Preventative Foot Care Project May Reduce Amputations, Hospitalization and Length of Stay in ESRD

At the 2015 BC Kidney Days, Dr. Shaoyee Yao and Sarah Lacroix present the preliminary results from a quality improvement project designed to reduce preventable complications from lower extremity wounds in patients on dialysis.

It has been know for some time that foot wounds are very common in patients on hemodialysis and peritoneal dialysis, affecting up to 30-40% patients.

In addition, lower limb disease is associated with an increase risk of death, with 5 year survival decreasing from 46% in those without lower limb disease, to 23% in those with disease.

The Fraser Health Renal program designed a CQI project to establish a multidisciplinary approach to early detection and treatment of lower limb lesions in patients with ESRD.

This project was funded via our discretionary fund for just these type of projects, in addition to funding from Amgen Canada.

We elected to roll out the pilot at the Abbotsford Regional Hospital (ARH) and compare outcomes in 2 ways.  We performed an observational analysis of patients outcomes, comparing outcomes at the same site the year prior to the intervention vs the year during the intervention.  Given some concerns over a possible Hawthorne effect or that foot care might have just improved due to general medical progress, we also elected to compared outcomes at control sites that were only offering routine foot care (Surrey Memorial Hospital and Royal Columbian Hospital).

Have a look at the slide deck included on this page (below).

Fraser Health Foot Care Project Shows Reduced Amputation, Hospitalization and Length of Stay in Dialysis Patients from Daniel Schwartz

In addition, Sarah Lacroix presents an excellent overview of the program and more details on our outcomes.

BC Kidney Days 2015 – Foot Care Nursing Breakout Session from Daniel Schwartz

Results

In brief, our raw data comparing pre/post outcomes at ARH suggests that:

a) Amputations were reduced from 2.6% to 1.6% (RRR 38%)
b) Days in hospital were reduced from 9.0 to 5.6 per patient (RRR 38%)
c) Hospitalization for infection was reduced from 8.9% to 4.4% (RRR 51%), overall hospitalization rate was reduced from 18.9% to 17.5% (RRR 7.4%) and total length of stay was reduced

Raw data comparing outcomes at ARH (active intervention) vs SMH/RCH (control sites) suggest that:

a) Amputations were reduced from 3% to 1.6% (RRR 47%)
b) Days in hospital were reduced from 9.9 to 5.6 per patient (RRR 43%)
c) Hospitalization for infection was reduced from 8.5% to 4.4% (RRR 48%), overall hospitalization rate was reduced from 24.2% to 17.5% (RRR 28%) and total length of stay was reduced

It’s interesting to note that we saw an increase in hospitalization for peripheral vascular disease but less amputations and lower admissions for lower limb infections, suggesting that we were intervening earlier in the disease process.  This is also supported by a much lower length of stay in hospital overall.  This suggests that intervening earlier results in earlier revascularization and overall better outcomes.

In fact, this intervention resulted in approximately 3.4-4.2 less days of hospitalization for each patient in our program.

Impact

Extrapolating to our entire program (were we able to roll this out more widely across the health authority), with a ‘back of the napkin’ calculation:

a) Approximate number of patients with ESRD at FHA: ~1100
b) Approximate cost per hospitalization day (as per CIHI report) : ~$1000 per day
c) Approximate reduction in length of hospital stay per patient (mean of pre/post & active/control results): 3.8 days

1100 patients X 3.8 hospital day reductions/patient X $1000 per day

= $4, 180, 000

The financial investment to achieve these outcomes was relatively modest, with total expenditure of $80 888.76 during the period for which we report outcomes.

So that’s a potential $4,180,000 saved per year as a result of preventative foot care in ESRD.

Next step is to perform appropriate statistical testing and an economic analysis.  We are hopeful that we will confirm this intervention is highly cost saving, while at the same time showing an improvement in patient outcomes; essentially that it is cheaper to provide better care.

If we are able to demonstrate that the results are both statistically significant and economically advantageous, we will go back to funders to seek support for a widespread implementation of this preventative care program across the region, and hopefully the province.

