This document summarizes a foot care initiative for dialysis patients in Fraser Health Authority. It found that lower limb disease affects 30-40% of dialysis patients and is associated with higher mortality. The initiative aims to establish early detection and treatment of lower limb lesions through a multi-disciplinary approach. A pilot at ARH involves a 'Socks Off Week' with 60-second foot assessments every 6 weeks. Preliminary results show decreased lower limb infection rates, hospitalization days and rates, and mortality rates after the intervention. The initiative aims to expand and perform further analysis and cost-benefit studies.

1. 2015
Foot Care Initiative in Dialysis Patients
Fraser Health Authority
Dr Shaoyee Yao

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. 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. Background
Kaminski M Et al. NDT 2015
Can we alter
these risk factors
to improve
outcomes ?

5. Project Intent
• To establish a multi disciplinary approach to early
detection and treatment of lower limb lesions in
patients with ESRD

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. Intervention
“Socks Off Week”

8. “Socks Off Week”
’60 Second’ Foot
assessment: performed on
all dialysis patients by Renal
RN every 6 weeks

9. Our “Clinic”

10. Preliminary Results
A
B
C

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. 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. 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. Caveats
• Preliminary data without full statistical
analysis (pending)
• Short follow up of 1 year
– Longer intervention time likely to show greater
improvements

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. 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. 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!!