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

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!!