What can we take away from this project?

a) Pending our statistical and economic analysis, it appears that investing in preventative care may result in better patient outcomes at markedly lower cost
b) Our discretionary project funds, in addition to industry sponsorship, can provide an amazing opportunity to explore new methods of improving outcomes (we are unique within FHA in that we have access to such funds)
c) Creating high quality project proposals is an important first step in identify projects that are set up for success.  While brief and simple, the foot care proposal we reviewed addressed the following:
a) the problem you’re trying to solve ie why does this matter?
b) what you’re going to do ie what’s the intervention?
c) how you’re going to define and measure success ie how will we know if we’ve succeeded?
d) what it’s going to cost
Have a look at the original proposal – it’s a great template for those considering future submissions.
View Foot Care Project Proposal

 
 

References

 
Ndip A1, Lavery LA, Lafontaine J, Rutter MK, Vardhan A, Vileikyte L, Boulton AJ. High levels of foot ulceration and amputation risk in a multiracial cohort of diabetic patients on dialysis therapy. Diabetes Care. 2010 Apr;33(4):878-80. PMID: 20067975.
 
Orimoto Y1, Ohta T, Ishibashi H, Sugimoto I, Iwata H, Yamada T, Tadakoshi M, Hida N. The prognosis of patients on hemodialysis with foot lesions. J Vasc Surg. 2013 Nov;58(5):1291-9. PMID: 23810259.
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Updating Renal Connect

Updating Renal Connect

RenalConnect is an open-source, web-based, and freely-available (via GitHub) clinical management tool we developed in the Fraser Health renal program in order to assist with management of PD peritonitis, as well as tracking and managing patients being followed by our “transition nurses”, ie those who are new starts to hemodialysis or at high risk of needing to start dialysis imminently.

We have phased-out usage of RenalConnect for PD peritonitis as the features have been rolled into PROMIS.  While we used RenalConnect for managing peritonitis as part of our quality improvement strategy, we noted a significant impact on our program and presented these findings at the American Society of Nephrology meeting in 2012.

Our transition nurses have been using RenalConnect to track and manage their caseloads.

We are strong believers that when we track data as part of our clinical care (rather than simply have clerks or analysts enter data retrospectively or prospectively), the data records and reports generated are more accurate and useful.  Simple put, our fantastic clinicians will likely enter data really accurately as it impacts the person they are caring for.

As a result of being “power users” of the software, our transition nurses were able to provide insightful feedback.  We took this feedback and brought it back to our software developer, Dr. Dimas Yusuf, now a senior resident in Internal Medicine.

We were able to add some nice upgrades (and bug fixes) to the web application.

Some highlights:

  • Often, reporting out mean results can be significantly impacted by just a couple outliers.  We added median results in our reports to give a more complete picture of our outcomes.
    • In the example in the image below, while mean interval from starting HD to meeting a transition nurse if 17.2 days (red arrow), the median is actually 7 days (blue arrow).  This is due to a handful of outliers which skew the mean.2015-06-19_08-56-17
  • When we report out mean and median results, sometimes the results just don’t look like they make sense.  This can happen if there has been an error in data entry.  We’ve added the ability to “Inspect data”.  This feature allows one to drill down on all the data points (by clicking “Inspect data”, blue arrow) that make up any given metric and see if any of the values may be erroneous.  Inaccurate data points can then be quickly fixed (by clicking “manage start”, red arrow).
    2015-06-19_09-04-35

2015-06-19_09-06-46

  • We added 2 new reports to assist with quality improvement in PD:  Time from PD referral to PD catheter insertion and Time from PD referral to PD start.2015-06-19_09-10-39

In general, patients on hemodialysis who are waiting to start PD are on dialysis using a central line.   We know that observational data suggests the any benefit of PD over HD in the short term is likely driven by central venous catheter usage1.  In addition, hemodialysis is much more costly that peritoneal dialysis2. Of course, people wanting to switch to PD from HD likely want it to happen sooner rather than later.  So it serves the triple aim of healthcare to move people onto peritoneal dialysis as quickly as possible.  This new reporting metric will allow our program to understand how we’re performing and try to tighten up our processes of care.

  • We added support for French and Spanish so it is more useful to other members of the global nephrology community.  Over time, we’d love to see contributors add support for more languages.
  • We added support for patients who may not yet have started dialysis (but were still being followed by our transition nurses), and for those who recovered after starting dialysis.
  • We fixed a ton of bugs, many of which were quite annoying.

