2015

Foot Care Initiative in Dialysis PatientsFraser 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. Diabetes Care 2010

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%

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 patients with ESRD

Project OutlinePilot 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

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 + PDPre 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 + PDPre Intervention (N=190) Post Intervention (N=183) Absolute Difference

Amputation only 36.0 32.1 (-) 3.9Other reasons (Lower limb infection, Lower limb Revascularization, Lower limb Angiogram, PVD)

106.3 32.8 (-) 73.5

Hospitalization rate by complication - HD + PDPost 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 + PDPost 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

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

Caveats• Preliminary data without full statistical

analysis (pending) • Short follow up of 1 year– Longer intervention time likely to show greater

improvements

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

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

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!!