Implementation of a foot assessment program in a regional satellite hemodialysis setting.

Individuals with chronic kidney disease are at higher risk for foot problems (i.e., ulcers, deformities, amputations) than the general population. Research demonstrates that assessment and active monitoring, teaching, and timely interventions can reduce the number and severity of lower limb amputations in the hemodialysis population. This paper reports on a quality improvement project aimed at implementation of a foot assessment program in a regional satellite hemodialysis setting based on the Registered Nurses' Association of Ontario's (2005) best practice guideline (BPG), The Assessment and Management of Foot Ulcers for People with Diabetes. Elements of the program include a one-time full assessment of risk for all patients transferring to the satellite program followed by monthly foot checks for those deemed high risk (i.e., people with diabetes). Evaluation of the program has been positive from both patients and hemodialysis nursing staff. There has been a greater emphasis on self-management around the care and management of patients and their high-risk feet. At the same time, the program has resulted in prompt identification of problems and timelier referral to the appropriate services in the patient's local community.

Hemodialysis Infection Prevention Protocols Ontario-Shower Technique (HIPPO-ST): A Pilot Randomized Trial.

INTRODUCTION: We developed the Hemodialysis Infection Prevention Protocols Ontario-Shower Technique (HIPPO-ST) to permit hemodialysis (HD) patients with central venous catheters (catheters) to shower without additional infection risk. Our primary objective was to determine the feasibility of conducting a parallel randomized controlled trial (RCT) to evaluate the impact of HIPPO-ST on catheter-related bacteremia (CRB) in adult HD patients. METHODS: Adult HD patients using catheters were recruited from 11 HD units. Patients were randomized to receive HIPPO-ST or standard care and were followed up for 6 months. Only CRB-outcome assessors were blinded. For the study to be considered feasible, 4 of 5 feasibility outcomes, each with its own statistical threshold for success, must have been achieved. RESULTS: A total of 68 patients were randomized (33 HIPPO-ST and 35 control) and were followed up to 6 months. Of 5 measures of feasibility, 4 were achieved: (1) accurate CRB rate documented (threshold: κ level >0.80); (2) 97.8% (279/285) of satellite HD patients with catheters were screened (threshold: >95%); (3) 88% (23/26) in the HIPPO-ST arm were successfully educated by 6 months (threshold: >80%); and (4) 0% (0/29) patients in the control arm were "contaminated," that is, using HIPPO-ST (threshold: <5%). However, only 44.2% (72/163) of eligible patients consented to participate (threshold: >80%). The rate of CRB was similarly low in HIPPO-ST and control groups (0.68 vs. 0.88/1000 catheter days). DISCUSSION: This HIPPO-ST pilot study demonstrated the feasibility of the larger HIPPO-ST study, especially given the high levels of education success with the HIPPO-ST arm and the low levels of contamination in the control arm.