Of note, all members of the Fraser Health renal team who need access, can login here http://renalconnect.com.

Login to RenalConnect

 

Any members of the FHA Renal team who need access, can do so by requesting it directly from the medical director.

 

We’ve made sure that RenalConnect remains a freely accessible tool that can be downloaded, installed, and implemented by anyone who wishes to use it around the world.  Our hope is that an open-source community will develop around this software and we’ll see it improve over time. Of note, the software developer has kindly agreed to offer a hosted and supported solution that allows medical teams to use the software without having to worry about setting up and maintaining their own installation.

 

 

References

 
Perl J1, Wald R, McFarlane P, Bargman JM, Vonesh E, Na Y, Jassal SV, Moist L. Hemodialysis vascular access modifies the association between dialysis modality and survival. J Am Soc Nephrol. 2011 Jun;22(6):1113-21. PMID: 21511830.
 
Chui BK1, Manns B, Pannu N, Dong J, Wiebe N, Jindal K, Klarenbach SW. Health care costs of peritoneal dialysis technique failure and dialysis modality switching. Am J Kidney Dis. 2013 Jan;61(1):104-11. PMID: 22901772.
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Wait times to create a vascular access drop 35-50%

Improving our incidence and prevalence rates for permanent vascular access on hemodialysis has been an FHA wide goal.

As part of our strategy to improve our rates, we looked at the wait times to get an access created.  We figured that if we could get an AV access created faster for patients on hemodialysis, our prevalence rates would improve.  And if we could ensure that wait times for patients with advanced chronic kidney disease were better, we’d see less people starting hemodialysis before their AVF was ready to be used, thereby improving our incidence rates.

As a result of a collection of strategies including a) more dedicated vascular access nurses, b) greater collaboration with our surgical colleagues and c) the implementation of a novel process of expedited vascular access creation under regional block or local aneasthesia with recovery outside the post-anesthetic care unit, we’ve noticing striking improvements in wait times from referral to vascular access creation.  Between January and September 2013, we’ve seen surgical creation wait times decrease from 138 days to 91 days for patients referred to the Surrey program and 111 to 95 days in the Abbotsford program.

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Alteplase: Program savings

This guest post was written by Kim Norman, BA (hons) Nursing who is the Clinical Nurse Educator for ARHCC and ACDU Hemodialysis Units in the Fraser Health Renal program.

It became quite frustrating to watch, as a Clinical Nurse Educator, the use of alteplase within our Renal Program at a cost of $64 a vial.

After identifying a $100,000 expenditure on alteplase use within the hospital hemodialysis units  it was time to ask why, what could be done to reduce costs and how? This needed to be done while keeping in mind the best interests of the patients in relation to best practices.

After  identifying a huge cost to our Renal program what was also highlighted in the review process was a large cost in sterile supplies.  Alteplase and sterile supplies added up to $716,000 being spent each year in the FHA hemodialysis units.

After collaborating with the community dialysis staff, educators across Canada and within my own province of BC, we identified products that could potentially cut the cost of alteplase by reducing the exposure of the hub of a catheter to air (theory, not evidence based) by using a needle-less hemodialysis cap designed to withstand the blood pump speeds of dialysis.

The needless cap would also potentially reduce the costs of our sterile supplies due to the cap only needing to be changed every 7 days.

Once the product had been approved by the leadership team, the educators made all efforts (through education) to implement the device along with streamlining our hemodialysis access and flushing techniques. The implementation did not go without its barriers which are highlighted in the education powerpoint; such barriers are still being addressed between the educators and the company who distributes the device.

We are now one year post implementation and have seen a significant reduction in total costs.  Specifically, we’re seeing approximately $112K reduction in sterile supply costs and $23K reduction in tPA costs per year.

In fast paced hemodialysis units, we have received reports that this new intervention allows for more efficient use of time at the bed side.

The cost savings documents and education tool are attached for review.

Cost analysis:

Renal Tray costs for ARHCC

Tego Connectors FHA Cost Analysis

TPA Monitoring Tego

Educational Information:

TEGO patient pamphlet

Tego Poster Fraser Health

 

Kim Norman

Clinical Nurse Educator

Fraser Health Renal Program.

 

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