debridement X 4
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Weekly Debridement 6 months-Healed
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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.
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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
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• 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
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Results of Foot Screen by RN
ARH HD – 6 week Foot Screen
Screening completed on approximately 80% of chronic HD population
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Results of Foot Screen by RN
ARH PD – At routine clinic visit
Screening completed on approximately 100% of PD population
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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
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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%
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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
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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%
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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
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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
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Let’s change this:
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To This:
Patient Centered Care
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Together, we CAN make a difference !
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Presented by:Sarah Lacroix, R.N.Lead Project Foot Care Coordinator, [email protected]: 604-809-9326