This document summarizes a foot care pilot project for dialysis patients at Abbotsford Regional Hospital. The project was initiated to improve foot health and reduce complications through regular foot screenings, education on proper foot care, and access to podiatry services. Initial results found reductions in lower limb amputations and hospital days compared to previous rates. Case studies demonstrated improved outcomes with regular debridement. The goals of the project are to continue improving patient outcomes and quality of life through a proactive, patient-centered approach to foot care.

1. Feet For a Lifetime
Fraser Health
Abbotsford Regional Hospital
Renal Foot Care Pilot Project

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

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

22. Deformity
 Podiatric referral

23. Footwear Appropriate?
Always wearing sandals can be indicative
of an undiagnosed foot issue!!

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)

27. What are we finding under our
patients socks and shoes…??

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.

31. ARH patient ST

32. Exposed
Bone

33. 5 weeks
Debridement X 4

34. Weekly Debridement
6 months-Healed

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

46. Let’s change this:

47. To This:
Patient Centered Care

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